Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old male with a many year history of pain-related problems reported to include fibromyalgia, reflex dystrophy, degenerative disc disease, right hand complex pain, severe recurrent abdominal pain of unclear etiology, irritable bowel syndrome (IBS), chronic fatigue, depression and various surgical procedures. Cymbalta was prescribed by the patients gastroenterologist as treatment for IBS and incidentally for fibromyalgia after several failed trials of other medications over an extended period of time. The patient was evaluated by a rheumatologist in January 2006, and was found to have fibromyalgia with uncontrolled acute and chronic pain. At the time of this evaluation, the patient was taking Cymbalta 60mg daily, Lyrica 50mg three times per day, Oxycontin 10mg twice per day, a Lidoderm patch daily and Ambien and was noted to be very symptomatic, with 18/18 tender trigger points.  Complaints of constantly severe pain above and below the waist, severe fatigue, and disturbed sleep were also noted. The rheumatologist recommended an increase in the dosage of Lyrica, a referral to a multidisciplinary fibromyalgia program and noted the possibility of additional supplements. There was no mention of Cymbalta in the providers progress note.The patients request for authorization of Cymbalta was denied by the Health Plan citing a lack of medical necessity.Treatment of fibromyalgia is difficult and various medications of different classes are often tried based on the knowledge and experience of the treating rheumatologists. The use of antidepressants is standard practice, though tricyclics and trazodone are used more often than the newer selective serotonin reuptake inhibitors (SSRIs) or dual-action agents. This may be because the older drugs are better for direct sleep promotion.Cymbalta is a newer, dual-action agent which has been proven to be useful in the treatment of depression. In addition, the benefit of Cymbalta in the treatment of fibromyalgia, with or without depression, has been reported in the medical literature as cited above. Given the limited number of useful agents for the treatment of this condition, prescribing Cymbalta is now considered standard practice for many rheumatologists.There is limited discussion of the patients response to Cymbalta in the medical records provided. As such, I believe a medically monitored three-month trial of Cymbalta is appropriate to ascertain if the medication provides a benefit to the patient. If it is effective, then its continued use would be considered medically necessary.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 60-year-old male who was admitted to the hospital for profound depression, spurred in part by his lack of employment. He had become increasingly withdrawn, had difficulty with sleep, and had very little appetite, evidenced by a 40-pound weight loss. The patient was also reported to have expressed that he saw no reason to continue living and had considered driving his car into an abutment on the highway as a means of suicide. The admission mental status exam made note of psychomotor retardation, no eye contact, profound speech latency with monosyllabic speech, thought blocking, attendance to internal stimuli, echolalia, and nihilism. His mood was described as very depressed and his affect as nearly flat. The patient was diagnosed with major depression with psychotic features and rule out of bipolar disorder, depressed state.  From a treatment standpoint, the record indicates the patient was profoundly withdrawn, anergic, bleak and refused food, drink and medications. His sleep was grossly impaired and repeated utterances of Im sorry and crying were noted.  Given the severity of his depression, the treating psychiatrist recommended electroconvulsive therapy (ECT) and the patient, with the support of his family, agreed to undergo the treatment.  He received three bilateral-lead treatments in the hospital and the record reflects a significant improvement. Continued outpatient ECT was planned and the patient was discharged on Paxil 20mg and Risperdal 0.5mg which he agreed to take as prescribed.  The patient was severely depressed and psychotic by the time he was admitted to the hospital. Considering his age and the severity of his depression and withdrawal, ECT was the treatment of choice. This approach is consistent with the recommendations of the American Psychiatric Association for the treatment of psychotic depression. Medications alone would have resulted in a more protracted course of treatment and would have needlessly extended the patients mental and physical distress. The patient benefited significantly from the ECT therapy he received, and it is very likely the treatment will continue to be beneficial.Based upon the information set forth above, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 48-year-old female with chronic dysmenorrhea and premenstrual syndrome (PMS). She reports menses every 30 days with worsening menstrual cramps from 3 days prior and continuing to the third day of her menses. The dysmenorrhea has not been relieved by Darvocet, codeine, Naprosyn, ibuprofen or conventional oral contraceptives. The patient also reports premenstrual symptoms of depression and insomnia that have not responded to Effexor or over-the-counter preparations. The patient was evaluated by a gynecologist in January 2006. She had an ultrasound, which indicated normal uterus and ovaries. Following her evaluation, the patient was placed on Seasonale, which has allowed her to have a menstrual period every three months rather than every month. She apparently has found this to provide significant relief from her symptoms and has tolerated it well. At issue is whether Seasonale is medically necessary.Oral contraceptives are the first-line treatment for dysmenorrhea. Seasonale is a contraceptive preparation containing levonorgestrel 0.15mg and ethinyl estradiol 0.03mg in each active tablet. It is unique in that it is packaged with 84 active tables followed by 7 days of placebo tablets, as compared to conventional contraceptive preparations, which contain 21 active tablets with 7 placebo pills. A patient taking Seasonale will in general have menstrual bleeding (or more accurately withdrawal bleeding) only when taking the placebo tablets, i.e., approximately every three months as opposed to the conventional oral contraceptives where withdrawal bleeding will occur approximately every month. However, any conventional oral contraceptive can be taken continuously for 84 days and thereby allow the patient to experience bleeding every three months rather than every month. In this case, the Health Plan formulary includes the conventional oral contraceptive Levlen, which has the exact formulation as Seasonale. The patient can obtain the same favorable outcome if she takes Levlen continuously, i.e., active tablets for 84 days followed by 7 days of placebo. Thus, Seasonale is not medically necessary as long as three packs of the formulary contraceptive Levlen are authorized at a time.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. Three packs of Levlen should be authorized at a time so there is no interruption in the patients treatment. If the Health Plan does not provide this authorization, the patients request for Seasonale should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 60-year-old female with an apparent history of chronic fatigue syndrome.   She has been followed by an infectious disease specialist for several years, initially for a chronic fungal sinusitis in 2001. The patient consulted with her provider again in October 2004 and the record notes chronic enteroviral infection and refers to the use of doxycycline for suppression. The patients laboratory results are generally within normal limits except for elevated serum glucose levels and Chlamydia pneumoniae antibody levels which are elevated in the range of 1:256 to 1:1056. A footnote from the laboratory indicates that the kit used for these tests is not FDA approved. The patients complaints include fatigue, difficulty with sleep and unspecified gastrointestinal problems. The patients provider recommended Pegasys and Actimmune therapy and the patient is now requesting reimbursement for the treatment received. The Health Plan denied the requested reimbursement based upon a determination that the Pegasys and Actimmune therapy was not medically necessary.There is no convincing data in the medical literature to substantiate the theory that Chlamydia pneumoniae infection can cause chronic fatigue. While the elevated C. pneumoniae serologies cannot be readily explained, further scrutiny of these results would be appropriate to fully assess their meaning. Similarly, there is no support in the literature for the treatment of this condition with interferons, which are associated with significant effects. Neither Pegasys nor Actimmune are approved by the FDA for this application. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 37-year-old female who was non-weight bearing after a motorcycle accident in June 2006. She received rehabilitation therapy which included sliding board transfers and activity of daily living (ADL) training. The patient progressed steadily with physical therapy (PT) from initially requiring maximum assistance in bed mobility and transfers to stand-by assistance/supervision in bed mobility and transfers and independence in wheelchair propulsion. As of July 2006 the patient required minimal to moderate assistance in toileting. In July 2006, after OT and PT were curtailed, the patient required maximal assistance for sliding board transfers. The patient has requested authorization for skilled nursing facility services provided after July 2006. The Health Plan denied her request based upon a determination that the requested services are not medically necessary.The patient was not ready for discharge in July 2006 as she was not independent in her PT and OT modalities and was continuing to make progress. Rehabilitation services continued to be medically appropriate. Additionally, the patients functional abilities regressed when her therapies were reduced and/or discontinued. The record indicates the patient attained weight bearing status in July 2006. SNF services should continue for one additional week and then the patients need for continued services should be reassessed.Based on the information cited above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old female with a history of L5-S1 laminectomy in 1984 and spinal disease apparently related to a traumatic injury in 2004. She has been treated with non-steroidal anti-inflammatory drugs and Flexeril and has achieved some symptomatic relief. MRI indicates severe disc collapse at L5-S1 and disc bulge at L4-5. The patients provider recommends fusion from L4 to S1 and revisional foraminotomies using a 360 degree approach. The providers request for authorization was denied by the Health Plan citing a lack of medical necessity.A thorough review of the MRI reports and clinical notes provides no clear indication for surgical intervention at L4-5. There is a central disc bulge but no evidence of foraminal encroachment. The basis for the dynamic component of foraminal compression alluded to cannot be ascertained from the records provided. The patient clearly has disc degeneration, Modic changes of the endplates and foraminal compression at L5-S1 and her symptoms appears related to disease at that level. I can find no medical rationale for the proposed L4-S1 anterior-posterior fusion. Additionally, I find no reason why the pathology at L5-S1 cannot be addressed from a posterior approach through either a PLIF or TLIF procedure. There is no compelling evidence in the medical literature that would favor a 360 approach through two separate incisions over a single posterior technique. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 53-year-old female with a 20-year history of multiple sclerosis (MS) and significant neuromuscular symptoms. Additionally, the patient has MS related chronic pain syndrome. She is currently on Elavil, Zonegran, Neurontin and Lyrica to control her pain. The patient has been using samples of Lyrica for over two months and reports that she has gained control of her pain and has substantially reduced her Neurontin dosage.The patients request for authorization of Lyrica was denied by the Health Plan citing a lack of medical necessity.Lyrica is currently prescribed by neurologists for neuropathic pain conditions with a wide range of etiologies extending well beyond the indications of post-herpetic neuralgia and diabetic peripheral neuropathy. As with this patient, the response has generally been very good. In this case, Lyrica was tried after several other medications were ineffective and the medication has provided the patient with relief from her chronic pain syndrome. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 45-year-old female with arthrofibrosis of the knee who is requesting reimbursement for physical therapy she received from January 2006 through February 2006. The Health Plan has denied the patients request on the basis that the physical therapy at issue was not medically necessary.Discharge to a home exercise program would have been an appropriate as of January 2006. Skilled physical therapy intervention was not medically warranted as of that date based upon the information provided. Range of motion exercises could have been self-taught via a HEP sheet. There is no evidence demonstrating that the patient warranted the level of care provided by a skilled therapist during the period in question. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old woman with type 2 diabetes mellitus. She has requested coverage for Byetta to be added to her current regimen. She has been taking metformin (Fortamet ER) 500mg a day since at least October 2005. Her A1c, a measurement of blood sugar control, was 6.2% in January 2006 while on this dose of metformin. The patient was started on Byetta by her endocrinologist in February 2006. A subsequent A1c in March 2006 was 5.5%. Her endocrinologist stated the patient was previously unable to tolerate Actos or Avandia due to unspecified side effects. He also stated that she lost a significant amount of weight on the Byetta. However, according to the providers notes the patient lost one pound between February 2006 and April 2006. She lost an additional six pounds on and off Byetta between April 2006 and June 2006. At issue is whether Byetta is medically necessary for treatment of the patients medical condition.This patient with type 2 diabetes appears to have been under good control while taking a small amount (500mg) of metformin. Excellent control is defined by the American Diabetes Association as an A1c of less than 7% and by the American College of Endocrinology as an A1c of less than 6.5%. The patients A1c prior to starting Byetta (while taking the metformin alone) was 6.2%. As such, the medical necessity of Byetta in this clinical setting has not been established.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 37-year-old female with relapsing-remitting multiple sclerosis (MS).  She did not receive disease-modifying therapy during pregnancy or immediately following delivery. The patient was treated with IVIG in the postpartum period as a preventative therapy to avoid relapse of her MS. The patient is requesting reimbursement for the IVIG therapy. The Health Plan has denied her request based upon a determination that the therapy was not medically necessary.The American Academy of Neurology Therapeutics Assessment Committee guidelines do not support the application of IVIG therapy in relapsing-remitting MS. Although there have been several small studies suggesting IVIG therapy reduces the rate of MS relapse in the postpartum period, these studies were primarily retrospective and open label. Further studies are necessary to establish the efficacy of IVIG therapy in this clinical context. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is an 18-year-old-male with a history of academic difficulty requiring an individualized education plan (IEP). He is currently in a non-public placement with a small class size. The patient has undergone significant educational and neuropsychological testing in the past.  The record indicates there is a possibility of a bipolar disorder and a history of depression was also noted. He has had several evaluations resulting in recommendations to the school district. Recently, he was evaluated by an audiologist for a central auditory processing disorder. The provider concluded the patient has a central auditory processing disorder which is affecting his academics and verbal IQ. She recommended AIT therapy or EASe Disc to improve auditory processing speed and to train for noise suppression; Fast ForWord to assist with processing speed; interactive metronome training to improve integrative function; individual work with an educational therapist on cognitive memory strategies; Making Math Real to improve math skills; and work with an educational or language specialist on Lindamood-Bell Visualizing and Verbalizing to improve verbal understanding and expression. The patients parent has requested reimbursement for the cost of the central auditory processing consultation and evaluation. The Health Plan denied the request based upon a determination that the services were not medically necessary.The case review included the patients central auditory processing evaluation as well as the IEPs provided. The record does not include a documented history of trauma, hearing loss or other disease or illness that can be associated with the symptoms attributed to the patient.  I also reviewed the scientific literature cited by the Health Plan and conducted an independent literature search of central auditory processing disorders. No additional literature on the topic was identified; there were no literature citations from the provider. I found no evidence to support the theory that a central auditory processing disorder is an illness, a disease process, or the result of trauma. In my experience, the symptoms described are generally associated with other learning disorders. Additionally, I found no data supporting the efficacy of the recommended therapies. As such, I cannot conclude there is a medical basis for the central auditory processing consultation and evaluation.  Based upon the information set forth above, I have determined the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a 54-year-old female patient admitted for inpatient detoxification from synthetic opioids and alcohol, as well as depressive symptomology. According to the records, the primary focus of inpatient treatment was her depression. Alcohol and synthetic opioid addiction are apparently secondary to chronic pain and other life stressors. The patients inpatient care was certified through April 2006, and she was discharged in May 2006. The patient was discharged in May 2006. She has requested reimbursement for acute inpatient days from May 2006. The Health Plan has denied her request based upon a determination that acute inpatient psychiatric services were not medically necessary after the end of April 2006.In light of the treatment notes cited above, there is no justification for continued inpatient services for either psychiatric or substance abuse treatment after April 2006. The patient had no symptoms of acute withdrawal from any substance nor did she have any acute signs or symptoms of psychiatric relapse.  Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 46-year-old female with a history of biopsy proven, Grade II, invasive ductal carcinoma of the left breast. Further treatment details are not provided. The patient presented to her provider in May 2006 complaining of a new nodule medial to the site of the previous left breast biopsy. Her provider noted that a mammogram and ultrasound were unremarkable, but also noted a need to determine whether or not these changes represented recurrent breast cancer. Accordingly, he requested authorization for a  PET scan. His request was denied by the Health Plan based upon a determination that the diagnostic procedure was not medically necessary.The patient has a history of breast cancer and now presents with left costosternal changes in the area of the previous left breast biopsy.  A PET scan to rule out a recurrence of her cancer appears to be consistent with the policy of the Health Plan. It is most certainly consistent with the current standard of care in Oncology and Nuclear Medicine practice. Therefore,  I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.