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

The patient is a 32-year-old female with a long history of alcohol dependence and pain medication abuse. The patient was admitted to a substance abuse residential treatment facility in January 2006. Admitting diagnoses included alcohol dependence, opioid mood disorder, and personality disorder  not otherwise specified. She remained at a residential level of care until February 2006. The Health Plan indicates a residential level of care was not medically necessary for treatment of the patients condition.Review of the submitted records reveals no need for treatment in a 24-hour setting. The patient was experiencing no withdrawal symptoms and her vital signs were stable. She was drug seeking and non-compliant with program rules. There was no substance abuse assessment noted in the records, just a reference to substance abuse. There was no evidence of failure at a lesser level of treatment and no evidence of prior participation in a 12-step program in her community. As such, the patient did not meet criteria or standards of care for residential treatment level of care. Based upon the information set forth above, 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 49-year-old woman with type II diabetes that had not been well controlled.  When first seen by her endocrinologist in April 2005 she was apparently on metformin, Amaryl, Avandia, and 70/30 Humulin insulin.  The patients hemoglobin A1c was said to be 7.5% in July 2005. Her endocrinologist also stated she had gained 40 to 50 pounds over the past one to two years. The patients provider changed her diabetic regimen to include Lantus insulin along with her three oral agents; Humulin insulin was discontinued.  By mid March 2006 Avandia was discontinued and Actos was added and later that month Lantus insulin was discontinued and the patient was begun on Byetta, 5mg twice per day. At that time, her weight was 198.5 pounds with a height of 5.  After two months on Byetta, the patients May 2006 hemoglobin A1c decreased to 6.1% and her weight was 190.5 pounds. While awaiting approval for coverage of the Byetta, the patient had been placed back on insulin.  Her current weight and degree of control is unknown. The patients request for authorization of Byetta was denied by the Health Plan citing a lack of medical necessity.The patient was an insulin requiring type II diabetic who failed to achieve good control with three oral agents and insulin. After discontinuing insulin and adding Byetta to the oral agents, her diabetic control improved and she lost weight. Although Byetta is FDA approved for patients who have failed a sulfonylurea or metformin it is commonly used in this community for patients who have failed other oral agents and insulin. The manufacturer has submitted studies to the FDA to expand the approved indications for Byetta to include Actos, Avandia and insulin. Because the patient has failed to control her blood glucose levels with three oral agents and insulin, I have determined Byetta is medically necessary for treatment of her 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 male who experienced neck, left shoulder, left wrist and upper back pain following a motor vehicle accident. He also has a history of right shoulder pain. The patient believes his physical therapy regimen was prematurely discontinued in May 2006. He has requested authorization and coverage for additional physical therapy visits. The Health Plan has denied his request indicating the requested therapy is not likely to be beneficial and therefore is not medically necessary. The submitted physical therapy notes do not document any long-term functional improvement with the patients past therapy. Nor does it appear the patient achieved the goals set at the beginning of therapy. In addition, the patient was instructed in a home program and should be able to continue exercising at home. Additional physical therapy is not likely to result in an improved clinical outcome. Therefore, I have determined the requested therapy 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

The patient is a 63-year-old woman with a documented long-standing history of back and shoulder pain that has been unresponsive to physical therapy and chiropractic intervention. The submitted photographs show bra strap grooving and large, pendulous breasts. The planned breast reduction exceeds the 22nd percentile on the Schnur table. The Health Plan has denied authorization for the proposed procedure on the basis that it is not medically necessary for treatment of the patients condition.Review of the submitted clinical evidence demonstrates breast reduction surgery is medically necessary for this patient. She has breast hypertrophy, and her complaints of shoulder, neck, and back pain and bra strap grooving are typical of symptomatic macromastia. The submitted photographs confirm pendulous breasts with significant residual volume despite her massive weight loss. Her symptoms have not improved with chiropractic treatments and physical therapy, which is not surprising since symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. The value of breast reduction in improving or correcting symptoms of macromastia is well documented in peer-reviewed scientific studies. As noted by Kerrigan, et al., weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms are very unlikely to improve unless she has a breast reduction.  Based upon the information set forth above, I have determined the requested procedure 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 54-year-old female with a long-standing history of diet pill dependence as well as what has been identified as an eating disorder due to long-standing binging on high-caloric foods such as pasta, pizza, and ice cream, though devoid of purging of any sort. By the point of her most recent inpatient admission, she was using up to 35 diet pills per day. Her past history was also notable for periods of depression and frank paranoia, the latter having been attributed to her use of the diet pills, including her feeling that she could read others thoughts and predict the future. She was admitted for inpatient treatment some seven weeks prior due to the psychotic symptoms but soon returned to use of the diet pills. The patient had also had a history of seven inpatient hospitalizations, having been considered as increasingly agitated and psychotic by friends and family as early as October 2003. Her most recent admission diagnoses included: Eating Disorder  not otherwise specified, Major Depressive Disorder, recurrent, and Amphetamine Abuse.  Chart notes from her inpatient treatment reveal the patient as often quite agitated, intrusive, hyperverbal, affectively incongruent, labile, and given to oddities such as constant humming or knitting. She was felt to be frankly disorganized and was also treated with a variety of medications including Seroquel, topiramate, and Prozac. Earlier trials of Ritalin and Strattera were abandoned. The patient was also found to be lacking in insight. Ultimately, she made what was considered enough progress to allow for her exit from the hospital in April 2006, having been admitted in March 2006.  Discharge diagnoses were those of Eating Disorder  not otherwise specified, Major Depressive Disorder, recurrent, and Amphetamine Abuse, with a deferral on Axis II.  The patient was discharged on Prozac 30 mg, Seroquel 25 mg, and Topamax 200 mg.At issue is whether acute inpatient hospitalization was medically necessary for treatment of the patients condition.Based on the patients premorbid history as well as the chart notes documenting her treatment in the hospital, there was ample reason for her to be hospitalized. One issue had to do with her constant use of amphetamines, which was likely either compounding or leading to psychosis and affective cycling. In regards to the latter, there is also much documentation pointing to either a prima facie or secondary Bipolar Disorder. The patient was quite labile and thought disordered. Whether one agrees or not with Topamax and Prozac as the most optimal treatments for her illnesses, it is apparent the patient was quite ill. Nowhere is there documentation speaking to a particularly healthy degree of mentation, though she did improve to some extent by the end of her hospitalization. All told, I find that acute inpatient hospitalization was medically indicated and necessary. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 48-year-old male who was apparently well until approximately two to three years ago when he was found to have low testosterone levels and significant fatigue. He also understands he had an Epstein-Barr virus infection at about the same time and has associated this with the development of his chronic fatigue. The records provided do not address these diagnoses. Some eight months ago, the patient developed a rash on his forearms which developed into what is described as pustular lesions. The patient was initially treated with cephalexin without relief and then with topical silver sulfadiazine with improvement of his symptoms. Additionally, the patient was found to have lesions on his finger nails that were diagnosed as onychomycosis  although they are referred to as splinter hemorrhages in some of the submitted material. The nail apparently grew a saprophytic fungus (not usually considered pathogenic) and the patient was treated with Sporanox. The patient indicates this therapy continued for approximately three months and was later resumed in July 2006 for an additional month and was responsible for marked improvement in his arm rash and significant resolution of his nail issues. He also indicates when he is not being treated with Sporanox, the nail condition worsens. The patient has been seen in consultation with both dermatology and infectious disease specialists. The skin rash was noted to be mild and of uncertain origin on a biopsy report dated April 2006. The dermatologist indicated the changes in the thumbnail were not consistent with splinter hemorrhages but were of unknown origin. The patient and his provider have submitted a request for an additional six months of treatment with Sporanox.  The Health Plan denied the request, citing a lack of medical necessity.There is no evidence from the record that the arm rash is fungal in origin and the evidence of a fungal infection of the nails (onychomycosis) is also less than clear. Assuming a diagnosis of onychomycosis, treatment with Sporanox would be indicated for a period of up to four months. This extended period is generally needed for toenail involvement, as these nails grow more slowly than fingernails. There is no published, peer-reviewed evidence to support six months of therapy with Sporanox. Therefore, 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 51-year-old woman who has requested coverage for intravenous (IV) Rocephin for an extended period. It appears the patient is requesting eight weeks of therapy, although four and six-week courses of treatment are recommended in the providers letters dated June 2006 and July 2006.The patient notes that she had received oral antibiotics for 15 months with minimal improvement before being started on IV Rocephin. She has apparently already received a three to four-week course of this treatment.A letter from one of the patients provider notes a history of fibromyalgia diagnosed before 2000. The provider appears to have cared for the patient from at least September 2004 to July 2005. He states that she has chronic Lyme disease.There is no history of exposure to ticks or information about place of residence or risk of tick exposure. The definitive tests for Lyme disease [IgM and IgG Western Blots] were both negative by CDC criteria. The patient has tests indicating past EBV virus infection; her provider indicates that he believes this virus is also responsible for some of the patients symptoms. Her non-specific symptoms include fatigue, low-grade fevers, swollen glands, migrating arthralgias, myalgia, palpitations, gastrointestinal disturbances, light sensitivity, flu-like symptoms, sleep disturbances, irritability, memory loss, poor concentration, depression, vertigo, numbness and headaches.At issue is whether additional IV antibiotic therapy is medically necessary.This patient has received at least three weeks of treatment with IV Rocephin. The recommended therapy with IV Rocephin for any form of Lyme disease [per IDSA recommendations] is a maximum of four weeks. There is not clear evidence of this infection in the submitted documentation.The evidence provided is not sufficient to make a diagnosis of Lyme disease. The CDC criteria, when applied to the patients Western Blot results, do not allow a diagnosis of Lyme disease. Furthermore, there is no clinical evidence of specific findings indicative of this infection. Because the diagnosis of Lyme disease is not substantiated, treatment with the IV antibiotic Rocephin is not medically necessary. Even if there was adequate evidence of Lyme disease, there is no support from peer-reviewed studies for a period of more than 30 days of treatment with IV antibiotics. Indeed, except for documented cardiac, neurological or joint disease, there is no indication for a months treatment with Rocephin. Therefore, I have determined the requested therapy 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 case concerns a 12-year-old female patient with cerebral palsy and its complications (scoliosis and contractures). Her parents are seeking reimbursement and prospective authorization for physical therapy three times a week. The Health Plan has denied coverage for the therapy at issue and believes a step-down in therapy is appropriate.Vigorous intensive physical therapy and a program of exercises supervised by physical therapists and performed by members of the patients family, usually help patients with cerebral palsy avoid multiple, time-consuming and invasive corrective surgical procedures. The patient is followed by a pediatrician, developmental pediatrician, and pediatric orthopedist; all three physicians as well as the patients treating therapist have recommended continued physical therapy at a frequency of three times a week. Upon review of all of the submitted clinical information, physical therapy three times a week is medically necessary and essential for this patient and is likely to improve the patients quality of life and help prevent major complications. The patient should be re-evaluated every six months. If there is documented evidence of clinical benefit, therapy at this frequency should be continued.For the reasons 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 four-year-old male with a history of articulation delay and phonological disorder. He has been receiving speech therapy since November 2005. The initial goals included production of /l/ in initial, medial and final positions. Long-term goals included production of /l/ and /r/ and fricatives /s/, /z/ and /sh/ at the sentence level.The patients parent has requested reimbursement for the speech therapy the patient has received as well as prospective authorization for additional therapy. The Health Plan has denied this request indicating the submitted documentation does not demonstrate the need for speech therapy.The Health Plans denial should be upheld. There is a lack of clinical documentation supporting the necessity of speech therapy. The short-term goals included in the therapists evaluations only address part of the first long-term goal. The remainder of the long-term goals are not addressed. In addition, there are no follow-up reports documenting attainment of short-term or long-term goals. Furthermore, the individual progress notes are not adequate to demonstrate objective improvement toward goals. As such, there is insufficient evidence to establish that speech therapy was or is medically warranted in this case.Accordingly, I have determined the therapy at issue was/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

The patient is a 21-year-old female with very long-standing Bulimia Nervosa. She was admitted to residential treatment in March 2006, remaining there until July 2206. Prior to her admission she had failed a number of outpatient treatment courses. The patient began her eating disorder by age 12, restricting her caloric intake, stating that she would go days without eating.  At age 15 she began purging by exercising excessively, later restricting her caloric intake to 1,000 calories per day by the age of 16-17.  In addition to sizable weight loss over the years, she began drinking heavily by 2003 and intensified her purging to include vomiting not only after drinking but also after each meal.  Later, she began to experience severe depressive illness with the usual array of neurovegetative disturbances. Though she began receiving treatment while living with her parents, she accelerated in her binging and purging to the extent of 7-8 times per day as well as continuing in vigorous exercise. Due to encroaching medical problems secondary to her binging and purging, she withdrew from school and remained quite depressed. She was regularly abusing alcohol. An admission mental status exam at the residential treatment facility revealed the patient as cooperative and with mild psychomotor retardation along with tearful affect and some lability.  She also described intense preoccupation with death and dying, stating I am tired of lifetired of feeling out of control and sad.   She was diagnosed as suffering from Bulimia Nervosa, Major Depressive Disorder, PTSD, and Alcohol Dependence.   During treatment, the patient received a number of therapies and was also treated with Prozac, which was eventually increased to 80mg per day.  She was felt to have improved to some extent though documentation cites her as still quite ruminative about her body image and weight.  Even by the point of discharge, she was not entirely resolved about such issues. At issue in this case is whether the residential treatment services the patient received from June 2006 to July 2006 were medically necessary. Review of the submitted clinical documentation indicates the patient experiences rather severe Bulimia Nervosa, Major Depression, and Alcohol Dependence. She had failed outpatient treatment, and therefore residential treatment was clinically indicated. The documentation points to a significant continuance of her illness much beyond June 2006, as exemplified in the aforementioned chart notes. As previously noted, even by the point of discharge the patient was still struggling with eating appropriately and with body image. Therefore, there appears to have been more than enough evidence that a residential level of care was indicated for her entire stay. As such, I have determined the services at issue were 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 seven-year-old female with Type I Diabetes who previously achieved glycemic control through the use of an insulin pump. The record indicates that despite blood glucose testing eight to ten times daily, her hemoglobin A1c had risen from 6.5% in 2003 to 7.2% in August 2005. The DexCom system was prescribed to improve the patients glycemic control and was implemented in May of 2006. The patients provider reported better blood glucose control with the DexCom system and improved detection of hypoglycemic and hyperglycemic episodes. The parents request for reimbursement for the cost of the device was denied by the Health Plan citing a lack of medical necessity.The patients hemoglobin A1c level falls outside of the hemoglobin A1c goals recommended by the American Diabetes Association (7.0%) and the American Academy of Clinical Endocrinologists (6.5%).  Her provider also reports she has had a number of hypoglycemic episodes (less than 60mg/dl) detected at night with the use of the DexCom system for the initial month. The device has recently been approved by the FDA for use in adults. The DexCom system is not intended to replace glucose monitoring by finger stick. The providers letter indicates that the problems with hypoglycemia have improved with the use of the DexCom device and that low readings on the monitor are appropriately verified by finger stick before action is taken. Hypoglycemia remains a significant limitation in children when their caretakers attempt to achieve better glycemic control, in line with the above recommendations. The risks associated with hypoglycemia can be minimized through the alarm feature of the DexCom system. The DexCom STS Continuous Glucose Monitoring System is a medically appropriate adjunct to the insulin pump and blood glucose testing by finger stick previously employed.Based upon the information set forth above, I have determined the device at issue was 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 64-year-old woman with a subacute onset of a painful asymmetric motor neuropathy. She has tried Darvocet, Percocet, Vicodin, and was placed on Actiq 800mcg as needed for pain control. She is also on Neurontin and Lidoderm patch. The patient has been treated with oral prednisone. There is no evidence she is taking long-acting narcotics. A request has been made for authorization and coverage for Actiq. The Health Plan has denied this request citing a lack of medical necessity for the drug.Based on the clinical information provided, it appears the patient has neuropathy of unknown etiology. She has severe pain associated with this condition. However, there is no evidence she is taking any long-acting opiates. Standard of care for patients such as this patient would include a long-acting opiate such as transdermal fentanyl or long-acting oxycodone or morphine. Actiq is typically used for breakthrough pain in patients with severe malignant and non-malignant pain. It is not indicated as primary pain management for neuropathic pain. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.