Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 42-year-old male who sustained an injury to his back six months ago and has since been on restricted work duty since. He has degenerative disc disease and is requesting coverage for an intradiscal electrothermal therapy (IDET) procedure for his disc herniation.There is no information available to warrant and support the use of IDET. No long-term prospective study has shown significant long-term benefits, and the risks of the therapy are still unclear. At this time, there is no class I data to support the use of IDET for the treatment of lumbar degenerative disc disease. In fact, the recent article by Freeman, et al. in Spine 2005 utilizes class I data to refute the effectiveness of the procedure. IDET cannot be recommended until the efficacy of the procedure has been established. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: This patient is a 42-year-old male with low back pain, which radiates down both legs and has not responded to conservative treatment. Imaging studies confirm disc pathology. Percutaneous discectomy and IDET has been recommended. The Health Plan has denied authorization for the IDET procedure on the grounds that it is considered investigational for treatment of the patients condition. IDET remains a controversial treatment for degenerative disc disease. Review of the medical literature reveals that several studies showed little to no efficacy of the IDET procedure. IDET is not the standard of care and it is not in the mainstream of lumbar degenerative disc disease treatment. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 42-year-old man with a history of degenerative disc disease. He has undergone conservative treatments with no long-term benefit. The patients provider has recommended that the patient undergo an IDET procedure. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.IDET remains an unproven procedure without clearly defined efficacy. There is no substantial proof of its effectiveness for the treatment of chronic back pain. Multiple studies have demonstrated that it is not beneficial or has limited effect. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old male with over a 20-year history of substance abuse of Vicodin and alcohol. He has had two prior instances of inpatient treatment, both resulted in relapses. The patient also apparently suffered from depression and post traumatic stress disorder (PTSD).  He stated his life was out of control related to his depression and significant abuse of multiple substances. On 2/21/04 the patient was admitted to an inpatient treatment program. He was discharged  in March 2004. A request has been made for reimbursement for the inpatient rehabilitation services the patient received.Review of the submitted clinical records indicates the patient was not acutely suicidal, or psychotic during the inpatient admission at issue. The records demonstrate the patient was medically stable. Although he had a long history of polysubstance abuse with symptoms of depression, there is no evidence he required inpatient treatment. The patient could have been appropriately treated at an outpatient level of care in a chemical dependency program by a psychiatrist. 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 17-year-old female with previously diagnoses of major depression, attention deficit hyperactive disorder (ADHD), reactive attachment disorder, and mild retardation. She was admitted to residential treatment in April 2005 principally for treatment of aggressive behavior.  The Health Plan authorized her stay through early May 2005, but the patient remained at the facility through late May 2005. Review of the treatment notes indicate that much of the patients behavior involved significant lability in the direction of anger alongside self-injurious acts such as cutting and burning herself or hitting walls, and aggressive acts towards others, both verbal and physical. She was treated with a combination of therapies as well as Trileptal, fluoxetine, and Adderall XR. While in treatment she was noted as often disheveled and refusing to actively participate in group. In addition, she was unpredictable and labile in the classroom, and frequently caused disruptions in the therapeutic community and in group therapy by yelling, defying authority, and attaching herself to peers who demonstrated negative and unsafe behaviors. She would often verbally attack her parents, yell, refuse to listen, and would terminate family sessions at her will. At issue is whether the residential treatment services provided from early May 2005 through late May 2005 were medically necessary for treatment of the patients behavioral health problems.Given the extent of the patients lability and aggressive and disruptive behavior, it appears diagnoses of bipolar disorder and certain conduct disorder may have been appropriate. There does not appear to be any documentation supporting the patient as suffering from mild retardation. The patient was admitted to residential treatment initially because of her tremendously aggressive behavior and was treated with a range of modalities including medication treatment aimed at these problems. As documented in the notes detailed above, the patient was not stable by early May 2005. Rather, she appears to have been just as labile, hostile, and aggressive by the end of May 2005 as she was at the beginning of that month. To this extent, the patient was felt to be in need of more treatment, her family still unable to manage her, and she was to be moved to another residential treatment program. What has previously been cited as stable with respect to the patients behavior actually points to the durability of her symptoms. The chronicity of the patients illness demonstrates its severity and supports the need for the services at issue. Therefore, 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: Upheld Decision of Health Plan

The patient is a 63-year-old male who had a right total knee replacement in April 2005.  This was complicated by a postoperative hematoma that required evacuation.  The patient did however, have physical therapy from May 2005 through October 2005.  His request for authorization of continued physical therapy was denied by the Health Plan based on their determination that it was not medically necessary.Review of the range of motion (ROM) measurements of the right knee documented by the patients provider does not reveal significant improvement in the patients condition since July 2005. Furthermore, no other objective evidence has been submitted which demonstrates improvement in the patients postoperative condition as the result of physical therapy.  Based upon the evidence provided, physical therapy has not resulted in significant progress in the patients rehabilitation. 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: Upheld Decision of Health Plan

The patient is a 54-year old woman with significant risk factors for coronary artery disease (CAD) including family history, marked elevation of LDL and systemic hypertension.  There was a trial of Lipitor with no clear elevation of her CPK or proximal muscle weakness.  The patient is requesting authorization and coverage for Zetia, and the Health Plan has denied her request based upon their determination that Zetia is not medically necessary. The current American Heart Association (AHA) and American College of Cardiology (ACC) guidelines strongly favor the lowering of LDL in a patient such as this with three risk factors and an elevated LDL. The data best supports a statin in terms of efficacy and safety.  There is specific data that favors an ace-inhibitor and Lipitor as having a direct impact on mortality.  There are indeed patients that cannot tolerate statins due to CPK-negative myalgia/ weakness syndrome.  However, the trials that support that the use of Zetia are efficacy only (reduction of LDL) and do not include safety or mortality benefit data.   A large amount of safety/mortality data does exist for the statin drugs, and therefore the current standard of practice is to try another statin, such as lovastatin, Pravachol or Zocor and see if the myalgias still occur.  If trials of formulary alternatives (another statin or niacin) are unsuccessful, then alternative medication such as Zetia would be tried with an understanding that data regarding the safety and mortality benefit is still lacking.  Many patients are able to tolerate a second or third statin, especially if the potency is lowered.  The Health Plan requirement that an alternative statin drug be tried first is a reasonable one, and is consistent with current medical practice guidelines.  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: Overturned Decision of Health Plan

The patient is a 42-year-old female with a body mass index (BMI) of 40.4 and significant comorbid conditions.  She has completed a psychological evaluation and was deemed a suitable candidate for weight loss surgery. The Health Plan has denied coverage for gastric bypass surgery on the basis it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 40.4 and comorbid conditions such as sleep apnea, hypertension, arthritis, and gastroesophageal reflux disease (GERD) the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. Therefore, I have determined the requested surgery 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 63-year-old female with a history of bronchospasm and dyspnea. She had a motor vehicle accident approximately one year prior and underwent various surgeries. She has a history of rib fracture and lung collapse. Pulmonary functions tests performed in April 2005 revealed a normal arterial blood gas pH of 7.34/PC02 41/PO2 86 on room air. Spirometry revealed a FVC of 87%, FEV1 of 79%, and the FEV1/FVC ratio was 74%. The DLCO was reduced at 53% and when adjusted to lung volumes the DL/VA was 68% of predicted value. There was no significant improvement after bronchodilators. According to a letter dated August 2005 from the patients pulmonologist the patient was found to have mild asthma and started on Advair 100. Her physical examination was normal. The pulmonologist said the decreased DLCO was due to atelectasis. He also stated that the dyspnea was largely due to anxiety and deconditioning. The patient was referred for pulmonary rehabilitation.The Health Plan denied coverage for the requested therapy indicating the patient does not have moderate to severe COPD. Pulmonary rehabilitation for patients with COPD is well established and accepted as a means of enhancing standard therapy in order to alleviate symptoms and improve quality of life. This is according to the position statement from the American College of Chest Physicians (ACCP) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) published in 1997. The paper concludes lower extremity training resulted in improvement in exercise tolerance, dyspneas, and subjective quality of life measures, but upper extremity training, ventilatory muscle training (VTM) and psycho-behavioral interventions did not result in added benefit. The evidence is based on patients with COPD (due to emphysema or chronic bronchitis); its role in the treatment of asthma is speculative.According to the patients pulmonologist, the patient has mild asthma and is being treated with the lowest dose of Advair. He states that the patients decreased DLCO may be due to atelectasis, but there is no radiographic evidence of this. Furthermore, the patients ABG is normal despite a decreased DLCO. It appears a cardiopulmonary exercise test is the next appropriate step in order to determine the cause of the patients dyspnea and should take place prior to consideration of pulmonary rehabilitation.Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 50-year-old female with a history of significant pain secondary to osteoarthritis of the hip. Anti-inflammatory medications and injections did not provide sufficient relief of the patients symptoms. The patient consulted two orthopedists; one recommended total hip replacement and the other suggested hip resurfacing arthroplasty. The patient decided to undergo the latter, which was performed in February 2005. At issue is whether hip resurfacing arthroplasty was medically necessary for treatment of the patients medical condition.  Hip resurfacing arthroplasty is an experimental procedure without proven efficacy. The current standard of care for the patients condition is a total hip replacement. Complication rates associated with hip resurfacing arthroplasty have been high in the short to mid-term. Furthermore, there is no data on the long-term efficacy and risks of the procedure. Given the current results of hip resurfacing arthroplasty, the procedure cannot be recommended at this time. Based upon the information set forth above, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 58-year-old woman with frequent migraine-like headaches. She was previously treated with Topamax 25mg, as she experienced paresthesia at 50mg. In addition, she has received Elavil 30mg with some improvement. There is no documentation of a trial of Depakote or beta-blockers in the submitted records. The patient takes triptans, which help relieve the headaches. She has received a trial of Botox in the past. Her provider has recommended additional Botox injections for migraine relief. The Health Plan has denied authorization for the proposed therapy on the basis it is not medically necessary.Review of the submitted clinical records indicates the patient has episodic migraine though it is not documented how many days per month she experiences headaches. The patient had some response to low doses of Elavil 30mg and her provider indicated she would likely respond to higher doses, but there are no records to indicate higher doses were tried. The patient may benefit from a higher dose of Topamax. The paresthesia she experienced at 50mg is typical and usually responds to KCI supplementation. Furthermore, the patient has not been tried on beta-blockers or Depakote, which may be helpful.Based upon the information provided, the patient has not exhausted standard medications for the treatment of migraines. 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: Upheld Decision of Health Plan

The patient is a 52-year-old male with a history of psoriasis. He has significant disease with involvement of over 30% of his body. His provider is requesting approval of the anti-TNF drug, Enbrel (entanercept). He has had suboptimal response to treatment with Soriatane and phototherapy. The submitted records include two years of clinical notes from his dermatologist. There are also laboratory records provided from February 2005 that note a normal CD4 count and an HIV DNA of 956/ml.  In the same battery of tests, there are abnormal liver function tests: the ALT is 88 (normal 1-40 U/L) and the AST is also elevated. It is unclear based on the records provided whether there is an explanation for these values. However, they are consistent with chronic viral hepatitis. The Health Plan has denied authorization for Enbrel based upon their determination that it is not medically necessary absent a negative tuberculin screening.Use of anti-TNF therapy in patients at risk for infection is of serious theoretical concern. A recent paper in Medicine noted the occurrence of cryptococcal, pneumococcal and mycobacterial infections in patients receiving entanercept and related agents. Similarly, a study published in Mayo Clinic Proceedings in 2000 noted multiple infections in a patient given this therapy. A post-marketing study of Enbrel identified serious infections associated with its use and led to a revised prescribing recommendation in May 1999.Based on this data, tuberculosis must be ruled out in the presence of HIV disease (and possibly chronic hepatitis). Anti-TNF drugs such as Enbrel need to be used with extreme caution.  If these criteria are met and the patients CD4 count and HIV viral load are near normal/negative, Enbrel could then be considered as a possible therapy with very careful monitoring.For the reasons 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 52-year-old female status post bilateral below the knee amputations and multi-digit distal phalanx amputations. She is requesting reimbursement for an Electra-Ride III stairlift that was purchased to assist with stair mobility in the home. The Health Plan has denied this request indicating the equipment at issue was not medically necessary for the patients mobility.The Health Plans denial should be upheld. The submitted clinical evidence does not demonstrate the Electro-Ride III stairlift is required for the patient to move between floors in her home. The information provided indicates the patient has the demonstrated ability to ascend and descend three flights of stairs. As such, the equipment at issue was obtained for convenience purposes rather than out of necessity. Therefore, I have determined the equipment at issue was not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old female status post gastric bypass with a stated 125-pound weight loss. She had a previous panniculectomy for intertrigo after her weight loss stabilized. In the postoperative period there were healing problems, which have resolved with a less than desirable scar. The patient is not satisfied with the appearance of the panniculectomy and has sought authorization from her Health Plan for a revision procedure. The Health Plan has denied this request on the basis that the requested procedure is not medically necessary.Received and reviewed were the patients medical records and color photocopies of photographs of the patient and her abdominal wall, which confirm the difficulties with the postoperative wound.  The size of the pannus does not present a functional problem. There is no evidence of untreatable intertrigo or rash. Therefore, 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: Upheld Decision of Health Plan

The patient is a 2-year 11-month-old female with a history of global developmental delay including a delay in ambulation until age 2. She has a history of recurrent otitis media with effusion and underwent bilateral tympanostomy and adenoidectomy at age 19 months. She has a history of esotropia. An MRI of the brain was within normal limits but according to the neurologist the patient showed delays in personal, social fine motor, and gross motor skills. At issue is whether continued speech therapy is medically necessary.Review of the relevant medical literature reveals no connection between hearing, speech loss and global developmental delay. It is certainly possible that the patient had hearing losses, but such losses were never documented before or after the tympanostomy and adenoidectomies. It is more probable that the speech loss is associated with the patients developmental delay. Speech therapy for the treatment of such a delay is educational rather than medical in nature. 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 has idiopathic short stature (ISS) in that he is below the 1st percentile for height and weight and has a poor growth velocity of 2.82 cm/year, but has normal growth hormone dependent IGF-1 and IGFBP-3 levels, normal thyroid tests, and a negative celiac screen. His predicted adult height based on a recent bone age of 11.5 years at a chronological age of 11 years and 3 months is 52. The patient has been examined by a pediatric endocrinologist who has recommended initiation of growth hormone therapy. The Health Plan has denied coverage for the proposed therapy on the basis that it is not medically necessary for treatment of the patients medical condition.As stated above, the patients predicted adult height is 52. As such, he fulfills the FDA guidelines of July 2003 for growth hormone therapy for ISS. The patients IGF screens document that he is not growth hormone deficient. He also fulfils the FDA intent that he be treated under the supervision of a pediatric endocrinologist. Growth hormone therapy for this patient is medically appropriate and indicated. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.