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

The patient is a 56-year-old female who has a long history of neuropathy. In addition, she also has peripheral vascular disease, carpel tunnel syndrome, and a rotator cuff tear. She has been wheelchair bound for two years. The patient has requested authorization and coverage for a power-operated vehicle (POV). The Health Plan has denied this request on the basis that the requested equipment is not medically necessary for the patients mobility.Review of the submitted records does not demonstrate a POV is a medical necessity for this patient. In June 2004, the patients provider indicated the patient had 5/5 strength in her upper extremities. He further indicated he did not believe the patient required a POV. A note from the patients physical therapist dated 4/14/04 reports the patient has 4/5 in lower extremity strength, 4/5 in upper extremity strength, and fatigues quickly. The note indicates the patient would benefit from a POV since she is unable to walk from the parking lot to a restaurant or shopping location. The notes also state the patient has had difficulty propelling her current wheelchair on carpeted surfaces due to shortness of breath. There is no documentation regarding the patients stage of asthma or functional classification of heart disease. Furthermore, there is no documentation of the severity of the patients carpel tunnel. Moreover, the submitted physical therapy evaluation provides no indication the patient was experiencing any difficulty maneuvering her wheelchair into rooms of her house. The patients documented 4/5 upper extremity strength should allow her to propel a manual wheelchair, albeit slowly, within the home. Carpets can be taken up if they create difficulty with mobility. Based upon the information set forth above, I have determined that the requested equipment is 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 53-year-old female with a bone mass density of the spine that is in normal range and a bone mass density of the greater trochanter of the hip that is barely in the osteopenic range and still within the usual accepted normal range of two standard deviations from the mean. The patients provider has recommended Miacalcin nasal spray (Miacalcin). The Health Plan has determined Miacalcin is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Miacalcin has not been found to be beneficial in prevention of hip or osteopenic spine fractures. Miacalcin is indicated only for treatment of osteoporosis not for prevention of fractures. Based upon the patients bone mass density, there is no indication for preventative measures or treatment at this time. Therefore, I have determined that 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 55-year-old woman who was diagnosed with osteoporosis following a Lunar DEXA scan in February 2002. Subsequently, the patient was started on Evista with an apparent increase in bone mineral density of 3% at the lumbar spine and 5% at the hips 20 months later on a similar DEXA machine. Evista was then apparently discontinued sometime thereafter. A repeat scan seven months later revealed no essential change with a T-score of -3.3 at the hips, and a 2.1% increase to a T-score of -2.4 at lumbar spines L1-L3.The patient has declined the bisphosphonates suggested by the Health Plan and wishes to start Forteo. The Health Plan has denied the patients request indicating that Forteo is not medically necessary for treatment of the patients osteoporosis.Review of the relevant medical literature indicates the patient does not meet medical necessity criteria for Forteo. The submitted records indicate the patient has no fragility and no apparent risk factors beyond her T scores. In addition, there is no evidence the patient has failed all other treatments (such as bisphosphonates). Furthermore, the patient does not have very severe osteoporosis (usually defined as T-scores greater than -4.0) or other high risks for fractures such as old age, family history of hip fractures or smoking. The literature suggests Forteo should be reserved for women who meet one of the above criteria.If the patient does not wish to continue on Evista, a bisphosphonate is a reasonable alternative and is medically appropriate. There is no medical indication for use of Forteo at this time. Therefore, I have determined that the requested medication is not medically necessary for the 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 41-year-old obese female with a history of diabetes and hypertension. The patient reports her body mass index (BMI) is 37. The Health Plan indicates the patients last documented BMI was 33. The patient has requested authorization for a consultation with a bariatric surgeon. The Health Plan has denied the patients request on the basis that weight loss surgery is not medically necessary for treatment of the patients obesity.Review of the submitted documentation reveals the patients current BMI is not known. If the patients BMI is 37, weight loss surgery may be medically indicated in light of the patients significant comorbid conditions of diabetes and hypertension. However, if the patients current BMI is less than 37, there is potential that further attempts at conservative weight loss may be successful and therefore, the requested consultation is not medically indicated.Based upon the information set forth above, I have determined that the requested consultation is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patients current BMI should be obtained. If the patients BMI is 37 or above, the requested consultation should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 58-year-old female with morbid obesity, pulmonary hypertension, cardiac arrhythmias, and arthritis. She has failed medical management. The submitted records indicate the patient is receiving anticoagulants because of cardiac disease. She has been deemed appropriate for bariatric surgery. It does not appear the patient has undergone a psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. She wishes to undergo gastric bypass with duodenal switch. The Health Plan has denied authorization for the procedure on the basis it is not medically necessary.In light of the severity of the patients cardiac disease and her need for continued anticoagulants, a malabsorptive procedure such as the duodenal switch procedure is more appropriate than conventional gastric bypass. There is a significant risk of marginal ulceration with the standard gastric bypass that does not appear to be present in the duodenal switch procedure. Furthermore, there is sufficient data to show that duodenal switch has a superior long-term outcome when compared to the gastric bypass procedure. However, although medically the patient meets criteria for consideration of the duodenal switch procedure there is no evidence the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. As such, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the requested procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the requested procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a seven-year-old female who has been receiving speech therapy since the age of two for speech delay. The results of an initial evaluation document both a receptive and expressive deficit with resolution of the deficits to within normal limits on follow-up testing. Because both receptive and expressive language was found to be within normal limits, an individual education plan was not established through the school system. The patients hearing test appears to be normal. A request has been made for reimbursement for speech therapy services from 1/6/03 through 5/27/03. The Health Plan has denied coverage for the therapy at issue on the basis that speech therapy was not medically necessary for treatment of the patients condition after December 2002.Upon review of the literature regarding auditory processing disorders there is no support for active therapy in a patient with expressive and receptive language skills that are within age appropriate norm. The patients test results reflect some deficiencies in auditory comprehension; however, there is no evidence speech therapy can improve these deficiencies within a reasonable amount of time. To date, no adequate scientific studies have documented the efficacy of speech therapy on these deficits. Therefore, I have determined that 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 57-year-old male who has adenocarcinoma of the kidneys with metastatic disease to the lung and retroperitoneum. He has requested reimbursement for human tumor cell in vitro chemoresistance assay services he received in December 2003. The Health Plan has denied the patients request indicating the services at issue were not medically necessary.Review of the medical literature does not support the use of chemoresistance assays for patients such as this patient. A recent article in the Journal Of Clinical Oncology concluded, the use of chemotherapy and resistance assays to select chemotherapeutic agents for individual patients is not recommended outside of the clinical trial setting. This statement summarizes the current status of the use of in vitro cell based assays, (including those involved in this patients case) to select chemotherapeutic agents for treating tumors. There is no clinical trial that is scientifically valid, which supports the routine use of such assays in renal cell cancer. Though there is interest in determining whether such assays may play a role in the future, to date they are of unproven efficacy. Furthermore, the combination of gemcitabine and Xeloda has been reported to have some efficacy in kidney cancer and it appears the combination could have been used in this case without in vitro sensitivity testing. As such, there was no medical indication for the services at issue.Based upon the information set forth above, I have determined that 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: Upheld Decision of Health Plan

The patient is a 50-year-old male with asthma who has requested authorization and coverage for an additional albuterol inhaler. He has a past medical history of asthma and hypertension. According to a progress note dated 4/15/04, the patient had been using albuterol MDI about two puffs four times daily. The patients physician had discussed use of Serevent for better asthma control but the patient wanted to consult an allergist before changing his regimen. The allergist continued the use of albuterol and had hoped to wean the dose after addition of Qvar.In June 2004, the patients physician stated the patients asthma was not under good control and the physician was concerned about the amount of albuterol being used by the patient. The physician also stated the patient needed better follow-up. A progress note dated 8/30/04 showed the patient was continuing to use albuterol more than two puffs four times daily.The patient has requested authorization for an additional albuterol canister. He states the three-month supply he receives (three MDI canisters) only lasts him two-and-a-half months. At issue in this case is whether an additional albuterol MDI canister is medically necessary for treatment of the patients medical condition.According to the National Asthma Education and Prevention Program (NAEPP) 2002 Update, patients who have symptoms requiring use of a fast-acting inhaler (such as albuterol) more than two times per week are not under good control. The recommendation for such patients is for controllers such as inhaled corticosteroids, leukotriene modifiers, long-acting beta-2 agonists, theophylline or systemic steroids.Since the patient is using albuterol on a daily basis, according to NAEPP Guidelines, he needs to be placed on several controller medications. It appears the patient is currently only on Qvar. The patient needs to be placed on a long-acting beta-2 agonist such as Serevent or Foradil in order to decrease the use of albuterol.Studies have shown that use of more than one albuterol MDI canister per month is associated with higher asthma mortality. The patients asthma is not under good control and the use of more albuterol puts the patient at higher risk for morbidity and mortality. The patient needs to be placed on additional asthma controller medications as has been recommended by his physician. Therefore, I have determined that the requested prescription is not medically necessary for the 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 17-year-old female with previously diagnosed dysthymic disorder, oppositional defiant disorder, and borderline intellectual function The patient was previously psychiatrically hospitalized in March and July of 2003 due to increasingly aggressive behavior and anger outbursts. A review of past records indicates anger and insubordination have been ongoing problems since the age of three, but have grown measurably in adolescent years. This has included unprovoked choking of her sister, shoving family members, non-compliance with rules at home and at school, lying, stealing, and killing cats, all of this without remorse. The patient later claimed some of her actions such as the killing of the cats were spurred by voices, typically that of a man, urging her to do so. However, in reporting her actions the patient was noted as matter-of-fact, only later adding that she was trying to break the habit of animal murder. Some of her aggression has also varied between parents.  Typically, the patient is more compliant with her adopted father than with her adopted mother. Other problematic behaviors have included some fire setting at home, intrusion into other peoples space, and loud speaking. An evaluation by her social worker reports the patient herself feels that she has no guilt or remorse, will do anything to get what she wants, has no regard for consequences, is aggressive, and plays one person against another. The hospital records from the patients prior two admissions do not indicate that residential treatment was necessary. At issue is whether residential psychiatric treatment services are medically necessary for treatment of the patients medical condition.While the patient may be suffering from dysthymic disorder and perhaps even bipolar disorder, she seems to have a fairly pronounced conduct disorder, rather than simply oppositional defiant disorder. It appears there is premorbid genetic loading for conduct disorder, given what is known about her biological parents pathology. Her actions are certainly egregious and of concern. However, none of the psychiatric records point to the patients symptoms being so robust as to warrant residential treatment. Out of home placement may be an option for the patient, given what is known about her behavior in the context of her adoptive mother versus that with her adopted father; however, this should not be confused with a need for residential treatment per se. As reflected in the patients psychiatrist note of 8/14/03, the patient does not require the level of structure found on a residential unit. Importantly, no up-to-date clinical information has been submitted to support the request for residential treatment. In the absence of such information, residential treatment cannot be supported.Based upon the information set forth above, I have determined that the requested services are not medically necessary for the treatment of the patients medical condition. Therefore, 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 with a body mass index (BMI) of 46 and obesity related comorbidities. She has requested authorization for bariatric surgery. She has obtained psychiatric clearance for weight loss surgery. The Health Plan has denied authorization for gastric bypass on the basis it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 46 and comorbid conditions such as diabetes mellitus and hypertension, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. Therefore, 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: Upheld Decision of Health Plan

This patient is a three-year-old male with a history of chronic ear infection requiring ear tube placement. The patient also has a history of moderate to severe delayed speech and language production. He had been receiving speech therapy once weekly with some goals being met. Of note, the patient missed multiple visits due to ear infections. Since that time he has been receiving speech therapy three times per week. The patients provider has noted multiple improvements in word production, but functional use of these words to communicate the patients wants and needs was inconsistent at the time of the follow-up evaluation. The patients therapist is recommending one-hour speech therapy sessions three times per week. At issue is whether it is medically necessary for the patient to receive three speech therapy sessions per week to improve his verbal apraxia.Review of the medical literature does not reveal any studies evaluating the frequency of speech therapy for patients such as this patient. The Health Plan has authorized speech therapy at a frequency of twice per week. There is no evidence that speech therapy three times per week results in a better clinical outcome than speech therapy two times per week. Therefore, the services authorized by the Health Plan are medically reasonable and appropriate and sufficient to treat the patients apraxia. As such, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Review of the patients records demonstrates the patient has previously received physical therapy for her condition without improvement. The patient began receiving physical therapy involving manual therapy techniques in November 2003. The submitted treatment notes indicate the patient experienced some ups and downs in her condition, but there is no documentation of any objective improvement (e.g., ability to sit for longer periods of time or tolerate intercourse). In a letter dated 4/16/04, the patient indicated she had recently begun to experience some improvement in her symptoms. She has requested authorization for continued physical therapy utilizing manual therapy techniques. The Health Plan has denied her request indicating the requested therapy is not medically necessary for treatment of the patients medical condition.The submitted medical literature does not contain any research studies establishing manual therapy is of proven benefit for the patients condition. The articles primarily discuss the validity of vulvodynia and summarize treatments that have been used. In addition, a review of the relevant literature demonstrates there is no case-controlled, randomized study supporting the efficacy of manual therapy techniques. Furthermore, the submitted therapy notes do not document objective improvement or indicate end points to treatment. Thus, there is no medical indication for continuation of the requested therapy.Based upon the information set forth above, I have determined that 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 34-year-old female who has requested reimbursement for fragile X testing. The patient indicates she has a maternal half-sister with attention deficit disorder. As a result, a genetic counselor recommended the patient undergo fragile X testing. The Health Plan has denied coverage for the services at issue on the basis that fragile X testing was not medically necessary.The Health Plans denial should be upheld. While the patient has a maternal half-sister with attention deficit disorder, she does not have a family history of fragile X syndrome or mental retardation. The Health Plan criteria for fragile X testing is medically reasonable and appropriate. The patient does not meet the Health Plans established risk criteria. Furthermore, review of the submitted evidence does not reveal any medical indication for the services at issue. Therefore, I have determined that 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

The patient is a 44-year-old obese female who is requesting a consultation with a plastic surgeon for treatment of mammary hypertrophy associated with her obesity. The patients provider has recommended the patient lose weight to control her comorbid condition of hypertension. The Health Plan has denied authorization for the requested consultation on the basis that it is not medically necessary for treatment of the patients medical condition at this time. Review of the submitted clinical information reveals the requested consultation is not medically necessary at this time. Though it appears breast reduction surgery may be necessary to treat the patients mammary hypertrophy in the future, it is not medically indicated at this time in light of the patients current weight. The recommendation that the patient lose weight prior to pursuing surgical treatment of her mammary hypertrophy in the future is medically reasonable and appropriate and will improve the likelihood of a successful outcome. Therefore, I have determined that the requested consultation is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld.