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

The patient is a 41-year-old female with severe rectus diastases documented by multiple physicians and therapists. She has had three successful pregnancies since June of 1999 and reports constant lower back pain resulting from weak stomach muscles and strain on her back. The patient had weekly chiropractic adjustments which did not help her condition.  She reports constant back strain and pain in her abdomen and she had to wear a support belt for her lower back and stomach; lifting even small items was difficult. The patient also worked with a personal trainer but the exercise program was ineffective in relieving her lower back pain. A recent examination revealed weak rectus abdominal muscles with protrusion of the anterior abdominal wall. No definite bowel herniation was present. Her chiropractor reported the patient had been unable to reestablish normal abdominal muscle tone and strength leading to spinal instability and recurrent pain.  The patient was noted to be 145 pounds and 51 tall. She proceeded with abdominoplasty in Ocotober 2006 and is now requesting reimbursement. The Health Plan denied her request citing a lack of medical necessity.There is no other diagnosed medical condition to explain the patients persistent lower back pain except her rectus diastases. The Health Plan identifies three criteria which must be satisfied for authorization of abdominoplasty: the patient must (1) provide photographic documentation of her condition; (2) show signs and symptoms associated with significant rectus diastases and or hernia; and (3) provide documentation of extensive diastases of the rectus abdominis muscles along with notes showing the types, duration and responses to various medical therapies. The patient has satisfied these three criteria and the American Society of Plastic Surgeons (ASPS) position paper supports the reconstructive nature of abdominoplasty in this instance. The ASPS indicates that `abdominoplasty is considered reconstructive when performed to correct or relieve structural defects of the abdominal wall and/or chronic low back pain due to functional incompetence of the anterior abdominal wall. The position paper further indicates that pregnancy may cause this condition, as it has in this case. Abdominoplasty was an appropriate intervention for the treatment of the patients lower back pain.Based upon the information set forth above, I have determined the procedure at issue was 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

This patient is a 59-year-old male with osteoarthritis involving the left knee. He received his first series of hyaluronan injections in 2002, which helped to relieve the pain in his knee. He received two additional series of hyaluronan injections over the past few years, both with positive results. At his point in time, his pain has returned and he has requested authorization for a fourth series of injections with Supartz. The Health Plan denied this request on the basis that Supartz therapy is not medically necessary for treatment of his osteoarthritis.The patient has achieved significant pain relief with hyaluronan injections. There have been no documented side effects or other complications from the therapy over the past several years. He is attempting to delay knee replacement surgery as long as possible. Repeat hyaluronan injections are medically reasonable and appropriate at this time to alleviate his pain and postpone surgical intervention. Therefore, I have determined the requested Supartz injections are 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 25-month-old female with a history of global developmental delay, esotropia, ptosis, hyperopia, and hypotonia.  She is status post a strabismus surgery and surgery to correct the ptosis. She wears glasses. She also has severe receptive and expressive language delays. The patient has been receiving speech therapy since April 2006. At issue is whether speech therapy is medically necessary for the patients developmental delays.Review of the relevant literature reveals no evidence to support that the patients vision issues are or can be a direct cause of speech delay. Rather, it appears the speech delay is part of a constellation of deficits associated with global developmental delay. Furthermore, no medical evidence from the patients ophthalmologist, geneticist or a pediatric neurologist is provided documenting that the speech deficits are associated with a disease, trauma or prior therapeutic intervention. The documentation from the speech therapist does not demonstrate the expectation that speech therapy will achieve measurable improvement in the patients condition in a reasonable and predictable period of time. Based on the information in the submitted reports the patients progress has been minimal and it does not appear likely that improvement will be seen in a reasonable and predictable period of time. Therefore, 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 an 11-month-old male with a history of bilateral profound sensorineural hearing loss. The patient had a CT scan, which showed hypoplasia of the cochlea with very small internal auditory canals. The CT scan report indicates there is an absence of cochlear nerves, however, as the patients provider points out the patients responses to ABR testing supports the presence of at least some cochlear nerve fibers. The patients provider has recommended the patient undergo simultaneous bilateral cochlear implantation. The Health Plan has denied authorization for the procedure indicating the patient does not meet criteria for the procedure as he is under the age of one year.Despite the fact that there is some literature showing the value of bilateral cochlear implantation, cochlear implantation performed on both ears simultaneously is not standard of care. Furthermore, there is no peer-reviewed literature demonstrating the benefits of bilateral cochlear implantation in patients such as this patient with severe malformation of the ear. However, it does appear the patient is a candidate for unilateral cochlear implantation in the better ear (as determined by his cochlear implant team). The patient should be re-assessed after the unilateral cochlear implant procedure to determine if he has benefited from the procedure prior to consideration of a second cochlear implant.Based upon the information set forth above, I have determined that although bilateral cochlear implantation is not medically necessary for treatment of the patients medical condition, unilateral cochlear implantation is 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 27-year-old male who had an 18-month history of low back pain. He underwent an MRI scan which revealed a small disc bulge at L5-S1, and a technetium-99 bone scan which was essentially normal. The patient was referred for facet injections which provided no relief and subsequently he was treated with a sacroiliac (SI) joint injection under fluoroscopy which provided pain relief. The patients request for reimbursement for the SI joint injection was denied by the Health Plan based upon a determination that the procedure was not medically necessary.Based upon a review of the records, is does not appear that the patient had significant radiculopathy or that he underwent a course of conservative therapy prior to the SI joint injection. In situations such as this one, a trial if anti-inflammatory medications, analgesics, physical therapy or chiropractic manipulation is generally appropriate. Conservative measures should have been exhausted prior to any course of interventional injection therapy being performed. Therefore, I have determined the procedure 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 42-year-old female who was evaluated by a surgeon in June 2006 for breast pain, cysts and nodularity. She also provided a history of a greenish-brown discharge expressed from the right breast. There is no family history of breast cancer noted in the record. On physical examination, there was asymmetry in the upper inner quadrant of the right breast with a suggestion for a 3cm to 4cm mass. Bilateral breast ultrasound performed in February 2006 showed benign-appearing bilateral nodules and an inframammary lymph node in the right breast. A six-month follow-up ultrasound was suggested. There is no report of a recent mammogram. The patients provider has recommended an MRI of the breasts for further evaluation. The Health Plan denied the patients request for authorization based upon a determination that bilateral breast MRI is not medically necessary.There are several indications for MRI of the breast which include a determination of the pre-operative extent of cancer, post-operative residual cancer, the extent of lobular cancer, the identification of an occult primary cancer with positive axillary lymph nodes, the screening of high risk patients, and problem solving. An indication for non-malignant disease is the evaluation of breast implants. High risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or BRCA 2 gene. High risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar or prior mantle radiation. This patient does not have any of the above-mentioned indications for a breast MRI and she is not at sufficient risk to be considered for screening at this time. Therefore, I have determined the requested MRI is 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 53-year-old male with the diagnosis of localized prostate cancer staged as T1C with Gleason grades 6 and 7. The patient presented with an elevated PSA indicating the need for a biopsy. The prostate cancer was non-palpable but was identified in both lobes on biopsy. The patient consulted with a non-Plan specialist regarding treatment options, and is now requesting authorization for proton beam radiation therapy at a non-Plan medical center. The Health Plan denied the patients request based upon a determination that this therapy is not medically necessary.The definitive treatments for prostate cancer are either surgery or radiation therapy. Surgery is defined as radical prostatectomy, and radiation therapy can be delivered as either external beam or in the form of brachytherapy. The current standard of care for radiation therapy is intensity modulated radiation therapy (IMRT). Proton beam therapy is another form of radiation therapy using protons instead of photons. The literature shows no significant advantages in terms of cure or side effects when these two modalities are compared. In fact, some centers mix both conventional and proton therapy in one treatment plan since time on the machine is by necessity limited. When proton therapy was compared with the older 3D conformal radiation it did have fewer side effects, however the patient has been offered IMRT so this is not a relevant consideration. The patient can expect excellent results with low morbidity with IMRT. 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 50-year-old male with malignant paraganglioma. He has a history of metastatic disease and in addition to radiation therapy, has been treated with multiple rounds of chemotherapy. A recent CT scan showed probable liver metastases and new mesenteric lymph nodes. The patients tumor marker (chromogranin A) is also elevated. A PET scan has been requested to re-stage the patients disease and thereafter plan treatment alternatives. The patients request for authorization of the PET scan was denied by the Health Plan based upon a determination that it is not medically necessary.There has not been extensive research on malignant paraganglioma due to its rarity. However, a recent study by Fitzgerald, et al, concluded that combined PET/CT fusion imaging is currently the state of the art for accurately detecting and quantifying paraganglioma metastases.  In the past, PET imaging has been useful in planning the patients treatment. The extent of the metastatic disease needs to be accurately determined at this juncture, in order to plan the next phase of treatment. CT or MR imaging cannot determine the metabolic activity of this patients metastatic disease. PET imaging however, can determine the metabolic activity of the metastatic disease and facilitate the commencement of appropriate treatment planning. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a diabetic 56-year-old male who has undergone left below-the-knee amputation in 2004 as well as a right superficial femoral and peroneal artery angioplasty followed by a right great toe amputation in January 2006. The amputation site has not healed. An arteriogram shows multiple tibial artery stenosis.  The patient consulted a vascular surgeon who feels that an attempt at limb salvage using either percutaneous atherectomy (the Silverhawk device) or distal bypass to the pedal vessels using lesser saphenous vein, arm vein, or homograft vein would be appropriate. At issue is whether percutaneous atherectomy or small distal bypass is medically necessary for treatment of the patients medical condition.Percutaneous atherectomy with the Silverhawk device has not been proven to be equivalent to standard, open surgical bypass for this patients condition and therefore, is not medically necessary.  Although the Silverhawk device is FDA approved, there are no randomized, controlled trials with long-term follow-up to prove the safety and efficacy of this device.  A recent article by Rubin reviewing the current literature on the Silverhawk device concludes, Like many endovascular technologies, reports have focused on rates of initial technical success and short-term outcomes, but long-term results remain unknown. This report reviews selected published or presented results of plaque excision, touches on areas of concern or controversy regarding both the device and some of its proponents, and suggests clinical or anatomic settings in which plaque excision appears most effective. The ultimate utility of this technology will depend on confirmation of its acute and long-term outcomes through unbiased, well-designed clinical trials.Although there is insufficient evidence to support percutaneous atherectomy for this patient, below-the-knee amputation is not the patients only option. The consulting vascular surgeon has determined that standard treatment (distal bypass) is a valid treatment option for this patient. In a patient with a contralateral amputation, aggressive attempts at revascularization of the remaining limb for limb salvage are warranted. As such, small distal bypass is within the standard of care and medically necessary for treatment of the patients condition.For the reasons set forth above, I have determined that percutaneous atherectomy is not medically necessary for treatment of your medical condition, but small distal bypass is medically necessary for treatment of your medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old female who underwent arthroscopic surgery on her right knee in March 2006. A cold therapy unit was utilized post-operatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary.Cold therapy units are extremely useful post-operatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, she clearly experienced a benefit from use of the cold therapy unit following her surgery. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 44-year-old female who is 54 weighing 228 pounds. She is status post gastric bypass. She lost 128 pounds following the weight loss procedure but now wants further bypass surgery in order to attain a goal weight of 150 pounds. The patient is not on a clearly documented dietary restriction regimen. She has multiple medical problems, which she states prevent her from exercising, though she was provided a modified program that she has apparently not attempted. Additionally, the submitted records indicate the patient has been non-compliant in stopping her tobacco use.At issue is whether gastric bypass surgery is medically necessary for treatment of the patients medical condition. Despite nearly a 40% decline in weight with gastric bypass, the patient continues to seek passive weight loss without demonstrating any initiative on her part to lose weight. Reoperative surgery carries a substantial risk without any clear assurance of ultimate benefit. The patient would be at significant risk of malabsorption. Moreover, the patients depression seems to be a confounding factor and there is no documentation indicating the patient has undergone a psychiatric evaluation. All told, the clinical indications for gastric bypass surgery have not been met. 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 53-year-old female with a history of hepatitis C, genotype 1 who received a 48-week course of Pegasys and ribavirin, but relapsed. She then received a full course of Infergen and ribavirin, but relapsed again. The patients provider has requested authorization for low-dose, Pegasys (interferon) maintenance therapy. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.There is, at present, no data to support the efficacy of maintenance interferon therapy. In fact, consideration of the toxicity, particularly bone marrow toxicity, and the cost would make this agent a poor choice for maintenance therapy. There is currently an on-going study (HACT-C) which may provide more information on the best course of treatment for patients such as this one, but for now Pegasys maintenance therapy cannot be considered medically appropriate. 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 27-year-old woman with pain in the right leg associated with varicose veins. The pain interferes with her employment. There is no documentation of a trial of conservative therapy with compression stockings. A venous duplex exam showed no saphenofemoral reflux or deep system occlusion. On exam, there were two small varicose veins behind the right knee in the area of the patients complaints of pain. The patients provider requests authorization for surgical excision of the right leg varicose veins. The Health Plan has denied this request citing a lack of medical necessity.Saphenous vein reflux need not be demonstrated to warrant varicose vein surgery.  Symptomatic varicose branches certainly can exist without concomitant saphenous reflux. General practice guidelines in the specialty of vascular surgery dictate that symptomatic saphenous varicose veins warrant invasive treatment when the symptoms are severe enough to interfere with activities of daily living and are refractory to at least three months of conservative therapy including prescription compression stockings. In this patients case, there is no documentation of a trial of conservative therapy with compression stockings. A significant proportion of patients obtain adequate relief with compression alone. Thus, based on the evidence provided at this time, the requested surgery is not medically warranted. However, if the patient undergoes a documented trial of conservative therapy without adequate relief her request for surgical intervention should be reconsidered.As set forth above, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a 63-year-old male on chronic anticoagulation therapy for atrial fibrillation. This condition requires periodic PT/INR monitoring. The patient has requested non-Plan INR testing using a fingerstick procedure; something not routinely available in the Health Plans laboratory. The patient has expressed concern that routine venipuncture will compromise his veins. The Health Plan denied the patients request for authorization of laboratory testing with the HemoSense system at a non-Plan laboratory, citing a lack of medical necessity.A review of the literature found no studies related to the long term outcome of venipuncture for patient with on-going laboratory testing. However, long term warfarin therapy has not been associated with venous compromise. There is continuing controversy about the value of fingerstick procedures, and some equipment manufacturers have submitted data demonstrating acceptable results. Nonetheless, venipuncture remains the standard for INR testing. As such, I have determined the requested services are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.