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

The patient is a 52-year-old female who is status post gastric bypass in January 2003, which resulted in a 100-pound weight loss. She now has an abdominal pannus. The patient states she experiences painful skin irritation as a result of the excess skin. She has requested authorization and coverage for a panniculectomy. The Health Plan has denied this request indicating the requested procedure is not medically necessary.Based upon the documentation provided, the patient does not meet medical necessity criteria for a panniculectomy. The patients panniculus does not hang to or below the level of the pubis. Furthermore, there is no clinical evidence or documentation of intertrigo. Therefore, I have determined that 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 has a history of bilateral axillary hyperhidrosis. In August 2001, the patients provider noted the patient had been experiencing recurrent episodes of skin irritation and offensive order. The patients provider also noted the patient had attempted over-the-counter medications without relief. After discussing available treatment options, the patient decided to proceed with surgical intervention. In August 2001, the patient underwent bilateral suction curettage of the dermis axillary skin. The Health Plan has denied reimbursement on the basis of medical necessity.The patient underwent surgery for the treatment of hyperhidrosis in August 2001. No pathology report of the specimen removed was included with the information submitted. Furthermore, the information submitted does not demonstrate the patient attempted and failed conservative treatment options. In the treatment of hyperhidrosis, given the potential risks and side effects associated with surgery, nonsurgical management should be exhausted prior to consideration of surgery. Furthermore, there is a question as to whether the surgery performed was the most appropriate surgical technique for correction of the patients hyperhidrosis. Because there is no evidence the patient attempted and failed available nonsurgical treatment options, I have determined 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: Overturned Decision of Health Plan

The patient is a 37-year-old male with a history of waking from sleep with a rapid pulse rate and difficulty breathing. He also has a history of hypersomnolence, vivid nightmares, and headaches. Chart notes also relate a history of snoring and witnessed apneas. Possible diagnoses for this patient have included asthma, gastroesophageal reflux disease (GERD), and obstructive sleep apnea (OSA). Evaluation by an otolaryngologist resulted in a diagnosis favoring GERD and the patient was started on Prevacid. A gastroenterologist evaluated the patient and did not agree with a diagnosis of GERD, but recommended an upper GI series for further evaluation. The gastroenterologist also noted the possibility of SVT associated with the patients known mitral valve prolapse. The patient had a polysomnography showing no significant evidence of sleep apnea with a RDI of 2.3 and oxygen saturation at 93%. However, the patients sleep pattern was noted to be consistent with upper airway resistance syndrome. In addition, the patients arousal index was elevated at 21.4 and his Epworth scale was 12. CPAP has been recommended for the patient. The Health Plan has denied this request. Although the patient does not meet criteria for the diagnosis of sleep apnea, he does meet criteria for the diagnosis of upper airway resistance syndrome (UARS). The Milliman Care Guidelines state that CPAP may be indicated with either home or sleep center titration for patients with an RDI greater than five or patients with UARS and unexplained EDS with typical UARS findings. This patient has UARS with an elevated arousal index and Epworth scale and as yet unexplained EDS. As such, the patient meets accepted guidelines for consideration of CPAP. Therefore, the patient should be provided a three-month trial of CPAP to determine whether it is useful in treatment of sleep disorder. If his condition does not improve after the trial, CPAP should be discontinued.Based upon the information set forth above, I have determined the requested therapy 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 49-year-old female who has a history of bipolar disorder, depression and anxiety. She had a manic episode in 2002, which resulted in incarceration and hospitalization. Recently, she lost her job due to her behavioral health problems and has low self-esteem. She had been receiving outpatient psychotherapy from December 2003 to April 2005 and has requested authorization for continuation of her therapy. The Health Plan has denied this request indicating the requested therapy is not medically necessary.Treatment of acute mood disorders requires both pharmacologic and psychotherapeutic methods for optimum treatment and both are standard of care. In this case the patient appears to be undergoing an acute crisis (loss of job). She has a history of state hospitalization for a severe manic episode. Based upon the information provided, it appears she has been relatively stable for four years. The patients psychologist does seem to document a worsening of symptoms as of April 2005. Yet, it appears the patient has not recently been seen by her psychiatrist. Optimal care involves coordination of care between the patients psychiatrist (providing medication management) and her psychologist. Based upon the information set forth above, I have determined the requested therapy is not medically necessary at this time. The Health Plans denial should be upheld at this time. However, the patient should be re-evaluated by her psychiatrist to determine if continued psychotherapy is warranted. If the patients psychiatrist indicates continued psychotherapy is medically indicated, the requested therapy should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 67-year-old male who is status post hip replacement and cerebral vascular accident with left-side hemiparesis. He has been receiving physical therapy since July 2004 with slow but steady gains and improvement. Initially the patient required moderate to maximum assistance with transfers, ambulated with a walker, had impaired balance, and had impaired left extremity strength. The most recent therapy notes provided indicate the patient ambulates with a quad cane and has had some improved strength in his left extremities. He can climb stairs, but not independently and with safety concerns. He continues to exhibit problems with his gait and continues to have impaired balance. The patient is seeking continued physical therapy. The Health Plan has denied this request.Based upon the information provided, it is unclear whether the patient continued to receive physical therapy after March 2005. Review of the submitted clinical notes demonstrates continued supervised physical therapy is medically necessary. The records demonstrate the patient was continuing to improve with balance, his ability to ascend and descend stairs, and to ambulate with the least invasive ambulation device possible. Furthermore, continued supervised therapy was indicated to minimize and/or eliminate the patients gait deviation. Based upon the records provided, the patient has not reached maximum potential function and has the potential for significant improvement in the above noted areas. Such improvement is not likely to be achieved for this patient through a home exercise program of unsupervised therapy. Therefore, I have determined an additional six weeks of physical therapy is medically necessary for the patient. At the end of this period the patient should be re-evaluated to determine whether discharge to a home exercise program would be appropriate.Based upon the information set forth above, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 16-year-old male with a history of depression, and bipolar disorder as well as drug use. He has attempted suicide twice within a four-month period. His medications include Depakote, Effexor, Dilantin, trazodone, and vitamin E. Psychological testing was performed to assess his risk of future suicide attempts. The Health Plan has denied coverage for the services at issue citing a lack of medical necessity.Psychological testing is not medically necessary to assess suicidal risk. Furthermore, such testing is not needed in order make or confirm a diagnosis of mood disorder. As such, there was no clinical indication for the psychological testing 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 47-year-old female with a history of whiplash from a bus accident in August 2004. She received 12 physical therapy visits. She had some improvement with therapy and is requesting additional physical therapy visits for her pain. Records indicate she has chronic cervicalgia. The physicians notes are not comprehensive. As of November 2004, the patients headache had resolved and her depression was stable in December 2004. The patient continued with therapies but records provide little evidence of progressive improvement. The symptoms continued with little change through January 2005.As of January 2005, the therapy at issue did not produce improved subjective or objective complaints. In addition, on-going exam findings have remained the same. Based upon a lack of improvement in the patients condition and no indications for on-going therapy in the records, it is evident therapy after January 2005 was not medically necessary. Therefore, 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 47-year-old female who developed a hematoma after a blood draw from the left antecubital region resulting in pain. She has continued arm pain. The physical therapy records provided show the patient had 44 visits. She has requested authorization for continued physical therapy. The Health Plan has denied this request indicating the requested therapy is not medically necessary.Review of the submitted physical therapy notes reveals the patients physical therapist instructed the patient in a full home-exercise program involving range of motion and strengthening exercises. The patient was discharged from physical therapy in December 2004 with goals reached. At that time, her range of motion was 150 degrees in flexion and 110 degrees in abduction. Based upon the documentation provided, the patient should be able to continue with her home program independently. Therefore, 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: Overturned Decision of Health Plan

The patient is a 43-year-old pregnant female with a history of bipolar disorder. The patients psychiatrist indicates the patient has been relatively unstable with depression that has affected her concentration, memory, and ability to work. In addition, the patient is currently being monitored off medications until the end of her pregnancy and into the post-partum period. The patient has requested authorization to continue to receive treatment from her current psychiatrist. The Health Plan indicates appropriate services are available from an in-network provider, and therefore, are not medically necessary.The patient has had a long-term relationship with her current psychiatrist. The patient is currently stable, however, she is pregnant. It is not in the patients interest to disrupt continuity of care at this juncture. Clinical monitoring by a psychiatrist familiar with the patient is essential during pregnancy in a patient with a history of bipolar disorder. Thus, the patients psychiatrists request to follow the patient through delivery and into the post partum period is medically reasonable and standard of care. Therefore, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should continue to be followed by her current psychiatrist for a six-month period following delivery.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 17-year-old male who has a history of spinal stenosis, degenerative disc disease, spinal radiculopathy, and facet arthroplasty. He underwent lysis of epidural adhesions in December 2004. The Health Plan has denied reimbursement for the procedure stating it is experimental for treatment of the patients back pain.The requested procedure is not standard of care and is of unproven efficacy. There is no class I literature to support lysis of adhesions at this time. The patient was likely to receive greater benefit from standard therapies. Therefore, I have determined that the procedure at issue was 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: The patient is a 17-year-old male who has a history of back pain as a result of spinal stenosis, degenerative disc disease, spinal radiculopathy and facet arthropathy. In December 2004, he underwent percutaneous lysis of adhesions. His parent is requesting reimbursement for the procedure at issue. The Health Plan has denied this request on the basis the efficacy of lysis of epidural adhesions has not been established.There is no clear evidence demonstrating the efficacy of lysis of epidural adhesions. This procedure is not the standard of care and remains investigational. Determination of its clinical worth awaits performance of blinded, controlled trials to establish true benefit. Consequently, the patient was likely to obtain superior results with standard therapy.  Therefore, I have determined that the procedure at issue was 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 17-year-old male who has chronic low back pain. The patient has undergone several pain management techniques including lysis of epidural adhesions. The patients parent has requested reimbursement for this procedure. The Health Plan considers the procedure at issue experimental in nature.The Health Plans denial should be upheld. This patient has chronic low back pain. Percutaneous lysis of epidural adhesions has not been proven to be effective for treatment of patients such as this patient. There have been no class I trials demonstrating the long-term efficacy of lysis of epidural adhesions for treatment of the patients condition. Accordingly, I have determined that the procedure at issue was 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: Overturned Decision of Health Plan

The patient is a 57-year-old female with a history of depression with associated vegetative symptoms including daytime fatigue. Her daytime fatigue apparently did not respond well while being treated with methylphenidate and Wellbutrin. Thereafter, the patient was tried on Provigil and fluoxetine. This combination of medications has improved the patients condition markedly. The Health Plan has denied coverage for Provigil.Prior to Provigil, the patient was tried on stimulant medication and SSRI agents without significant benefit. The patient is benefiting from her current medication regimen. There is sufficient evidence in the medical literature to support Provigil as useful as an adjunct medication for the treatment of the vegetative symptoms associated with mood disorders. Based upon this evidence and the patients clinical response, I have determined Provigil is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 38-year-old female who is status post massive weight loss after gastric bypass surgery performed in April 2003. She is requesting authorization and coverage for bilateral mastopexy and brachioplasty. She has been evaluated by her plastic surgeon for treatment of intertrigo of the inframammary folds caused by the hanging deflated breasts. The surgeon evaluated the patients condition and recommended mastopexy to relieve the symptoms.  In addition, the patient wishes to undergo body contouring for her hanging skin on her arms (brachioplasty). The Health Plan has determined bilateral mastopexy and brachioplasty are not medically necessary for the patients condition.Review of the submitted medical records and photographs of the patient demonstrate bilateral asymmetric pendulous breasts with intertrigo. The abdominal pannus is modest, though its hanging position is exaggerated by the angle of the photographs. There is no documentation of any significant redundancy of arm skin. There is documented evidence of intertrigo of the breast area that has been refractory to conservative management. Thus, a mastopexy is medically warranted to relieve the patients functional impairment. However, the proposed breast augmentation is considered cosmetic in this case and is not medically necessary. Furthermore, there is no medical necessity for the requested brachioplasty based on the information provided. Accordingly, I have determined that although the requested mastopexy is medically necessary for treatment of the patients medical condition, the requested brachioplasty is not medically necessary for treatment of the patients 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 12-year-old male with Duchenne muscular dystrophy who has transitioned into a wheelchair. It appears the patient currently has a power wheelchair, which he uses for community mobility and a manual wheelchair, which he can propel less than 100 feet. The patients parents have requested authorization for an E-Motion Power Assist, a device to allow him to use his manual wheelchair in the community to assist with exercise and to improve his mobility on incline carpets and varied terrain. In addition, a request has been made for authorization for an Easy Stand 5000 with motion option and attachments.At issue is whether the requested equipment is medically necessary for treatment of the patients medical condition.Regarding the E-Motion Power Assist, there is no literature directly evaluating the use of power assist devices in Duchenne muscular dystrophy. If the only issue were community mobility the patients current wheelchair would be sufficient. However, the power assist device has the added advantage of allowing patients such as this patient some ability to exercise. There is evidence that exercise provides some benefit to patients with muscular dystrophy. Since the requested equipment will be used for community mobility and as exercise equipment, it is medically appropriate and indicated for this patient.Regarding the Easy Stand 5000, it is a standing frame, which is a static device that holds the person in a standing position and does not require muscle activation to maintain the position; therefore, a standing frame does not improve muscle strength. Rather, a standing frame uses the positioning of the straps to provide a prolonged stretch to improve range of motion and uses the landing forces of the patients weight on the joints to improve bone density. In the case of this patient, a standing frame is medically necessary. However, the submitted information does not include an equipment evaluation for a standing frame. In the absence of such an evaluation, it has not been established that the Easy Stand 5000 is medically necessary. Furthermore, a mobility base is generally considered a convenience item and is not medically necessary.The patient should be formally evaluated by a therapist to determine the type of standing frame that is medically appropriate and indicated for this patient. Thus, although a standing frame is medically necessary, at this time there is insufficient evidence the requested Easy Stand 5000 is medically necessary.Based upon the information set forth above, I have determined that an E-Motion Power Assist is medically necessary for treatment of the patients medical condition. In addition, I have determined that although a standing frame is medically necessary, it has not been established that an Easy Stand 5000 is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 42-year-old female who was seen by a podiatrist in February 2005 for thickening of the right hallux nail. The patient states the toenail is painful and cracked. She also reports the toe is red and swollen with resultant pain and difficulty with walking and wearing shoes. Chart notes indicate severe thickening and yellow discoloration of the toenail. Lamisil has been recommended. The Health Plan has denied authorization because the diagnosis of onychomycosis has not been confirmed through appropriate testing.The Health Plans denial is correct. Although the patients clinical presentation is strongly suggestive of onychomycosis, further testing (KOH, fungal culture or nail biopsy) is necessary to confirm the diagnosis and establish the need for Lamisil. If appropriate testing confirms a diagnosis of onychomycosis, Lamisil should be authorized. However, at this time Lamisil cannot be authorized because of the lack of a confirmed diagnosis.Based upon the information set forth above, I have determined the requested medication is not medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time. If a diagnosis of onychomycosis is confirmed through appropriate testing, Lamisil should be authorized.