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

This case concerns the treatment of a 13-year-old male with diagnoses of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). The patient has been treated at the partial hospitalization program (PHP) level of care since January 2006. The Health Plan covered the care until February 2006. The submitted records reveal that the patient was adopted shortly after birth.  He developed symptoms consistent with ADHD and ODD, but did not respond to the traditional medications and continued to destroy property at home.  He also failed an outpatient course of treatment.  The Health Plan authorized a PHP level of care with the goals of stabilizing the patient pharmacologically, offering the parents guidance and providing assistance with management of his behaviors at home and at school.   The patients provider indicated in February 2006 that the patient has had mild response to treatment with Focalin. In addition, it was noted he continues to exhibit ongoing severe dysfunction at home and in our highly structured milieu.  The provider states the patient is unable to function in a community school and continues to have conflicts with his mother and father at home.  At that time it was recommended that the patient continue to receive PHP services. The Health Plan denied coverage for the PHP beyond February 2006 on the basis that the services were no longer medically necessary.A review of the chart reveals that the patient has made mild improvement with interaction with peers and in school.  There has been continuing problems with the child-parent relationship.  Based upon his behavior in the PHP the patient is likely to need a special education program or a private school. His response to medication has been atypical for a child with ADHD and ODD.  The current approach to medications appears to be helpful, but the optimal approach to the stabilization of this patient will be a combination of a structured school, pharmacological intervention, parental training in the use of a behavioral modification program and individual therapy for the patient.  The PHP was able to utilize pharmacological intervention and to start to engage the parents. As of February 2006, the patient was sufficiently stable to receive treatment on an outpatient basis. There is no evidence in the submitted records that continued PHP was required beyond February 2006. Accordingly, I have determined the requested services are 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 61-year-old female with visual field obstruction, heaviness of brows and upper eyelids. Surgical intervention was planned and the surgical consent included a brow lift and upper lid blepharoplasty. The patient indicates it was her expectation that the upper lid procedure would be performed during the July 2005 surgery. The Health Plan indicates the patients provider felt a brow lift and possibly an upper blepharoplasty were medically necessary. The patient added lower blepharoplasty and facelift to the reconstructive procedures. Surgery was performed in July 2005. No operative note was enclosed for review. Blepharoplasty of the upper eyelids was not performed as anticipated. The patient has requested authorization and coverage for an upper blepharoplasty for persistent visual field deficit not corrected by the brow lift. The Health Plan has denied this request on the basis that the requested procedure is not medically necessary for treatment of the patients medical condition.Although concerns were noted over the patients dry eyes, it does not appear this condition was significant as there is no evidence a Schirmers test was ordered following an ophthalmology evaluation performed in January 2005. Nor was there any follow-up to evaluate the success of a plug placed in the left lower punctum. Furthermore, it does not appear the right eye required a plug. A submitted visual field test was performed post-operatively, but without any evaluation of the lids or brow. The medial brows still rest well below the orbital rim. The patient still has redundant upper lids. The fact that visual fields performed one month postoperatively continue to show loss of upper visual field above 10 degrees of axis reflects the lack of improvement from her brow lift. As such, an upper blepharoplasty remains medically necessary and should be authorized.Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 70-year-old male with a complex medical history including bronchoalveolar carcinoma, coronary artery disease, cerebral vascular accident, chronic obstructive pulmonary disease, two myocardial infarctions and angioplasty in 2002. He is receiving chemotherapy and was recently hospitalized for a gastrointestinal bleed.  The patients physician has recommended a POV. The Health Plan has denied this request on the basis that a POV is not medically necessary for the patients mobility.The occupational therapy evaluation of December 2005 indicates the patient is independent with transfers, activities of daily living, and gait for short distances. Strength was within normal limits. The occupational therapist did not recommend a POV as the patient is independent at home with use of a walker. Review of the physicians notes does not reveal any documentation of facial weakness or sensation or balance issues. Furthermore, the physicians notes do not indicate the patient is unable to walk for household distances. Therefore, I have determined the requested POV is not medically necessary for the patients mobility. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 34-year-old woman with a history of an abnormal pap smear and genital/cervical warts.  Her provider has recommended treatment with cervical laser and biopsy.  The patient reportedly has a low pain tolerance and a history of hemorrhage after a previous procedure. Her provider is requesting authorization to perform the procedure under general anesthesia in the hospital setting.  The Heath Plan has denied this request based on a determination that general anesthesia and inpatient care are not medically necessary.There is no medical indication for the proposed procedure to be performed under general anesthesia.  The patient is medically stable with no significant past medical history.  General anesthesia for healthy patients (ASA Class I or II) may be indicated for a procedure of greater complexity, a higher level of preoperative anxiety or a greater need for a pain-free operative period.  A contraindication to local anesthesia might also require that a general anesthetic be administered.  In this particular case, the procedure is typically performed under local anesthesia with no sedation required.  The patient has no contraindications for pre-medication with Valium, Xylocaine, or cryo to the cervix.  The record provided does demonstrate the necessity of an inpatient procedure under general anesthetic.Based upon the information set forth above, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 21-year-old male admitted to residential treatment after an overdose of alcohol, cocaine, and methamphetamine superimposed on a long-standing history of such drug usage, which began on a daily basis at age 17. After an initial period of 18 months worth of abstinence following an outpatient treatment program at age 18, he subsequently relapsed using prescription opiates, cocaine, methamphetamine and alcohol. By the point of referral to residential treatment, he demonstrated an impaired ability to execute daily tasks such as personal grooming, responsibility, and adherence to a daily schedule. He also lacked a recognition regarding the severity of his chemical dependency and demonstrated characteristics of an undiagnosed bipolar disorder. He remained in residential treatment from January 2006 through March 2006.During treatment he was seen in formal psychiatric consultation, diagnosed with bipolar disorder, and begun on Depakote, titrated up to 500mg twice daily and from which he was felt to have benefited.The issue at hand is whether residential treatment beyond January 2006 was medically necessary for treatment of the patients condition.Based upon the submitted progress notes, it appears that the patient was fairly hypomanic, at the least, much beyond January 2006 and though he was felt to have improved from the prescribed Depakote, he was still seen as easily agitated in groups through March 2006. As such, he was noted as agitated and irrational, and was discharged with a relapse potential rated as moderate. Given that his bipolar disorder was not only problematic in and of itself, but would also predispose him to recurrent substance abuse, there are grounds to consider him in need of continued residential treatment beyond January 2006. Clearly, ending residential treatment with an evaluation of agitated and irrational does not speak to a particularly stable position, and therefore the patient was not suitable for transfer to a lesser level of care at that time. Accordingly, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old male with a history of hepatitis C who is being treated with Peg-intron and ribavirin. There are issues with thrombocytopenia. The patients provider has recommended the use of Neumega to treat the low platelets so interferon can be continued. The Health Plan has denied authorization and coverage for Neumega on the basis that it is not medically necessary for treatment of the patients condition.The use of Neumega in this clinical setting is medically appropriate and indicated. It appears the patients provider is anticipating cutting back on the interferon dose in addition to using the growth factor. This is recommended in the setting of low platelets. The use of Neumega is medically necessary in order to continue the full course of therapy and to allow the patient to finish the treatment. Therefore, I have determined the requested medication 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 16-year-old female with a longstanding history of depression, anorexia, suicidal threats, running away, alcohol and amphetamine use, and promiscuity. She was admitted to a residential treatment facility in December 2004 and resided there through August 2005.  She then ran away to California with a male friend she met along the way and was eventually found by her brother at the home of a friend. After being hospitalized for three days in a California psychiatric facility, she returned to the residential treatment facility. The residential treatment staff noted that she was feeling dead inside and numb upon her return.  These feelings, in conjunction with her depression and underweight condition, led to her referral for inpatient psychiatric treatment.Her inpatient psychiatric treatment focused on preventing her from binging and purging and active treatment for her depression with Zoloft 100mg and Abilify 7.5mg twice per day. She was not actively suicidal at any time during her acute inpatient stay and was reported to have gained some weight. Clinical notations indicate her sadness had decreased somewhat, though her mood still fluctuated from happy to sad.  Her parents are now requesting reimbursement for the acute inpatient psychiatric services.  The Heath Plan denied the request based upon a determination that the services at issue were not medically necessary.Prior to her acute inpatient psychiatric admission, the patient was already in a residential treatment facility. The purpose of residential treatment is to treat longstanding psychiatric illnesses and it is not clear from the record why the patient required transfer to another psychiatric facility. The charter of residential treatment programs is to provide active, ongoing, psychiatric treatment. The patient was not actively suicidal and her difficulties, inclusive of self-destructiveness, were chronic, not acute in nature. As such, she ought to have continued her treatment in the residential facility. There was no indication for acute inpatient psychiatric care and 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 10-month-old male with documented congenital muscular torticollis and lambdoid synostosis. A neurosurgeon recommended treatment with a DOC cranial band. The Health Plan has denied reimbursement for the device on the basis that it was not medically necessary for treatment of the patients condition.Since it is now recommended that infants sleep exclusively on their backs, positional plagiocephaly is becoming more common. Conservative positional treatment is effective in most cases. Use of a cranial band is reserved for treatment of patients with severe problems. Given this patients documented congenital muscular torticollis and lambdoid synostosis and the failure of positional treatment, cranial band therapy was medically reasonable and appropriate and should be continued. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is 13-year-old female with short stature, low IGF-1 and a hypoplastic pituitary gland on MRI. On 3/3/04 her bone age was estimated at 8 years 10 months at a chronological age of 11 years and 2 months. No height prediction was made. Celiac disease and hypothyroidism were excluded. The patient began growth hormone (GH) therapy in September 2005 and by February 2006 had apparently grown one inch. The mothers note indicates that a brother had also been treated with GH therapy for years. The submitted growth chart indicates growth along the 1.2 percentile (-2.25 SDs). The parents height was not given but a note dated in February 2006 indicated that the patients growth was 2 SDs below the family mean.   The parents request for continued authorization and coverage of growth hormone therapy was denied by the Health Plan based upon a determination that the therapy was not medically necessary.On the basis of the record provided, it appears probable that the patient has hypopituitarism, which is an accepted indication for GH therapy. Furthermore, the submitted records document that she is clearly responding to GH therapy. As such, the requested therapy is medically appropriate and indicated in this instance and should be authorized. Therefore, 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

A 56-year-old male enrollee has requested reimbursement for laparoscopic adjustable gastric banding (Lap-band) performed in August 2003. At that time he had a BMI of approximately 43.5 and comorbidities including diabetes and Crohns disease. The patient had tried supervised and unsupervised dietary weight loss programs and medications without successful long-term weight reduction. The patients provider indicated the patient was not a candidate for gastric bypass due to the risk of Crohns recurrence at the point of bowel anastomosis. The Health Plan has denied reimbursement for the Lap-band procedure indicating that it was not medically necessary for treatment of the patients condition.The presence of Crohns disease presented a significant surgical dilemma in this case. Patients with Crohns disease are known for forming enteroenteric fistulas in addition to strictures. The placement of a foreign object such as the Lap-band in a patient prone to fistula-abscess formation is not recommended. It appears a lateral gastrectomy would have been medically appropriate in this setting. 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 58-year-old male who has been treated for hypercholesterolemia for several years.  His provider states the patient was not able to tolerate dosages of Lipitor greater than 10 mg or the combination drug Vytorin.  In October 2005 the patients total cholesterol level was 154 mg/dL to 189 mg/dL and his LDL level was 97 mg/dL to 116 mg/dL. The patient reports that he began treatment with Zetia in October 2005.  The record does not include any cholesterol or LDL levels after October 2005.  The patients request for authorization of Zetia was denied based upon the Health Plans determination that it was not medically necessary to treat the enrollees hypercholesterolemia.The NCEP/ATP III guidelines recommend statin drugs as the standard therapy for managing high cholesterol in adults.  Non-standard therapies such as Zetia are indicated when statin therapy is not tolerated or LDL goals cannot be achieved with statin therapy alone.  Although the provider points out that Lipitor and Vytorin have been tried, there is no documentation of other statin drugs that have been tried and found ineffective or intolerable.  Additionally, the clinical indication for Zetia is not clear. Laboratory values from October 2005 demonstrate LDL levels that are near optimal, before Zetia was prescribed. Peer-reviewed studies have demonstrated that statin therapy reduces the risk of coronary artery disease (CAD).  Zetia alone has been shown to reduce LDL cholesterol, and Zetia in combination with a statin drug further reduces LDL cholesterol.  However, research outcome data has not yet demonstrated that the LDL reduction with Zetia is superior to statin therapy alone.  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: Upheld Decision of Health Plan

This patient is a 14-year-old female with a history of ulcerative colitis. Specimens were sent to the Prometheus laboratory which included the IBD first step in June 2005 and the metabolite test in August 2005. The patients parents have requested reimbursement for the cost of the laboratory testing.  The Health Plan denied their request based on a determination that the testing at issue was not medically necessary.Currently, the gastroenterology societies do not recommend the routine use of the Prometheus studies.  The gastroenterology community does not recognize the medical necessity of this testing and the value of these analyses is primarily academic.  To fully explore the applicability of thiopurine methyltransferase (TPMT) genotyping and E-6-thioguanine nucleotide (E-6-TGN) and E-6-MMP level analysis for therapeutic drug monitoring, large prospective studies with patient entry at the start of AZA therapy are required. Until the results of such studies are available, the AZA dosage adjustments should be primarily guided by clinical response and blood counts. Metabolite level measurements are only applicable in the identification of non-compliance with the prescribed therapy.Based upon the information set forth above, I have determined the laboratory testing 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: Overturned Decision of Health Plan

The patient is a 16-year-old female with an eating disorder who required acute inpatient hospital services. Relevant to that care was a body weight of only 64% of ideal body weight (IBW) and severe hypophosphatemia and severe bradycardia with heart rates as low as 30 beats per minute.  Her primary care provider noted that during her outpatient medical follow-up. her weight dropped consistently and her vital signs remained marginal.  Both the inpatient and the outpatient specialty providers stated the patient required close medical, psychiatric and nutritional follow-up.  The patient did receive post-discharge Eating Disorder specialty care. Her parents are now requesting reimbursement for the specialty medical care provided and continued authorization and coverage for Eating Disorder specialty medical care and nutritional counseling.  The Health Plan denied the parents request based upon a determination that Eating Disorder specialty services are not medically necessary.There is general agreement within the pediatric community that anorexia nervosa is a complex illness with manifestations in both the psychiatric and medical realms. General pediatricians are often ill prepared and hesitant to treat adolescents with this condition. The primary care pediatricians role in this context is more typically to aid in the identification of the problem and to then assist the family in accessing the needed specialized care.  The American Academy of Pediatrics released a policy statement in 2003 regarding this illness. The following sections are relevant to the issue under review:Management of medical complications, provision of nutritional rehabilitation, coordination of psychosocial and psychiatric aspects are often handled by pediatricians who have expertise or experience in the care of adolescents with eating disorders.  other than the most severely affectedmost children and adolescents will be managed in the outpatient setting by a multidisciplinary team coordinated by a pediatrician or subspecialist with appropriate expertise in eating disorders.There is no question that an adolescent with disease of such severity as to require urgent hospitalization and then readmission to a residential treatment facility due to post-discharge decompensation, has a medical need for providers expert in, not just familiar with, the treatment of adolescents with eating disorders.  Specialty medical care and nutritional counseling are medically appropriate for this patient.Based upon the information set forth above, I have determined the services at issue are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.