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

The patient is a 25-year-old female who complains of shoulder grooving and back pain related to her large breasts. The patient is seeking authorization for breast reduction surgery. No photographs evidencing the patients condition have been submitted. In addition, there is a lack of evidence demonstrating the patient has pursued conservative treatment. The Health Plan has denied authorization for the requested procedure.The Health Plans denial should be upheld. There is no photographic evidence demonstrating the patients shoulder grooving. In addition, there is no evidence the patient has attempted and failed conservative therapy such as weight loss. Without such evidence there is no indication that breast reduction surgery is indicated for this patient. 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: Overturned Decision of Health Plan

The patient was a 73-year-old male with a history of prostate cancer who was admitted for acute care in July 2005. Upon admission the patient was critically ill with gram negative bacteremia, dehydration and hepatic encephalopathy. He was in 50% oxygen to maintain his oxygen status; he required intravenous antibiotics, intravenous hydration, and had a rising white blood cell count for a period of three days in July 2005. He was dependent with his activities of daily living. Although the patient had a DNR he had not agreed to hospice or discontinuation of life-sustaining treatment. The rise in the patients white blood cell count created a clinically unstable situation. The patient was recommended for a lower level of care in July 2005, which was prior to addressing the patients rising white blood cell count. The patient expired in late July 2005. The patients representative has requested reimbursement for the acute inpatient services the patient received for the three days in July 2005.As of July 2005, the patient remained clinically unstable. The patients elevated white blood cell count had not been stabilized and left a number of issues unresolved. The records submitted provide no evidence that the patients white blood cell count had been addressed or that there was a plan to address the patients condition. Because the elevated white blood cell was not addressed or planned for the patient was not clinically stable and was not ready for transfer to a lower level of care. No evidence has been provided that the patient was appropriate for transfer to a lower level of care prior to late July 2005.Based upon the information set forth above, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plan should provide coverage for inpatient services the patient received for the three days in July 2005. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 50-year-old postmenopausal woman who is presenting with long-standing back pain. Her MRI of the lower back shows mild spondylosis at L4 and L5 and L5-S1 without focal disc herniation. Her bone density shows a T-score of 1.8 in L2-4, -2.2 left femoral neck and 2.2 right femoral neck. The patient had treatment with Actonel. She is requesting coverage for Miacalcin.The patient is a 50-year-old woman with osteopenia. Osteopenia may be treated in women who are at risk of developing osteoporosis and compression fractures. Risk factors include family history of osteoporosis, history of fractures, steroid use in the past or present, significant alcohol intake and tobacco use. The submitted information does not indicate whether the patient has any of these risk factors. This patient requests Miacalcin spray for prevention of osteoporosis. The FDA allows for the use of Miacalcin in women with established osteoporosis who are five years beyond menopause. Miacalcin is not indicated for the prevention of osteoporosis. It appears that Miacalcin may reduce pain in women with severe osteoporosis and compression fractures. Review of the relevant literature reveals no clinical study investigating this issue.Miacalcin spray is not indicated for this patient. If this patient is at high risk, estrogen therapy would be medically appropriate. The patient should have her TSH level checked to be sure she is on the right amount of thyroid medications because over-supplementation may cause bone loss. The patients back pain is not related to osteopenia. Further investigation would be appropriate to rule out hyperparathyroidism. 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

The patient is a 17-year-old male with a history of relatively long-standing use of marijuana beginning at age 12, eventually amounting to an intake of about 1-3 joints per day. In addition, the patient participated in very sporadic use of other drugs such as cocaine and amphetamine since the age of 16. His last use of marijuana occurred in August 2004, the patient thereafter having entered a residential treatment program from September 2004 through November 2004. For reasons not entirely clear, he was thereafter admitted to another residential treatment program in November 2004 where he was diagnosed as suffering from marijuana dependence, alcohol dependence, alcohol abuse, and oppositional defiant disorder. He was noted to have a somewhat contentious relationship with his father, the latter deemed rather demanding and occasionally emotionally abusive. The patient has been principally living with his mother - his parents are divorced. He was also noted as depressed, mainly due to rejection by his most recent girlfriend who cheated on him with several of his close friends, though his depression was otherwise poorly described. He was also thought of as having difficulty contending with his feelings, particularly about family conflicts.He remained in the residential treatment facility from November 2004 through February 2005 and was subsequently admitted to partial hospitalization in March 2005 where he remained until May 2005. He was treated with a number of psychotherapies and periodically saw a psychiatrist, but was not thought to be so depressed as to warrant any antidepressants. The psychiatrist's notes of the patient include descriptors such as
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 58-year-old male who has requested authorization and coverage for Celebrex. The Health Plan has denied this request indicating the requested medication is not medically necessary for treatment of the patients osteoarthritis. A review of the medical documentation indicates the patient has a history of anxiety, benign prostatic hyperplasia, and degenerative joint disease. He reports gastrointestinal intolerance to ASA, Aleve, and Advil. He has not had a history of peptic ulcer disease and is not on therapy with Coumadin or corticosteroids. He was maintained on Vioxx prior to the medication being removed from the market. He has been maintained on Celebrex therapy and reports adequate pain relief without any adverse effects. There is no documentation provided demonstrating the medical necessity of treatment of the patients condition with Celebrex. The patient has not tried formulary alternatives with a low incidence of gastrointestinal symptoms (Lodine, Relafen, Clinoril, salsalate) with or without concomitant PPI use. There is no documentation in the medical literature indicating COX-II inhibitors such as Celebrex are more effective for pain control than traditional NSAIDS. The patient should undergo a trial of formulary alternatives prior to giving consideration to Celebrex therapy. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 38-year-old female who is 59 weighing 316 pounds with a body mass index (BMI) of 46. She has tried multiple diets without success. The patient would like a consultation with a bariatric surgeon to determine if she is an appropriate candidate for weight loss surgery. The Health Plan has determined the requested consultation is not medically necessary for evaluation of the patients condition.The patient is morbidly obese with a body mass index of 46. She has failed multiple attempts at weight loss surgery. The patient meets nationally accepted criteria for consideration of weight reduction surgery. The requested consultation is medically indicated to help determine if surgery is an appropriate treatment modality for this patient. Therefore, I have determined the requested consultation is medically necessary for evaluation 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 54-year-old female with a history of complex migraine headaches that have been treated with a triptan (Frova) and more recently an anticonvulsant medication (Topomax). She has asked for an increase in her Frova prescription to 18 tablets a month. The Health Plan has denied this request and has authorized nine tablets a month. The Health Plans denial should be upheld. There is no evidence demonstrating an increase in the patients Frova prescription is medically indicated or necessary. The patient has had a bubble study, which suggests a patent foramen ovale and could explain the source of her neurological symptoms. A common treatment regimen for patients with patent foramen ovale is Depakote for prophylactic treatment and Zomig nose drops for acute migraine episodes. Perhaps a change in the patients treatment regimen could be beneficial. The Health Plan is correct that there is no medical justification for increasing the patients Frova prescription. Therefore, I have determined the requested prescription increase is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 44-year-old female with onychomycosis of the toenails, which has spread to all of her toenails. Based upon the information provided, treatment with Lamisil tablets resulted in an apparent drug eruption. In addition, the patient has a family history of diabetes. Because of the patients reaction/allergy to Lamisil, the patients provider prescribed Penlac lacquer for the patient. The Health Plan has denied authorization for Penlac.The fact that the patients condition has spread to all of her toenails demonstrates the patients condition is not cosmetic in nature. Because the patients resistance to this infection appears minimal at best treatment is medically necessary. Although oral Sporanox may also be helpful in treating the patients condition there is no contraindication to Penlac and Penlac is appropriate for treatment of the patients condition. 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: Overturned Decision of Health Plan

The patient is a 53-year-old woman requesting Inspra for treatment of her secondary hyperaldosteronism (SHA) associated with nephropathy and hypertension. She has been tried on spironolactone to block aldosterone receptors, but has been intolerant. The patient has nodular hyperplasia of the adrenals and high levels of aldosterone and renin even off medications. The Health Plan has denied coverage for Inspra on the basis it is not medically necessary for treatment of the patients condition.This patient continues to have abnormally high levels of renin and aldosterone and evidence of nodular hyperplasia of both adrenals after discontinuation of spironolactone and diuretics. Other secondary causes for the patients nephrology, hypertension, and hypokalemia have been ruled out. Inspra has been approved for use in patients with hypertension or congestive heart failure. It is a standard treatment for patients who have SHA with hypertension and hypokalemia and who are intolerant to spironolactone. Therefore, I have determined the requested medication is medically necessary for treatment of the patients condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 15-year-old female with mandibular retrognathic class II dental malocclusion and deep overbite. Additionally noted is macrogenia. The patient had pre-operative orthodontic treatment. She underwent bilateral mandibular ramus osteotomies for mandibular advancement and concurrent reduction genioplasty. The Health Plan has denied coverage for the reduction genioplasty on the basis it was not medically necessary for treatment of the patients condition.The submitted cephalometric analysis would indicate a mandibular advancement of approximately 4mm with minor clockwise rotation of the body of the mandible. Photographs and cephalometric analysis do not show evidence of lip incompetence and other functional deficits related to macrogenia. The reduction genioplasty likely improved the cosmetic result of the surgery, but there would not have been significant facial deformity if the genioplasty had not been performed. As such, the procedure at issue was cosmetic in nature and not medically warranted.Based upon the information set forth above, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 35-year-old male requesting reimbursement for V-beam laser therapy. The patient reports experiencing facial redness and pain. The patients provider reports the patient has tried and failed conservative therapy. The patient reports the therapy has been successful and therefore, he has also requested authorization for continued V-beam laser treatments. The Health Plan has denied coverage for V-beam laser therapy on the basis it is considered investigational.The Health Plans denial should be upheld. There is no documentation of prior trial and failure of conservative therapy. Review of the relevant medical literature does not provide any evidence that laser treatment of superficial telangiectasia prevents focal edema and papular and pustular breakouts. Furthermore, this therapy is considered cosmetic in nature. Therefore, I have determined that the therapy at issue is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 35-year-old male requesting coverage for V-beam laser therapy for treatment of rosacea. The patient reports he has failed conservative treatment, but V-beam laser therapy has been successful. The Health Plan has denied coverage for V-beam laser therapy on the basis it is considered investigational.Review of the relevant medical literature reveals no studies demonstrating that V-beam laser therapy is more effective than standard pharmacologic treatments at reducing the symptoms of rosacea. While use of laser therapy is an acceptable treatment for rosacea, the submitted evidence does not demonstrate such treatment was medically warranted. Therefore, I have determined that the therapy at issue is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 35-year-old male requesting coverage for V-beam laser therapy. The submitted clinical information indicates the patient has facial redness and pain. Conservative therapy has not been effective for this patient. The Health Plan has denied coverage for V-beam laser therapy on the basis it is considered investigational.V-beam laser therapy is both safe and efficacious in the treatment of telangiectasia associated with rosacea. This is documented in the Journal of American Academy of Dermatology articles cited above. Furthermore, V-beam laser therapy is standard of care for patients such as this patient. It is not likely the patient would have benefited from topical agents. Therefore, I have determined that the therapy at issue is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old female with an almost two-year history of persistent tinnitus. The patient states the onset of this problem coincided with a severe flu she had in November 2003. The tinnitus began as a small noise in the right ear that occurred only when the enrollee lay on her right side. It has since become constant and is a swooshing noise most prominent with each heartbeat. The patient also has pressure around her ears and upper neck. In March 2004, an audiometric evaluation demonstrated the presence of bilateral mild to moderate high frequency hearing loss. In May 2004, an MRI was within normal limits. In November 2004, the patient was evaluated by another otolaryngologist. At that time hearing thresholds were found to be normal on the right with mild high frequency loss on the left. Tympanograms were slightly negative but within normal limits. The patient has been treated with Flonase, Claritin, and Niacin and continues to be symptomatic. The patient has requested a referral to a sinus specialist. The Health Plan has denied this referral.Tinnitus is not a fully understood disorder, but it is not dangerous. It is unclear whether the patients tinnitus is pulsatile. In addition, although a bilateral vascular lesion would be rare, a CT scan of the temporal lobes would rule this out. In addition, although the patient is 43, bilateral pulsatile tinnitus can be secondary to carotid artery disease and a carotid doppler could rule this out as well. Furthermore, because of the discrepancy in audiograms a repeat audiogram would be helpful.The patient has requested a referral to a sinus specialist; however, tinnitus is not a sinus disorder and a referral to a sinus specialist is not indicated or necessary. Further testing and evaluation could be performed by the patients primary care physician or an otolaryngologist. Therefore, I have determined the requested referral 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 56-year-old female with a BMI of 39 and a number of referenced comorbidities including hypertension, gastroesophageal reflux disease (GERD), and depression. A psychological evaluation recommended the patient receive psychotherapy. She is seeking authorization for a duodenal switch procedure. The Health Plan has denied this request.The Health Plans denial should be upheld. Based upon the patients history and psychological evaluation, the patient does not appear prepared for the lifestyle changes necessary for weight loss surgery to be successful. The patient should follow through on the recommended psychotherapy and undergo re-evaluation in approximately six to nine months. If at that time the patient is considered an appropriate candidate for weight loss surgery the Health Plans denial should be reconsidered. At that time the patient should also be re-evaluated by her bariatric surgeon.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old woman with a history of pelvic pain and abnormal bleeding. A pelvic sonogram diagnosed a fibroid uterus and a 2.7cm ovarian cyst. The patient was given Provera for a short time. She is requesting authorization and coverage for surgical intervention. The Health Plan indicates the requested surgery is not medically necessary for treatment of the patients medical condition.Standard of practice for the management of abnormal bleeding is to try hormone therapy for three to four months to control the bleeding and to dissolve the cyst. In addition, an endometrial biopsy should be performed to rule out endometrial cancer. Standard of practice for the management of pelvic pain is to determine if there is a gynecologic cause. A fibroid and a small cyst do not necessarily cause pelvic pain. If the above medications do not provide relief, then a laparoscopy may be indicated. If no gynecologic causes of pain are found, then genitorurinary (e.g., interstitial cystitis), gastrointestinal, and neuromuscular causes need to be considered with referral to the appropriate specialty.A trial of gonadotropin releasing hormone agonists might be considered to reduce amenorrhea, treat pain, and decrease the size of the fibroid. There is no medical indication for surgical removal of the cyst at this time. Furthermore, a myomectomy is not indicated in women of this age. Therefore, I have determined the requested surgery 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 case concerns a 37-year-old male patient who is seeking reimbursement for a CT scan of the chest he underwent in June 2005. The Health Plan has denied this request because it has determined the CT scan was not medically necessary.The Health Plans denial should be upheld. A review of the information provided demonstrates the patient has a history of obesity, reactive airway disease, and hiatal hernia  status post Nissen fundoplication in May 2005. The patient underwent a chest CT scan in June 2005 for evaluation of continued complaints of chest pressure. The patient had been previously evaluated by pulmonology and otolaryngology. He also underwent a stress test in December 2004, which was normal. The CT scan was normal with evidence of fatty liver infiltration.The information provided does not demonstrate a CT scan of the chest was medically necessary. The patient had been previously evaluated by pulmonary medicine and had a normal chest x-ray in December 2004. He was also evaluated by otolaryngology and had a negative stress test. A lung exam in June 2005 revealed no adventitious lung sounds with a forced cough. He also denied any history of chest trauma, hemoptysis or history or findings consistent with pulmonary embolism. In addition, there is no information suggesting an ongoing malignant process (nonsmoker, no history of weight loss, no night sweats, no adenopathy) or suspected inflammatory disease. Therefore, there was no evidence of the need for a CT scan.Based upon the information set forth above, I have determined the CT scan at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.