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

The patient is a 34-year-old woman with a history of diabetes mellitus type 2, which appears to date back to at least May 2004, as the patient was on metformin at that time. It is possible that she might have gone through a pregnancy on insulin at that time. It appears that some time after delivery, she was given Avandia and metformin. She apparently took Avandia from May 2005 through April 2006. It is unclear whether she was given Avandamet concurrently. Because of weight gain and edema, Avandia was discontinued. In May 2006 the patient was begun on Byetta and metformin. She lost 18 pounds over 2 months. Her A1c in June 2006 was 5.5%. Her endocrinologist recommends continuation of Byetta, apparently to further increase weight loss. The patients current medications and blood sugar control are not documented in the records provided.At issue is this case is whether Byetta is medically necessary for treatment of the patients medical conditionIt appears the onset of the patients diabetes predates September 2004. It seems that her blood sugars were in good control on Avandia and/or Avandamet.  However, because of an unspecified weight gain and edema, Avandia was discontinued, and she was begun on Byetta and metformin.  There is no documentation beyond an August 2006 glucose of 157 mg/dL to indicate her glycemic response to treatment.  The patient states that she has lost 18 pounds on her new regimen. Her physician asserts that Avandia was discontinued because she developed weight gain and edema. It is not known whether the patients subsequent weight loss was achieved by the Byetta or the metformin. The submitted evidence does not demonstrate the patient experienced a lack of controlled blood sugars on metformin alone. As such, the medical necessity of Byetta has not been established. For the reasons 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: Overturned Decision of Health Plan

The patient is a 20-year-old male who has been struggling with severe refractory headaches for over five years. He has been seen by numerous headache specialists around the country. The patient has failed treatment with 17 preventative  medications, 14 acute or abortive therapies and a variety of non-pharmacologic therapies as well. He is  currently followed by a pain specialist who has recommended a trial of Lyrica beginning at a dose of 300mg per day. The patients request for reimbursement and continued authorization and coverage of Lyrica was denied by the Health Plan citing a lack of medical necessity.The patients headaches are severe and unquestionably refractory to standard treatment modalities as numerous pharmacological and non-pharmacologic therapies have been tried and failed. The safety of Lyrica has been sufficiently tested in other clinical applications and it was found to be safe at dosages up to 300mg twice per day. Lyrica should be approved on a trial basis with medically supervised titration until either therapeutic success or failure is demonstrated. If treatment with Lyrica is beneficial and without untoward side effects, authorization should be continued.Based upon the information set forth above, I have determined the medication at issue was/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 56-year-old female who has a long-term history of low back pain. She has had multiple sessions of physical therapy (PT) with only mild, temporary improvement. Her provider indicates her correct diagnosis is sacroiliitis although previous treatment was for lumbo-sacral disc disease. MRI reveals mild to moderate stenosis of the central canal at L1-2. The patient had approximately three months of PT in 2005 and approximately two months in early 2006. The patients request for additional PT was denied by the Health Plan citing a lack of medical necessity.The physical therapy previously provided does not seem to have had any lasting impact on the patients condition and the documentation submitted does not suggest that a new treatment modality will be implemented. Although the provider indicates that treatment should now address sacroiliitis in addition to low back pain, therapy for sacroiliitis generally involves the same treatment modalities as for back pain. It does not appear that additional physical therapy would likely result in an improved clinical outcome for this patient. 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

This patient is a 50-year-old female who presented to her primary care physician with a complaint of back pain in the lower left thoracic region and occasionally radiating down the left leg. She was referred to an orthopedist who ordered MRIs of the thoracic and lumbar spine which demonstrated abnormal signal in T9 and the adjacent right 9th and 10th ribs, suspicious for metastatic disease. Abnormal signal was also reported in T11 consistent with a hemangioma. A bone scan done in May 2006 showed increased activity in the left aspect of T9-10. CT scans were obtained to further evaluate for the possibility of metastatic disease. The CT scans of the chest, abdomen and pelvis showed non-specific changes in the thoracic spine and a probable benign lesion in the lower pole of the left kidney and some small ovarian cysts. No masses or metastatic disease were identified. Tumor markers including CEA, CA 125, CA 15-3, and CA 19-9 were also obtained and were within normal range. The patient is now requesting reimbursement for the CT scans. The Health Plan denied her request indicating these diagnostic procedures were not medically necessary.The CT scans were ordered because both the MRI and the bone scan done previously suggested the possibility of metastatic disease. The CT scans were part of a diagnostic work-up based upon the patients symptoms and findings from other imaging. Katagiri, et al found that in a retrospective review of 64 patients presenting with symptoms of skeletal metastases, CT scan was essential in making the diagnoses for 78% of lung cancers, 80% of hepatocellular carcinomas, 100% of renal cancers, and 100% of pancreatic cancers. CT scans are clearly indicated when metastatic disease is suspected. Therefore I have determined the diagnostic procedures at issue were 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 46-year-old male with a body mass index (BMI) of 52. He is requesting authorization for a Lap-Band procedure. He reports a number of comorbid conditions including sleep disturbances, breathing difficulty, joint pain and abdominal discomfort. At issue is whether the Lap-Band procedure is medically necessary for treatment of the patients condition.Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not indicated in this case. The patient can be appropriately treated with standard bariatric surgery procedures. 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 is a 50-year-old male with diabetes mellitus, type 1. He has been using an insulin pump for management of his diabetes for some time. Symlin injections were added to the patients treatment plan and his poor glycemic control was transiently improved as evidenced by a decrease in the patients hemoglobin A1c from 8.8% to 7.4%. Shortly thereafter (three months) the patients hemoglobin A1c was again over 8.0%. At his peak of success the patient had lost 14 pounds, but the record did not include a recent weight. The patients request for authorization Symlin was denied by the Health Plan based upon a determination that the therapy is not medically necessary.The actual benefit of Symlin therapy for this patient is questionable. After a transient improvement in his hemoglobin A1c of 1.4%, he reverted back to his baseline of over 8%. This suggests that the initial improvement may have been due to either a placebo effect or an intensified effort toward lifestyle change which subsequently waned. Additionally, a patient with a baseline hemoglobin A1c of greater than 8% may be in need of a therapeutic modification to his diabetic treatment plan and would likely benefit from consultation with an endocrinologist. I see no clinical benefit in continuing Symlin therapy for this patient.Based upon the information set forth above, 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 59-year-old edentulous male with a history of hepatitis C. He reports that he has difficulty eating. His present weight is 140 pounds. The patient is 67.75 inches tall, resulting in a body mass index of 21.6. The submitted materials indicate he has lost 10 pounds within the past year. The patients provider has prescribed Boost Plus nutritional supplement. At issue in this case is whether the requested supplement is medically necessary for the patient. Review of the submitted clinical records reveals no evidence of malnutrition. There is no documented history of odynophagia. The patient has no pathology involving his swallowing mechanism. Furthermore, based on his body mass index he is currently at ideal body weight. Moreover, there is no documentation indicating the patient cannot tolerate pureed, juiced or blenderized food. Therefore, I have determined the requested supplement 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 54-year-old female with a complex medical history of including extensive spinal deformity, myelopathy, multiple surgeries and osteoporosis. She uses a walker for mobility and her physical therapist recommended the additional of forearm platforms to transfer weight bearing from the hands and wrists to the forearms. There is no information in the record provided for review regarding the current condition of the patients upper extremities. The patient has purchased the forearm platforms, and has submitted a request for reimbursement to the Health Plan.  The Health Plan denied the requested reimbursement based upon a determination that the forearm platforms were not medially necessary for the patients mobility.The medical information provided through July 2006 contains no reference to upper extremity strength, sensation, or functional ability. There are no physician records documenting an upper extremity neuropathy or a recent work-up of upper extremity deficits. The patients physical therapist did provide a letter dated August 2006 indicating that the patient needs the forearm platforms.  However, there are no physical therapy progress notes or any indication in the physicians notes the patient was referred for physical therapy. As such, the available records do not contain sufficient information to substantiate the medical basis for the requested forearm platforms.Based upon the information set forth above, I have determined the equipment at issue was not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a four-year-old male who was diagnosed with autism in late 2005 at the age of three years and seven months. He began speech therapy in December 2005 following an evaluation where deficits in the areas of expressive, receptive, functional and pragmatic language were identified. His re-evaluation in March 2006 showed progress and he had a good prognosis for continued functional improvement according to the therapists assessment. The patient is also followed by a developmental psychologist who recommends continued speech therapy sessions, twice per week to address expressive language delays. The parents request for reimbursement for the speech therapy already provided and prospective authorization of speech therapy was denied by the Health Plan based upon a determination that the therapy was/is not medically necessary.Autism is a serious neuropsychiatric disorder of unknown cause with a potentially devastating impact on childhood development. Without age appropriate language skills, children with autism are disadvantaged in educational and social venues. According to the records provided for review, this patient has made positive strides with twice a week speech therapy. Although the etiology of autism is not clear, it is nonetheless a serious condition with significant impact. The March 2006 Update Report recommended an additional four months of therapy, at which time the patients goal achievement and need for further therapy should be re-evaluated. As such, I have determined the speech therapy provided from November 2005 through July 2006 was medically necessary for treatment of the patients medical condition. Authorization of continued speech therapy should be based upon the next re-evaluation in the July 2006 timeframe. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 36-year-old female with multiple sclerosis (MS).  She utilizes a Baclofen pump for management of spasticity and has tried several medications for relief of her painful neuropathy. A trial of Lyrica has successfully treated her symptoms, and she no longer requires narcotic pain medication. The patient has submitted a request for authorization of Lyrica. The Health Plan denied her request based upon a determination that the medication is not medically necessary for treatment of her neuropathic pain.Many patients with MS complain of painful neurological symptoms likely due to the MS plaques situated at the nerve root exit within the spinal cord. Lyrica, although typically prescribed for patients with diabetic neuropathy or herpes zoster, should theoretically provide benefit in the relief of pain resulting from nerve root involvement. Lyrica has been found to be safe and is approved for the treatment of other types of neuropathic pain. The efficacy of Lyrica in treating this patients symptoms has been clearly established by subjective report and objective measures such as the discontinuation of narcotic pain medication. The prescription of Lyrical is a logical and appropriate approach to management of the patients neuropathic pain and is associated with fewer side effects than narcotic pain medications. 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

This patient is a 29-year-old G4P1Ab3 female who has a history of two spontaneous abortions followed by a successful term pregnancy, then another spontaneous abortion. She was found to have a borderline lupus anticoagulant antibody level at the time of her third pregnancy and was treated with Lovenox and aspirin. The patient was diagnosed as having antiphospholipid syndrome and after her third miscarriage, she was advised to have treatment with intravenous immunoglobulin (IVIG). The record provided for review reveals a single, borderline lupus anticoagulant level with two subsequent negative levels in July and August 2005. Screening for anticardiolipin antibodies was negative and the natural killer (NK) cell assay performed in July 2005 was within the normal laboratory reference ranges. The patient would like to become pregnant again, and her provider has recommended treatment with IVIG to decrease the risk of pregnancy loss. The Health Plan denied the patients request for authorization based upon a determination that IVIG therapy is not medically necessary.The record indicates a diagnosis of antiphospholipid syndrome and elevated NK cells. However, the NK cell levels were within normal limits and the lupus anticoagulant level was borderline high and the elevation did not persist. ACOG Practice Bulletin #68, which addresses antiphospholipid syndrome, states there must be a positive test on two or more occasions at least six weeks apart. As such, the diagnosis of antiphospholipid syndrome is suspect and is not supported by the records provided for review. Practice bulletin #68 also states that a recent small, randomized, controlled study demonstrated no greater benefit from IVIG (plus heparin and aspirin) than with heparin and aspirin alone. Because the efficacy of IVIG has not been proven in appropriately designed studies and the drug is extremely expensive, it is not recommended as primary therapy.  Therefore, even with a confirmed diagnosis of antiphospholipid syndrome, the current evidence would support treatment with aspirin and heparin, not with IVIG therapy.  Based upon the information set forth above, 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 32-year-old female with a history of rib fractures following a bicycle accident in December 2005. X-rays obtained in March 2006 showed healed posterior right rib fractures. The findings of a nuclear bone scan were consistent with healing fractures. The patient continues to have pain and has requested authorization for a CT scan for further evaluation. The Health Plan has denied her request citing a lack of medical necessity for a CT scan in this setting.The Health Plans denial is correct.  The patient has rib fractures that appear to be healing based on the plain radiographs. The results of a nuclear scan also showed healing. A CT scan is not clinically indicated for this injury. The patient does not require surgery. No added benefit would be obtained from a CT scan and therefore, the proposed scan is not medically warranted. Accordingly, I have determined that the requested CT scan is not medically necessary for evaluation 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 48-year-old male with onychomycosis confirmed by a April 2006 fungal culture which was positive for alternaria species. His symptoms include crumbling and deterioration of the toenails. Liver function tests from June 2006 were within normal limits. The request for authorization of Lamisil from the enrollees provider was denied by the Health Plan based upon a determination that the medication is not medically necessary.Loss of one or more toenails is a medically significant functional impairment. The toenails serve a protective purpose for the toes and feet and generally decrease the risk of infection. Additionally, the loss of a toenail is often painful. The patients dermatologist has proposed treatment with the oral medication Lamisil. This is a medically appropriate treatment approach as topical agents are minimally effective at best. 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 36-year-old female who underwent surgery for chondromalacia in November 2005. Following surgery she was prescribed a continuous passive motion (CPM) machine. The patient has requested reimbursement for the CPM device. The Health Plan has denied this request based upon their determination that the device at issue was not medically necessary.The use of a CPM device following the type of surgery that was performed in this case is a well documented treatment option for postoperative management. CPM therapy is beneficial to the healing and rehabilitation processes. Many surgeons prescribe the CPM machine for their patients postoperatively and such prescriptions are consistent with the surgical communitys standard of care. The use of the CPM device was medically appropriate and indicated in this clinical setting. 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: Upheld Decision of Health Plan

The patient is a 41-year-old woman with a twin pregnancy following a successful IVF cycle. Her EDC is in January 2007. She has a history of chronic hypertension. Due to her history, she was referred to a perinatology group, who has followed her in consultation with her obstetrician. During the consultative follow-up, she underwent an ultrasound at the perinatology office in July 2006, at 14 weeks gestation for fetal anatomy studies, advanced maternal age and twin pregnancy. The ultrasound was normal for dates. A repeat ultrasound was performed in August 2006 at 18 weeks gestation for the same indications. The ultrasound was again normal for dates. The cervix was also screened for changes consistent with cervical incompetence, and there was no evidence of that finding. The perinatologist, in the second report, recommended that the patient undergo serial ultrasound scans every 4 weeks until 33 weeks, to screen for the presence of intrauterine growth restriction which is at risk in twin gestations. He also recommended these scans on the basis of the risk of prematurity due to the increased risk for the onset of premature labor or cervical incompetence. The Health Plan has approved the ultrasounds at a local hospital within the network and has denied coverage for in-house scans at the perinatologists office as requested by the patient.With a history of twin pregnancy, IVF multiple pregnancy and chronic hypertension, it is within the standard of care to recommend serial ultrasounds to monitor the patient. These ultrasounds should be performed at a facility that demonstrates competence and experience in perinatal ultrasound. In addition, the facility must offer the ordering perinatologist immediate, stat results early on the day of the examination. It is essential that changes indicating an increased risk of premature labor or cervical incompetence be reported immediately to the subspecialist. No evidence has been presented that the diagnostic facility approved by the Health Plan does not offer the above level of service. Therefore, it is medically reasonable and appropriate for the patient to undergo ultrasound examinations at the approved facility as long as the patients perinatologist is provided with the diagnostic results on an immediate basis.Based upon the information set forth above, I have determined the requested in-house ultrasounds are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.