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

The patient is a 50-year-old female with a history of coronary artery disease. She underwent percutaneous transluminal coronary angioplasty in 2001. The submitted medical records indicate the patient has vasospastic angina, controlled hypertension, and dyslipidemia. On 7/7/04, an exercise myocardial perfusion study was normal. The patients physician has requested a follow-up cardiology consultation. The Health Plan has denied this request on the basis that a consultation with a cardiologist is not medically necessary.By requesting the consultation, the patients primary care physician requested the opinion and advise of a cardiologist. Vasospastic angina is an uncommon condition and is not expected to be within the diagnostic and therapeutic expertise of a primary care physician. As such, the requested consultation is medically warranted and should be authorized. Therefore, I have determined that the requested consultation 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 has a body mass index greater than 40 with obesity related comorbidities. She began a program to lose weight preoperatively and lost 10 pounds. She then took a break from the program for personal reasons and regained to 255 pounds. The Health Plan indicates the patient must meet the preoperative weight loss goal of 220 pounds prior to weight loss surgery. The Health Plans denial should be overturned. There is not significant additional risk to the patient if she weighs 255 pounds versus 220 pounds when gastric bypass surgery is performed. There is no specific medical reason to require the patient to undergo preoperative weight loss from a technical or evidence-based point of view. Therefore, I have determined that it is not medically necessary for the patient to decrease her weight to the recommended preoperative weight prior to gastric bypass surgery. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 34-year-old who has a 10-year history of facial redness. The submitted documentation demonstrates the patient has seborrhea dermatitis involving the eyelids. It has been recommended the patient use Elidel cream for treatment of her dermatitis. The Health Plan has denied authorization and coverage for Elidel on the basis it is not medically necessary for treatment of the patients medical condition. Non-steroidal medication is indicated for treatment of dermatitis involving eyelid regions because of safety issues surrounding use of topical steroids. Topical steroids can be absorbed into the eye resulting in harm. Thus, a non-steroidal medication such as Elidel is medically appropriate and indicated for treatment of this patients active skin condition. Therefore, I have determined that 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

A 73-year-old man who experienced an intertrochanteric hip fracture five months ago underwent a DEXA scan, which suggested osteopenia in the opposite hip and probable osteoporosis of the spine. He has been taking calcium citrate. No workup for the etiology of his fragility fracture is presented in the information provided. The patients physician wishes to begin treatment with Forteo. The Health Plan has denied authorization and coverage for Forteo on the basis it is not medically necessary for treatment of the patients medical condition.The Health Plans recommendations are in line with most recommendations to reserve Forteo for patients who meet the following criteria: failed other treatments defined as statistically/clinically significant decreases in bone mineral density; occurrence or recurrence of fragility fractures while on treatment; intolerance to other treatments; severe osteoporosis usually defined as T-scores <-4.0; or other high risks for fractures such as old age, family history of hip fractures, or smoking or as assessed by various fracture risk indices. The submitted records do not demonstrate the patient meets any of these criteria. The patients physician does not document any etiology for the patients osteopenia or indicate whether the patient has any additional risk factors. The Health Plans recommendation of a formulary bisphosphonate is a medically reasonable alternative. Based upon the information set forth above, I have determined that 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 55-year-old male with right hand Dupuytrens contracture involving the middle, ring, and small fingers. The patient reports the right small finger is the most symptomatic. He consulted a hand surgeon who offered surgical release of the Dupuytrens contracture in the right hand. The patient wishes to undergo a needle aponeurotomy instead. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition.Review of the medical evidence reveals no peer-reviewed data demonstrating the efficacy of needle aponeurotomy for treatment of patients such as this patient. Standard treatment for worsening Dupuytrens contracture is not a needle aponeurotomy, but rather, surgical release via an open procedure. The Health Plan has offered the patient care with a hand surgeon. As such, the services offered by the Health Plan are medically reasonable and appropriate. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old male who is requesting a referral to a pain management clinic for a long history of back pain. He has tried physical therapy, which has not provided sustained relief. In addition, the patient does not want to take muscle relaxers or pain medications. The patient has requested a referral to a pain management clinic that offers DRX Spinal Decompression. The Health Plan has denied the request on the basis the requested referral is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. DRX Spinal Decompression is a form of traction and its benefits and efficacy for back pain as compared to conventional treatment has not been established in scientific literature. In fact, traction itself is not of established efficacy for treatment of low back pain. The Health Plans alternative treatment is more clinically appropriate.  As such, there is no medical justification for referral to a pain management clinic. Therefore, I have determined that the requested referral 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 female who possibly has bilateral lower quadrant lymphedema. She has been receiving lymphedema therapy since 1999, which resulted in improvement in her condition. Her physician has recommended she continue with lymphedema therapy. The Health Plan has denied coverage for past and future lymphedema therapy on the basis that lymphedema therapy is not medically necessary for treatment of the patients medical condition.Review of the clinical information indicates the patient is morbidly obese. The submitted photographs do suggest lymphedema. However, the submitted clinical information does not include evidence from the patients primary care provider to support the diagnosis of lymphedema. As such, the medical necessity of the therapy at issue has not been established at this time. However, if objective documentation of lymphedema is provided by the patients primary care provider, coverage for past and future lymphedema therapy should be provided by the Health Plan.Based upon the information set forth above, I have determined that the therapy at issue is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. However, if the patients primary care physician provides objective evidence of lymphedema, the therapy at issue should be covered by the Health Plan.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 61-year-old male with asthma and chronic obstructive pulmonary disease (COPD). According to progress notes dated between June 2004 and July 2004, his physician prescribed Alupent via nebulizer and Advair. Progress notes described rhonchi on lung exam. The patient was started on Xopenex. The submitted progress notes indicate that the patient continued to smoke cigarettes. The patient has requested authorization and coverage for Xopenex. The Health Plan has denied this request on the basis that Xopenex is not medically necessary for treatment of the patients medical condition.According to literature from the manufacturer of Xopenex, the indication for the drug is for use in bronchospasm. Xopenex has a higher affinity for human beta-adrenergic receptors than racemic albuterol. Since it is more specific, less cardiovascular side effects are noted such as tachycardia and arrhythmia. According to the submitted study by Lovtall, et al., racemic albuterol is comparable in efficacy to Xopenex. The standard of care is to use albuterol as meter-dose inhaler or nebulized treatments prior to using Xopenex. As such, use of Xopenex is not medically warranted at this time. Therefore, I have determined that 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 64-year-old man who has had a rising PSA since 1999, which has become 6.5 with a free PSA of 12.3% in March 2004. In March 2004, his urologist performed prostate biopsies and Gleason score of 6 (3+3) was found on both sides of the prostate. There was 60% involvement on the right and 30% involvement of the biopsied specimen on the left. His clinical stage by the urologist was T2b. In addition, he had severe urinary obstruction. In July 2004, the patient was placed on Lupron. He was also told that because of his severe urinary obstruction, I-125 brachytherapy or HDR were not optimal for his tumor.  On 9/8/04, he underwent laser TURP. The patients symptoms were relieved. IMRT was recommended primarily because of the patients urinary obstruction. The Health Plan has denied coverage for IMRT on the basis it is not medically necessary for treatment of the patients medical condition.This patient has a PSA of 6.5, Gleason of 6 and T2b prostate cancer. Based on Partins Tables, his chance of having a confined tumor to the prostate is 48%. He has a 45% chance of capsular involvement, a 5% chance of seminal vesicle involvement, and a 3% chance of lymph node involvement. Additionally, based on the biopsies he has 60% involvement by tumor on the right side and 30% on the left. This is a substantial volume of tumor. Lupron has a 75% chance to reduce the volume of the tumor. Based upon the information provided it does not appear that the patient has a significant urinary obstruction at this time. As such, HDR is a better form of conformal therapy for the patients prostate cancer in combination with external beam to his pelvis. IMRT dose is planned for 75.2Gy while HDR plus external beam physical dose is 70 Gy with a biological dose in excess of 100 Gy. As such, IMRT is not the most appropriate treatment for this patients cancer.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the 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 56-year-old male who has a history of low back pain. He is requesting an MRI to assist in diagnosing his back pain. The Health Plan has denied this request indicating the requested MRI is not medically necessary for evaluation of the patients medical condition.The patient presented on 8/27/04 with a history of fatigue and generalized anxiety disorder. No history related to the patients back pain has been documented in the submitted records. The records provided do not demonstrate how long pain has been present. The exam only notes swollen right sacroiliac and TFL. Furthermore, there is no evidence that a neurologic exam has been performed. Thus, there is insufficient evidence that an MRI is medically warranted at this time. The alternative service of physical therapy recommended by the Health Plan is more clinically appropriate. Therefore, I have determined that the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old male is requesting coverage for a cranial DOC band. The patient has been diagnosed with a cranial deformity secondary to left torticollis-plagiocephaly deformation sequence. The patients physician noted a difference in the patients cranial diagonal measurement of 0.5cm. A cranial DOC band was recommended. The Health Plan has denied coverage for the requested equipment on the basis it is not medically necessary for treatment of the patients condition.  Review of the current medical literature indicates most experts have not found benefit to band treatment after one year of age. Cranial band treatment is recommended for those with greater than 1cm differential, i.e., one ear greater than 1cm anterior over the other. Based on the records provided, the patient does not meet this criteria. In light of the evidence provided, cranial band treatment is not likely to be of benefit for this patients condition. Therefore, I have determined that the requested equipment 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 58-year-old female with a history of irritable bowel syndrome (IBS) and constipation. The patient has tried multiple medications and only Zelnorm has been successful. She is currently on 6mg of Zelnorm per day. Her physician has requested continued treatment with Zelnorm. The Health Plan has denied this request indicating the recommended dosage of Zelnorm should not exceed 24 weeks. Although the FDA approval for Zelnorm is limited to several weeks, IBS is a lifelong condition. It appears that this patient has tried multiple other alternatives without relief. It also appears that the patient has had a positive response to a low dose of Zelnorm. Since IBS is a chronic disease, it is well known that many patients will require re-treatment or require maintenance on Zelnorm in order to control their symptoms. Clinical experience with Zelnorm over the past two years provides sufficient evidence to support this pattern of use. In light of the information set forth above and given the patients good clinical experience with Zelnorm with no evidence of toxicity or side effects, continued use of Zelnorm is medically appropriate and indicated. Therefore, I have determined that 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

A 20-year-old male has irregular thickening of his left first toenail. The patient reports that his toe is painful and foul smelling. His physician prescribed Lamisil tablets. The Health Plan has denied coverage for Lamisil on the basis it is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical records provides insufficient evidence that the patient has a fungus infection. The results of a fungus culture have not been provided. The foul smelling nature of the toe suggests the possibility of a bacterial infection. Both a fungus culture and a culture for bacteria should be obtained. Based upon the submitted information, there is no medical justification for use of Lamisil at this time. Therefore, I have determined that 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 34-year-old female who has had difficulties with cosmetic augmentation. The original procedure was performed in 1997. The patient has had revisional procedures with implant replacement in 2001 and eventual removal in 2002. She has requested authorization and coverage for revision and new implant placement as well as a mastopexy to correct asymmetry. The Health Plan has denied the patients request on the basis that the requested surgery is cosmetic in nature and therefore, not medically necessary.Review of the submitted information does not demonstrate the requested surgery is medically necessary for treatment of the patients condition. There is no evidence that breast reconstructive surgery is medically indicated to improve a functional impairment. Based upon the provided records and photographs, breast reconstructive surgery is cosmetic and not medically warranted. 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: Overturned Decision of Health Plan

The patient is a 44-year-old woman has been treated with Elidel for severe prurigo nodularis with good results. Prior treatment with topical corticosteroids and oral antihistamines was ineffective. The Health Plan denied coverage for Elidel on the basis it is not medically necessary for treatment of the patients medical condition.Prurigo nodularis is a form of atopic dermatitis. The patients treatment history demonstrates Elidel has been successful for this patient whereas a trial of steroids was not successful. Furthermore, chronic topical steroid use may result in permanent atrophy and telangiectasis of the skin. Given the proven efficacy and greater safety of Elidel, its continued use is medically appropriate and indicated for treatment of the patients severe prurigo nodularis. Therefore, I have determined that 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 41-year-old female who weighs 373 pounds and is 55 tall with a BMI of 62.1. In addition, she has comorbid conditions of sleep apnea and arthritis. She has undergone a psychological evaluation and is considered an appropriate candidate for bariatric surgery. She has requested authorization and coverage for gastric bypass surgery. The Health Plan has denied this request indicating the patient has not undergone a six-month supervised weight loss program and therefore, does not meet plan criteria for the requested procedure.With a BMI of over 60 the patient meets nationally accepted criteria for consideration of weight loss surgery. In addition, it is unlikely that the patient will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Furthermore, the patient has undergone an appropriate psychological evaluation and is considered an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old woman with chronic migraine headaches and comorbid stress and depression. The patient experiences approximately three headaches per week. She reports her headaches are fairly well controlled by taking Neurontin and Imitrex nasal spray. The patient has requested authorization and coverage for 18 Imitrex 20mg nasal spray units per month. The Health Plan has denied her request on the basis the requested prescription is not medically necessary for treatment of the patients migraine headaches. Review of the submitted medical records indicates the patient requires vigorous prophylactic treatment for her headaches. In addition, the patient requires treatment for her comorbid depression in the form of a mild antidepressant. The requested dosage of Imitrex nasal spray will likely result in rebound headaches. This condition is frequently noted in patients who take large quantities of medications aimed at the acute treatment of migraine headaches. Further attempts at prophylactic headache treatment are medically indicated and likely to be more effective than the requested regimen. Therefore, I have determined the requested prescription 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 63-year-old male with T1c adenocarcinoma of the prostate and a Gleason score of 3+3=6. He presented with minimal symptomatology and an initial PSA of 14. He sought multiple opinions from urologists, radiation oncologists, and medical oncologists. The patient was treated with two Lupron injections. His PSA decreased to 0.76 ng/ml. He wishes to undergo proton beam radiation therapy. The Health Plan has denied coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients medical condition.This patient with T1c prostate cancer received hormone therapy. His PSA has since dropped to 0.76 ng/ml. Review of the relevant medical evidence does not demonstrate a direct advantage of proton beam therapy over standard treatment modalities. The services offered by the Health Plan are medically reasonable and appropriate for treatment of the patients prostate cancer. There is no medical indication that proton beam therapy would be more beneficial in this patient than any available standard therapies. 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.