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

The patient is a 46-year-old female with chronic neck pain. The patient has been seen at least twice by a pain specialist. In 1993, the patient received cervical spine x-rays, which showed degenerative disc disease at C6-7, facet degenerative changes at C6-7 and on the left at C4-5. The patient had two prior MRI scans of the cervical spine in 1997 and 2001. The 2001 scan revealed a disc bulge at C4-5 and mild loss of disc height at C5-6 with disc protrusion encroaching on the left of the neuroforamina. In addition, there was loss of disc height at C6-7. A neurological exam performed in April 2002 revealed hypesthesia on the right at C5-6 distribution. The patient has been on significant pain medications such as oxycodone and MS Contin. She continues to experience significant neck pain. The patients pain specialist has ordered a follow-up MRI of the cervical spine. The Health Plan has denied authorization for the requested MRI indicating that it is not medically indicated for evaluation of the patients condition.MRI is the best test to evaluate the cervical spine. As indicated in the article cited above, MRI is the procedure of choice for the detection and definition of spinal cord compression and intrinsic myelopathic processes associated with spondylosis and disc herniation. The advantages of MRI include direct multiplanar capability, lack of interfering bone artifact, and inherently high tissue contrast. In a patient such as this patient with chronic neck pain requiring significant pain medications, objective evaluation can be difficult. MRI provides valuable assistance in assessing the patients current status especially when there is a prior exam for comparison. The MRI, which was ordered by a pain specialist as part of the patients reevaluation of known cervical disc disease, is medically reasonable and appropriate in this case.Based upon the information set forth above, I have determined that the requested MRI is medically necessary for evaluation 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 56-year-old female enrollee with a body mass index (BMI) of 38. In addition, the patient has comorbid conditions including sleep apnea, hypertension, and degenerative disc disease. The patient has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery. The patient wishes to undergo gastric bypass surgery. With a BMI of 38 and documented comorbidities including significant sleep apnea and hypertension, gastric bypass surgery is medically indicated and necessary for this patient as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. Furthermore, 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old woman with a body mass index (BMI) of 37. She has comorbid conditions including gastroesophageal reflux disease, hypertension, and degenerative disc disease. She has requested authorization for gastric bypass surgery. The Health Plan has denied the patients request. With a BMI of 37 and her comorbid conditions, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. 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 32-year-old male with apparently well-documented cutaneous psoriasis, with extensive involvement of trunk and all four limbs. Records from his dermatologist and his primary physician make only one mention that the arthritis still affects the knees and the ankle joints, and this is not described elsewhere in the record. The dermatologist states that the patient has failed trials of Soriatane, oral prednisone, and topical triamcinolone, and further notes that methotrexate is contraindicated because the patient drinks alcohol. Nonetheless, the dermatologists last note of 1/30/04 states the patient has been started on methotrexate 7.5mg per week.The diagnosis of psoriatic arthritis is not established by the medical records. Cutaneous psoriasis itself is obviously very common, and is appropriately managed by dermatologists. In the management of patients with psoriatic arthritis, among whom a wide spectrum of cutaneous psoriasis is seen, it is quite obvious to all involved that tnf inhibitors produce major and sometimes dramatic improvement in skin manifestations, along with the joint benefits. Most providers using these drugs fully expect that drugs such as Enbrel will become accepted, standard therapy for cutaneous psoriasis itself in the near future. Tnf inhibitors combined with Enbrel or related drugs is not yet standard therapy for psoriasis in the absence of psoriatic arthritis.This patient needs evaluation by a rheumatologist to determine if he indeed has psoriatic arthritis, and, if so, to then consider therapeutic options. The use of methotrexate for psoriatic arthritis remains standard and often very effective treatment, for which the short-term toxicities and long-term risks are well understood and quite acceptable. The contraindications to methotrexate use primarily relate to pre-existing or active liver disease of certain types, and to uncontrolled alcohol abuse. The dermatologists statement that methotrexate would be contraindicated in this patient because the patient drinks alcohol would only be correct if the patient had a disorder of alcohol abuse; occasional alcohol use in moderation is acceptable behavior in the rheumatologic community, as the actual liver toxicity of methotrexate at anti-inflammatory dose levels has proven to be minimal. If this patient were shown to actually have psoriatic arthritis, then a trial of methotrexate by a rheumatologist would be accepted and standard therapy. In the event methotrexate fails due to lack of benefit or due to intolerable side effects, then the use of tnf inhibitors such as Enbrel would be appropriate and standard treatment. However, without a diagnosis of psoriatic arthritis and unless the patient fails an appropriate trial of treatment with methotrexate, Enbrel is not indicated. 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: Overturned Decision of Health Plan

The patient is a 54-year-old woman with a long history of depression, bipolar disorder, and post-traumatic stress disorder. She has been receiving weekly outpatient therapy from the same provider for the last two years. The patient has requested authorization for continued weekly outpatient therapy with her treating provider. The Health Plan has denied the patients request indicating that continued weekly outpatient therapy is not medically necessary for treatment of the patients behavioral health problems.Review of the submitted records indicates that the patient has clearly benefited from weekly psychotherapy. It is clear from the patients providers progress notes that his intervention has not only kept the patient out of the hospital, but has prevented self-injury. The documented pharmacotherapy seems to be of much less benefit. The patients psychiatrist also indicates that the requested therapy is clinically indicated. Clearly, discontinuation of the current frequency of therapy is likely to increase self-injurious behaviors and impair the patients level of functioning, possibly to premorbid levels. Furthermore, if therapy is discontinued it is likely to lead to rapid and significant clinical deterioration. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Weekly outpatient therapy with the patients current provider should be continued for a period of nine months with reevaluation of the patients clinical condition at that time. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 44-year-old female with a BMI of 45.5. She has comorbid conditions including degenerative disc disease. She wishes to undergo gastric bypass. Based upon the information provided it does not appear that the patient has undergone a psychological evaluation in order to determine if she is appropriate candidate for weight loss surgery. The patient wishes to undergo gastric bypass. The Health Plan has denied the patients request.With a BMI of 45.5 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 33-year-old male who sustained a complete ACL tear in June 2003. He underwent reconstructive surgery in September 2003 and apparently went through a rehabilitation program. On or about 10/29/03, a custom right knee orthosis was requested in order to allow the patient to return to sporting activities. There is no documentation of the patient having any post-operative instability, arthritis or pain.The information provided gives no indication that the patients knee was unstable post-operatively. It appears the equipment was ordered as a prophylactic over concern regarding further injury. There is no literature demonstrating the efficacy of braces in a stable knee following ACL reconstruction. Based upon this information, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has chronic daily headache, which has been responsive to daily triptans over the past two years. The submitted information indicates the patient has had success with a variety of triptans and generally uses one-half of a full dose. She currently is on Zomig 5mg and uses one-half tablet daily. She has previously failed Neurontin, Topamax, Depakote, NSAID, and Zonegran. A request has been made for 18 Zomig tablets per month. The Health Plan has denied the request.Analysis and Findings:While daily low-dose triptans are not standard of care, they are prescribed by headache experts around the world for patients who have failed standard treatment. This regimen is quite effective in a select group of patients. Additionally, daily triptan use does not appear to raise any safety concerns when prescribed for healthy patients. Thus, it is medically reasonable to treat chronic daily headache with 2.5 mg of Zomig daily. Therefore, I have determined that 16 tablets of Zomig 5mg per month are medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be partially overturned. Furthermore, due to the possibility of rebound headache, a seven-day discontinuance of triptan may be indicated to see if the patients headaches improve.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1The patient is a 42-year-old woman with a five-year history of right scapula pain. In addition, a review of the record indicates the patient experiences frequent headaches. The patient has requested authorization for Botox injections. The Health Plan has denied this request indicating that the requested injections are considered experimental.Use of Botox for headaches associated with cervical dystonia is an investigational application. There is no demonstrated efficacy of Botox for treatment of the patients condition. Until the FDA approves Botox for this indication, other treatment modalities are more appropriate. Therefore, I have determined that the requested therapy 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 2The patient is a 42-year-old woman with a history of a cervical and shoulder musculoligamentous strain resulting in cervicogenic headaches. The submitted records reveal a cervical disc bulge at C5-6, but not a ruptured disc. One of the patients treatment modalities has consisted of trigger point injections, which have provided some degree of relief. In addition, Neurontin has been prescribed. The patient has requested authorization for Botox therapy. The Health Plan has denied her request.The efficacy of Botox therapy for treatment of the patients condition has not been established. There is not sufficient data to demonstrate that Botox will help alleviate the patients symptoms. Repeated trigger point injections, combined with spasmolytic agents and massage are more likely to benefit the patient than Botox therapy. Therefore, I have determined that the requested therapy 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 3The patient is a 42-year-old woman with a history of a cervical and shoulder musculoligamentous strain resulting in cervicogenic headaches. The submitted records reveal a cervical disc bulge at C5-6, but not a ruptured disc. One of the patients treatment modalities has consisted of trigger point injections, which have provided some degree of relief. In addition, Neurontin has been prescribed. The patient has requested authorization for Botox therapy. The Health Plan has denied her request.The efficacy of Botox therapy for treatment of the patients condition has not been established. There is not sufficient data to demonstrate that Botox will help alleviate the patients symptoms. Repeated trigger point injections, combined with spasmolytic agents and massage are more likely to benefit the patient than Botox therapy. Therefore, I have determined that the requested therapy 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 50-year-old man with AIDS who has been treated with highly active antiretroviral therapy. The patients AIDS is under control on his present regimen. He is in excellent health otherwise. He has an undetectable viral load. The patient is concerned about AIDS wasting syndrome and wishes to undergo bioelectrical impedance analysis (BIA) testing. This is a method used by nutritionists and trainers to measure/estimate body composition. The Health Plan has denied the patients request indicating that BIA testing is not medically necessary.Review of the patients clinical information indicates that there is no evidence of HIV wasting disease. BIA testing has been used for many years but remains far from standard practice in assessing nutritional status. The most detailed recent studies include an NIH assessment in 1996. The conclusion was that BIA testing is affected by numerous variables including body position, hydration status, consumption of food and beverages, ambient air and skin temperature, recent physical therapy, and conductance of the examining table. The study further indicated that reliable BIA requires standardization and control of these variables. As the patient notes, different equipment used for BIA testing yields different results. Furthermore, there is no medical evidence to suggest that BIA testing is important for measuring wasting in HIV-infected patients. Based upon the information set forth above, I have determined that the requested testing is not medically necessary for evaluation 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 53-year-old man with dementia who failed treatment at a board and care facility due to decreased insight and an inability to perform activities of daily living. The patient was stabilized in an inpatient psychiatric unit and was discharged on 12/17/02. The patient was immediately re-admitted on an involuntary hold reportedly due to advanced disability and an inability to accept help. A request has been made for reimbursement for acute psychiatric treatment services received from 12/17/02 through 1/3/03.During the period in question, the patient had placement issues due to a failed stay at a board and care facility. Review of the submitted clinical records indicates that as of 12/17/02, the patient did not have psychiatric issues and did not pose a threat to others. Furthermore, the patient was not a threat to himself from a psychiatric standpoint, but rather, was at risk due to an inability to perform activities of daily living. As such, he did not require acute psychiatric care during the period in question. Therefore, I have determined that 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: Upheld Decision of Health Plan

The patient is a 57-year-old woman who has a long history of low back pain. The patient has participated in several treatment modalities including physical therapy, steroid injections, and medications; the patient continues to experience pain. She wishes to undergo lumbar spine surgery. The Health Plan has denied her request on the basis that the requested procedure is not medically necessary.The Health Plans denial should be upheld. Upon review of the submitted clinical information, there is no medical necessity for lumbar spine surgery. There is lack of agreement between the results of the MRI and the discography. Thus, the levels causing the patients pain cannot be precisely defined. As such, the patient is not likely to benefit from lumbar spine surgery. 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 60-year-old man who was diagnosed with HIV in 1995. The patient has been diagnosed with facial collapse grade IV lipodystrophy. He has requested subcutaneous facial augmentation to reconstruct the contours of his face. The Health Plan has denied the request indicating that the requested procedure is cosmetic in nature and is not medically necessary.Upon review of the submitted documentation, including photographs of the patient, there is no evidence of intertrigo, rashes, erythema or lacerations. Furthermore, the cheek is not a functioning unit and there is no evidence of a structural abnormality. Thus, the requested procedure is not reconstructive in nature and therefore, is not medically indicated. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old woman with a history consistent with an anxiety disorder. Her recent family and legal issues have apparently exacerbated her anxiety. The patient has been treated with benzodiazepines including Xanax, Ativan, and Klonopin. The submitted records do not indicate that any other medications were tried. The patient apparently only had beneficial results with Klonopin wafers. No records of any psychiatric consultation have been provided. The Health Plan indicates that Klonopin wafers are not medically necessary for treatment of the patients condition.The patient has only undergone trials of treatment with benzodiazepines. No attempts of non- medicinal treatment of the patients anxiety have been documented. In addition, there have been no documented trials of other classes of medications including tricyclics, selective serotonin reuptake inhibitors, beta-blockers, or Buspar. Trials of other medical and psychotherapeutic treatments should be attempted for treatment of the patients anxiety. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for the 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 34-year-old man who was admitted to inpatient status on 9/13/2003 and discharged on 9/29/2003. The patient was sent to the hospital via ambulance when his treating psychologist became concerned about the patients safety and deteriorating condition. The submitted clinical information indicates the patient was very seriously ill just prior to his admission. This patient has a 12-year history of depression and has been treated with various medications, which he apparently discontinued on his own requesting inpatient evaluation to establish a baseline. The patient reportedly also admitted to auditory hallucinations and paranoid delusions. The attending physician indicated the patient was paranoid regarding taking his medications while hospitalized. On 9/19/03, the patient started on a course of Remeron, Wellbutrin, and Zyprexa with a reported remarkable response. The Health Plan has denied reimbursement for the services at issue indicating that the patient could have been treated at a less intensive level of care.Review of the detailed clinical records indicates that this patient was experiencing a serious major depressive disorder with psychotic features at the time of his hospitalization. Given the patients deteriorating condition, concerns regarding his safety were justified. As such, acute inpatient behavioral health treatment was medically appropriate and indicated at the time. Therefore, I have determined that the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.