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

The patient is a 47-year-old female with metastatic non-small cell adenocarcinoma of the lung. She provided an annotated history detailing the course of her treatment.  In May 2003 Carboplatin and Gemzar were started with minimal response. Later in 2003 the patient began a clinical trial with G3139, which resulted in a minor response and then disease progression.  The patient was treated with Iressa in August 2004, and remained stable. In February 2005 there was progression of the patients bone disease and treatment with Tarceva was attempted and aborted.  One CT was done during this timeframe, but there is no information indicating whether Tarceva might have been active at the time. The patient was treated with radiotherapy in April 2005 and restaging showed further progression of her disease. Pemetrexed and Carboplatin were attempted in May 2005 but discontinued due to a non-specific neurological reaction. In June 2005 the patient began treatment with Avastin plus Alimta. A July 2005 CT showed mixed response and a September 2005 CT showed disease progression. Tarceva was then added and a November 2005 CT showed some regression of the patients disease.  The patient was treated with Avastin in combination with other drugs from June 2005 through February 2006.  The Health Plan authorized the initial three months of therapy, and the enrollee has requested reimbursement for the six months of therapy from September 2005 through February 2006.  The Health Plan denied her request based on a determination that continued therapy with Avastin was not medically necessary.The Health Plan initially denied authorization of Avastin as part of a fourth-line treatment approach, but subsequently authorized three months of treatment.  Nonetheless, the September 2005 CT showed progression of the patients disease after approximately three months of Avastin and Alimta therapy. In September 2005, in an apparent effort to achieve remission, her provider added Tarceva to the Avastin and Alimta regimen and a November 2005 CT did in fact show a regression of the patients disease. The patients clinical history leads to the conclusion that the addition of Tarceva was helpful in achieving the regression noted in November 2005. This is logical as there was no apparent failure of Tarceva when it was initially tried in February 2005.  Continued Avastin therapy was not indicated in September 2005 and it is unlikely that it contributed to the regression of the patients disease.Based upon the information set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 34-year-old female who does not have a diagnosis of cancer. Her mother does have a history of breast cancer as well as fallopian cancer. The patients mother has tested positive for a mutation of the BRCA2 gene, a marker of familial susceptibility to cancer. The patient wishes to have BRCA2 testing done and has submitted a request for authorization to the Health Plan.  The Health Plan has denied her request based upon a determination that the requested diagnostic procedure is not medically necessary.The presence of a mutation in the BRCA2 gene places a woman at high risk for both breast and ovarian cancer. The record provided for review included documentation of the patients mothers BRCA2 positivity.  BRCA testing may have several important implications for the health of the daughter of a woman with this mutation. A female who is positive for the BRCA2 mutation may require breast MRI in addition to routine mammogram and may also need to consider preventative mastectomy or oophorectomy.  Therefore, I have determined the requested diagnostic procedure 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 31-year-old female with dysfunctional dental malocclusion not treatable with orthodontic therapy. She has difficulty masticating a normal diet. The patients oral and maxillofacial surgeon notes posterior dental cross bite and left condylar hyperplasia. He recommends maxillary corticotomy. The patients orthodontist notes malocclusion and the need for surgical intervention for correction. The Health Plan has denied authorization for orthagnathic surgery on the basis it is not medically necessary for treatment of the patients condition.A review of the dental models, photographs, x-rays, cephalometric analysis, reports and recommendations of the patients doctors reveals a dysfunctional dental malocclusion with posterior cross bite secondary to mild maxillary bilateral hyperplasia and mandibular asymmetry. Additionally, it appears the left mandibular condyle is 3-4 mm longer than the right condyle. Furthermore, the patient has mild facial asymmetry with displacement of the mandible to the left. Based on these findings, surgical intervention is necessary to resolve the patients malocclusion. The requested maxillary corticotomy will result in functional dental occlusion and carries less risk and post-operative morbidity than other procedures. Surgical correction of the mandibular asymmetry secondary to condylar hyperplasia is not necessary. The requested procedure is needed to improve function and is not likely to result in cosmetic benefit, as it will not impact the patients facial asymmetry.  Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 61-year-old woman with knee arthritis. She had a series of Synvisc injections last year, which provided pain relief for six months. A request has been made for a repeat series of injections. The Health Plan has denied this request on the basis that Synvisc is not medically necessary for treatment of the patients condition.The patient is relatively young to have severe arthritis and appears to be in eventual need of knee replacement. A second series of injections is a reasonable treatment option. The first series resulted in significant relief. A repeat series of Synvisc injections is appropriate to alleviate pain and postpone surgical intervention. Therefore, I have determined the requested injections are 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 43-year-old female who is 51, weighs 210 pounds, and has a body mass index (BMI) of 40. She also has significant comorbid conditions including gastroesophageal reflux disease and dyspnea upon exertion. Previous attempts at weight loss have not been successful.  It is not known if the patient has received psychological clearance for weight loss surgery. The Health Plan has denied coverage for laparoscopic adjustable gastric banding (Lap-Band) based upon their determination that it is not medically necessary for treatment of the patients medical condition.The long-term success of the Lap-Band when measured in terms of maintaining excess body weight loss is inferior to the gastric bypass or duodenal switch operations. The limited result of the procedure does not come with limited risk. In a three-year follow-up study of 299 patients with the Lap-Band, 88% had post-operative complications ranging from reflux to stomach-band outlet blockage.  In this study one-fourth of the patients had the band removed.  This patient already has reflux disease according to her provider, so she is at even greater risk of complications with the Lap-Band procedure.  Based upon the information set forth above, 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 female with multiple sclerosis (MS).  According to the record, she can walk with a cane for limited distances.  The patient states she has fatigue after walking short distances, and has decreased upper body strength.  The record did not include an objective assessment of the patients strength, range of motion, and mobility skills. The patient has requested authorization for a power-operated vehicle (POV). Her request was denied by the Health Plan based upon a determination that the equipment is not medically necessary.The records provided are not supportive of the patients need for a POV. Although the patient indicates she cannot operate a standard wheelchair, there is no specific evaluation of the patients mobility and no indication of a need for a POV within her home. The information provided indicates the patient can still walk a block with a cane. Also, the records indicate the patient walks with a cane most of the time. Therefore, I have determined the requested equipment is 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 64-year-old woman with knee arthritis. She underwent a series of Hyalgan injections in July 2005. A request has been made for authorization for a second series of injections. The Health Plan has denied this request on the basis that the injections at issue are not medically necessary.The patient achieved great pain relief with her first series of injections. She is a surgical candidate with severe arthritis in her knee. She is attempting to postpone surgery as long as possible. A second series of injections is a reasonable treatment option. The first series resulted in significant relief. The patients only other option is total knee replacement. A second series of Hyalgan is appropriate to alleviate pain and postpone surgical intervention. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old female who is requesting reimbursement and prospective authorization for the use of Celebrex for osteoarthritis of her hip. The Health Plan has denied coverage for Celebrex indicating the patient has not undergone a sufficient trial of NSAIDs. At issue is whether Celebrex is medically necessary for treatment of the patients condition.Review of the submitted clinical evidence does not demonstrate that the medical necessity of a Cox-2 inhibitor (Celebrex) has been established. There are a number of NSAIDs available, and the medical records do not demonstrate NSAIDs are contraindicated or have been ineffective. Thus, there is no evidence that Celebrex is medically necessary at this time. Therefore, I have determined that the medication at issue was/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 who has had rosacea for many years. Her previous provider indicates she had much greater improvement with Finacea gel than with MetroGel or Doxycycline.  The patients request for authorization of Finacea gel was denied based upon the Health Plans determination that it was not medically necessary to treat her rosacea.The patients rosacea has been effectively treated with Finacea gel for some time after the failure of MetroGel and Doxycycline.  To discontinue an effective treatment in favor of additional trials would not be medically appropriate.  Therefore, I have determined that Finacea gel 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 53-year-old female with a reported history of anorectal hygiene problems as a result of excess skin following substantial weight loss. The record does not include any physician documentation of medical complications related to her concerns. The patients primary complaint is related to the inconvenience of performing anorectal hygiene due to her excessive skin. She has requested authorization and coverage for a buttock lift, which has been denied by the Health Plan on the basis that it is not medically necessary.The patient complains of problems with post-bowel movement hygiene related to her excess buttock skin. Skin excess following massive weight loss is a common clinical condition. The submitted photographs do not demonstrate skin excess that is exceptional or different than what is ordinarily found in either obese or post-bariatric patients.  Furthermore, review of the medical literature does not reveal any studies or topic reviews identifying perirectal hygiene as an indication for surgery in this group of patients. The records do not document any skin rashes or perirectal inflammation secondary to her condition. Buttock lift is generally considered a cosmetic procedure, and the patients complaints are subjective and primarily related to inconvenience rather than a true medical problem.  The Health Plan is correct that the patients concerns should be manageable with normal hygiene and perhaps treatment directed toward hardening her stools. Improvement of anorectal hygiene is not a standard or medically necessary indication for a buttock lift.Based upon the information set forth above, 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 is a 17-year-old male with bronchial asthma. He received Xolair injection therapy between October 2004 and June 2005.  His provider indicates that while receiving Xolair, the patient was stable and did not require acute office visits or hospitalizations, and was able to return to school.  Prior to the institution of Xolair therapy, he had high absenteeism due to his symptoms.The Health Plan denied continued coverage for Xolair in June 2005. The patient experienced acute exacerbations of asthma in September 2005.  Off Xolair therapy he again required systemic steroids, as well as Advair, Singulair and Zyrtec. In October 2005, the patients provider indicated the patient had not been able to advance to optimal maintenance level on his allergy shots without Xolair, and that prior to Xolair therapy a DEXA scan showed the presence of osteoporosis. Based on the fact that the patients asthma worsened off Xolair therapy, the patients provider has requested that the therapy be reinstated.At issue is whether Xolair is medically necessary for treatment of the patients medical condition.Upon review of the submitted clinical evidence, the patient qualifies for treatment with Xolair in all categories, and is unable to use high dose inhaled corticosteroids and oral steroids due to a diagnosis of osteoporosis. Clinical criteria for Xolair therapy includes:  age greater than 12 years; allergic asthma; and asthma that has not responded to standard medication such as Advair, Singulair, and albuterol. The submitted records document that the patient continues to suffer from allergic asthma when limited to standard medication and is unable to achieve an optimum dose of allergy immunotherapy. Xolair anti-IgE therapy has been shown to be effective in advancing immunotherapy to effective doses.The physician letters, clinical notes, and letter from the patients parent clearly indicate that the patient responded to Xolair therapy and had a documented deterioration of asthma during a trial without Xolair therapy. Thus, continued Xolair therapy is medically necessary given the patients diagnosis and concurrent medical complications.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 15-year-old male with an ACL tear. He is scheduled to undergo ACL reconstruction in April 2006 and his orthopedic surgeon has prescribed a CPM machine as part of his postoperative rehabilitation. The patients parent has requested authorization and coverage for the rental of the device. The Health Plan denied the request based upon their determination that the CPM machine is not medically necessary following the patients surgery. A CPM machine is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. Patient compliance appears to be high and many surgeons find that patients regain their range of motion faster and have better pain control with the device. The orthopedic community recognizes the benefit of early range of motion following this type of surgery and the use of the device postoperatively is medically appropriate. Therefore, I have determined the requested device 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 46-year-old female with a history of degenerative joint disease, rheumatoid arthritis, total knee replacement, cervical spondylosis, herniated disc at C4-5, cervical disc excision with fusion and spinal stenosis and disc protrusion at L5-S1. The record did not include an objective assessment of the patients strength, range of motion, and mobility skills. The patient has requested authorization for a power-operated vehicle (POV). Her request was denied by the Health Plan based upon a determination that the equipment is not medically necessary.The records provided are not supportive of the patients need for a POV. There is no specific evaluation of the patients mobility and no indication of a need for a POV within her home.  In January 2006 her provider noted that the patient cant walk very far, really just in house and based on the patients letter, the POV is requested for mobility outside of the home. Therefore, I have determined the requested equipment is 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 12-year-old male with short stature, who had been growing clearly below the 3rd percentile prior to the initiation of therapeutic growth hormone at the age of eight years. The therapy has continued and he is followed by a pediatric endocrinologist. An interval note dated January 2006 indicated a height of 140.1cm (11th percentile) with a bone age appropriate for his chronological age. Before growth hormone therapy was begun the patient had two IGF-1 levels in the low and very low normal ranges. The endocrinologists letter indicated that an MRI was planned, but there is no record of this in the material submitted. The parents request for continued authorization and coverage of growth hormone therapy was denied by the Health Plan based upon a determination that the therapy is not medically necessary.It is probable that this patient has a growth hormone deficiency. Prior to the initiation of growth hormone therapy he had repeatedly low IGF-1 levels with no other identified cause for his short stature and retarded bone age.  Following the initiation of growth hormone therapy both his bone growth rate and his IGF-1 levels were normalized. In light of the patients response, he should continue to receive growth hormone and see his endocrinologist regularly to ensure that no side effects have developed and that he continues to have a positive growth response to the therapy. Follow up regarding the MRI of the brain is also important.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old female with bilateral lower extremity pain.  She reports that her symptoms were previously treated with sclerotherapy, but the provider is no longer with the Health Plan. A vascular surgery consultation from November 2005 revealed only telangiectasias (spider veins). The patients request for additional sclerotherapy was denied by the Health Plan based on a determination that the procedure is not medically necessary.Universally, vascular surgeons consider telangiectasias to be a cosmetic condition.  While the patient may be reporting pain and other symptoms, there is no evidence in the literature that treatment of telangiectasias with sclerotherapy will resolve those symptoms. 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 is a 53-year old male admitted for acute medical care in November 2005 continuing through March 2006.  He underwent LVAD placement in December 2005 and closure of tongue wounds in March 2006.  He had a subsequent rupture of the tongue wound with massive bleeding and returned to surgery.  The patient participated in physical and occupational therapy during his acute medical hospitalization.  According to the physical therapy notes he received physical therapy twice per day in March 2006 with LVAD precautions. He required moderate two person assistance to stand and transfer and minimal assistance for ambulation from 120 to 600 feet. As of March 2006 he was independent with upper body activities of daily living (ADLs) and needed maximal assistance with lower body ADLs.  The patient was transferred to the acute rehabilitation program in March 2006 and was not taking anything by mouth at that time.  He was fed via nasogastric tube secondary to his tongue wound. He worked closely with speech therapy and began oral feeding in March 2006.  The patient required careful monitoring to advance his diet.  Per the physician notes, at the time of admission the patient had an LVAD, a PICC line, several open wounds, and required careful medical monitoring by his physician.  Physical and occupational therapy findings during acute rehabilitation were consistent with his previous therapy. He continued to make slow progress through March 2006 when he was discharged home.The patients request for reimbursement for the acute rehabilitation services was denied by the Health Plan based upon a determination that the services were not medically necessary.Based on the records provided, the patients primary rehabilitation issue was general deconditioning.  In most cases this problem in and of itself, would not have required acute rehabilitation and the patients progress with therapy was somewhat slow. However, the patients medical problems were significant and he required daily medical evaluation and acute nursing care in addition to his on-going rehabilitation needs. The necessary level of medical care could not have been provided in a subacute or skilled rehabilitation program. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.