Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 45-year-old male with two level degenerative disc disease at L4-5 and L5-S1, confirmed by MRI and discogram.  It has been recommended that he undergo percutaneous lumbar disc annuloplasty using the IDET technique.  The Health Plan considers the procedure experimental and therefore, has denied authorization.The proposed procedure is experimental at this time.  There is no class I data to support the use of percutaneous lumbar annuloplasty for the treatment of multi-level lumbar degenerative disc disease.  The outcomes for this interventional procedure, like many similar techniques for degenerative disc disease, are historically poor. This patient should be treated conservatively with physical therapy, anti-inflammatories, and other non-interventional measures.  Because the proposed annuloplasty is not of established efficacy, I have determined that it is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 45-year-old male with back pain that interferes with his work and routine daily activities.  He has tried some conservative treatments without measurable success.  It has been recommended to him that he undergo percutaneous lumbar disc annuloplasty utilizing the IDET technique. The Health Plan has not authorized the procedure based on its experimental/investigational status.The requested procedure has not been proven effective in any long-term prospective studies, and it is therefore experimental/investigational.  It is noted in this particular case, the likelihood of success is only about 50%.  This is not an acceptable risk for a procedure with limited documentation of its reliability.  The patient is likely to achieve superior results from standard treatment modalities. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient has a history of chronic low back pain. He has attempted conservative therapy including medications and physical therapy without lasting benefit. He has undergone a discogram that was positive at multiple levels. He is now requesting authorization for percutaneous lumbar disc annuloplasty using the IDET technique.All evidence regarding percutaneous lumbar disc annuloplasty is either non-controlled or non-prospective. The proposed procedure does not have proven long-term efficacy. Complicating this case is the patients multilevel positive discography. Given these results, it is highly unlikely that percutaneous lumbar disc annuloplasty will provide the patient any benefit. Therefore, I have determined that the requested procedure 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

This patient is a 54-year-old woman with a history of multiple myeloma. There is also a reported diagnosis of amyloid heart disease. She developed a pneumonia that required hospitalization in August 2005. This followed several plasmapheresis treatments and the patient was said to have been markedly hypogammaglobulinemic at the onset of her pneumonia. As an inpatient, she was treated with vancomycin and levofloxacin. When discharged, she was given linezolid (Zyvox) and levofloxacin (Levaquin). Authorization for the Zyvox was denied because the Health Plan determined it was not medically necessary.Key to this case is the fact that no culture of sputum was performed although the patient was noted to have a productive cough. Zyvox is an excellent drug for methicillin-resistant staphylococcus aureus (MRSA) pneumonia. It is also a more desirable option than continuing vancomycin by outpatient IV administration. In this case however, the presence of staphylococcal infection was not documented.  Given the absence of documented evidence of staphylococcal infection, the use of Zyvox was not medically warranted. Therefore, I have determined the medication 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: Upheld Decision of Health Plan

The patient is a 59-year-old female with a history of fatigue, fibromyalgia, Fanconis syndrome and Bartters syndrome. The patient had a traumatic brain injury at the age of 35 when she fell off a horse. She was unconscious for four hours. In 2002 she was felt to have growth hormone deficiency resulting from her brain injury 24 years earlier. Her IGF-1 level in 2002 was 107 ng/ml. In July 2002 she had a peak response of 3.2 ng/ml during Arginine GH stimulation testing. She appears to have been treated with Genotropin since 2002. According to the notes of her treating physician, the patient had some improvement of her fatigue after beginning growth hormone therapy. The patient is also receiving estrogen and Prometrium. Her cortisol level was normal on two laboratory tests. There is no ACTH level, TSH level and free T4 level documented in the records provided, nor has imaging data of the patients brain been provided.At issue is whether growth hormone therapy is medically necessary for treatment of the patients condition.This is a 59-year-old female patient with a history of head trauma at the age of 35. Pituitary insufficiency has been documented after head trauma. Most deficiencies occur within the first to fifth year following the injury. Pituitary deficiencies after five years are rare. Furthermore, the patients IGF-1 level before treatment was normal at 107 ng/ml. Her Arginine stimulation test showed stimulation to 3.2 ng/ml. An Arginine stimulation test alone is not sufficient to document growth hormone deficiency. ITT and ARG-GHRH are the gold standards for determining if a patient is growth hormone deficient. Moreover, there is no documentation in this case of TSH, T4 and ACTH levels and no imaging studies are documented. For these reasons, 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

The patient is a 38-year-old female stated to have weighed nearly 500 pounds prior to gastric bypass surgery in November 2004. The patients physician and her bariatric surgeon have suggested the patient needs to be evaluated for panniculectomy by a plastic surgeon. The Health Plan has denied authorization for a consultation with a plastic surgeon citing a lack of medical necessity.The submitted materials include photographs of the patient, medical records, and a letter from the patients bariatric surgeon. These clearly demonstrate that the patient has a significant pannus hanging well below the pubis and the potential for intertrigo. However, there is no definitive evaluation by a plastic surgeon familiar with this significant deformity to assess medical necessity. Based upon the information provided, it is highly likely the patient will require a panniculectomy at some point to relieve her back pain as well as the potential for intertrigo. The patient should be evaluated by a plastic surgeon to determine if surgical invention is medically appropriate and indicated at this time. Therefore, I have determined 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: Upheld Decision of Health Plan

The patient is a 52-year-old woman who had a benign dermatofibroma of the right calf removed in June 2005. She was concerned about the appearance of the scar two to three months after the procedure.  The patient requested a scar revision, which the Health Plan has denied as not medically necessary.Reviewed are the records of the patient, which include her initial dermatological evaluation, operative procedure note, pathology report, and follow-up evaluation by her surgeon (photographs not provided). All records concern the removal of a benign dermatofibroma of the right calf and the resulting scar, which measured 1.5 cm x 1.0 cm x 0.5 cm. Scars in this area of the body can take upwards of eighteen months to reach maturity and to lose their excess bulk and pronounced color. Thus, the patient is not an appropriate candidate for scar revision at this time. 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 61-year-old male who underwent excision of a right calcaneal spur in April 2005. Left heel spur surgery was performed several years ago. After wearing the same pair of orthotics for over 10 years, the patients podiatrist recommended a new pair of custom orthotics. The Health Plan has denied authorization for the requested orthotics on the basis they are not medically necessary.There has long been a debate regarding the efficacy of pre-fabricated orthotics versus custom orthotics. Recent literature concludes that pre-fabricated orthotics are equally effective as custom orthotics. There is no evidence that the patient will not benefit from pre-fabricated orthotics. Although pre-fabricated orthotics may lose their efficacy sooner than custom orthotics, they can be replaced as needed. Therefore, I have determined the requested orthotics are 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 57-year-old female with a history of brain surgery for a tumor. The patient has cognitive defects, fatigue and depression. She has been treated with multiple medications. A combination of Aricept and Provigil has improved the patients cognitive functioning and mood. At issue is whether Provigil is medically necessary for treatment of the patients condition.The patient has benefited from her current combination of medications. Trials of other stimulants and antidepressants were not as beneficial. Provigil is significantly safer than amphetamines or Ritalin for this patient. It is used in the psychiatric community off-label for the treatment of depression, fatigue, and poor concentration with good results. As such, continuation of Provigil is medically appropriate and indicated in this clinical setting. 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

The patient is a 41-year-old male with mobility limitations and a weight of 414 pounds or greater.  The Health Plan authorized a power-operated vehicle (POV) for him.  The patient has specifically requested the Pride Maxima 4-Wheel Heavy-Duty Scooter, but the Health Plan determined the Sprinter Jumbo 3 power scooter was a better choice for this patient because it has a greater maximum weight capacity (500 pounds vs. 450 pounds).  The Health Plan has denied the patients request for the Pride Maxima scooter asserting it is not medically necessary that the patient have this particular model of POV.I have reviewed the records provided and am aware that there are varying reports of the patients weight.  He himself reported a weight of 449 pounds in a letter written in August 2005.  His lowest recorded weight was 414 pounds in October 2005, as noted by his primary care provider. The exact weight of the patient is not as significant as the fact that his weight fluctuates significantly. When you consider a weight delta of 35 pounds over a period of approximately two months, a POV with a weight limit of only 450 pounds is not appropriate.  I concur with the Health Plans determination that a POV with a 500-pound weight capacity is the more appropriate selection for this patient.Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 50-year old male who has a history of atrial fibrillation and possible prior angina or coronary artery disease (CAD).  He underwent a non-contrast electron beam computerized tomography (EBCT) scan of the heart in January 2005. At the same time, non-contrasted CT scans of the pelvis and abdomen were performed for screening for prostate cancer. The Health Plan has denied coverage for these diagnostic imaging services based on a lack of medical necessity.EBCT is not currently recommended as a screening test for CAD by the American College of Cardiology or the US Preventative Services Task Force.  For high-risk patients, non-invasive risk stratification with a myocardial perfusion agent is recommended. Once prior CAD has been established, an EBCT offers little more in terms of treatment direction. Thus, the use of EBCT scanning in this case was without clinical value and therefore, not indicated.Regarding the CT scans of the pelvis and abdomen, although CT scanning is often used to determine if metastatic disease is present, non-contrasted screening scans as were performed in this case, are of limited value and do not exclude the possibility of metastasis. The documentation provided does not clearly indicate the level of concern for prostate cancer or what other test results (bone scan, x-rays) identified the need for CT scanning. If a CT scan were indicated, a non-contrasted scan for tumor would not normally be the first step and therefore, the CT scans of the pelvis and abdomen were not medically warranted.Based upon the information set forth above, I have determined the diagnostic imaging at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has Hepatitis C infection and began treatment with Pegasys in December 2003. His Hepatitis C viral load was less than 50 IU/ml in November 2004. The therapy was discontinued in January 2005 because of side effects. He resumed therapy with Pegasys in April 2005. Laboratory studies from May 2005 showed a viral load of 11, 500,000 IU/ml. The patient has requested authorization and coverage for continued treatment with Pegasys. The Health Plan has denied the patients request on the basis that Pegasys is not medically necessary.Review of the patients Hepatitis C PCR results indicates there was only one undetectable viral load in November 2004. Treatment with Pegasys clearly has not been effective for this patient. The goal of therapy is to eliminate the virus rather than to decrease the viral load. Given the patients inadequate response to therapy, continued use of Pegasys is not medically warranted. 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

The patient is a 39-year-old female with a body mass index (BMI) of 37.5 and multiple comorbid conditions including diabetes mellitus and hypertension. She has undergone a psychological evaluation and received clearance for weight loss surgery. The patient indicates that she has researched all of the surgical procedures and has selected the duodenal switch operation for treatment of her obesity. The Health Plan has denied coverage for the duodenal switch procedure asserting that this surgical procedure is not medically necessary for treatment of the patients condition.With a BMI of 37.5 and significant co-morbid conditions, the patient is an appropriate candidate for surgical intervention to treat her morbid obesity. The literature shows that duodenal switch is a safe and effective form of weight loss surgery. Furthermore, there is a large body of scientific evidence that shows superior short and long-term outcomes with the duodenal switch procedure when compared to the gastric bypass or the lap band procedure. Consequently, duodenal switch is an accepted and medically necessary procedure for this 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 54-year old male with a history of chronic neck and back pain resulting from a slip and fall in his bathtub in August 2004.  According to the patient, traditional treatment, i.e., physical therapy and medication, had not given sustained relief.  He did however report that he had benefited from acupuncture treatments.  The patient had 12 acupuncture treatments and has requested authorization for additional treatments.  He also had open-heart surgery in February 2005 and does not want to be dependent on heavy medication.  The Health Plan has denied his request for additional acupuncture treatments as not medically necessary.The patient had 12 acupuncture treatments from April 2005 through August 2005 and states these treatments have given him relief from pain and he had been able to reduce his pain medications.  Unfortunately, the treatment notes for these dates do no reflect any change in his symptoms with the exception of the July 2005 notes, which do indicate some pain relief and reduction of medications.  The provider notes after that date only indicate low back, neck and shoulder pain.  There is no indication in the records of whether the symptoms have improved or worsened with the additional treatments.   Therefore, based on the lack of outcome information in the submitted records, 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

The patient is a 50-year-old female with multifocal breast cancer, which has been appropriately treated. She is of Dutch heritage and is the only child of her mother, who also was an only child who succumbed to breast cancer. The patients grandmother (mothers mother) also died of cancer, type unknown. The patient has four children. She has requested authorization and coverage for BRCA 1 and BRCA 2 genetic testing. The Health Plan has denied this request on the basis the requested genetic testing is not medically necessary in this clinical setting.This patient developed breast cancer at the age of 49. Even without a strong family history the patient qualifies for consideration of BRCA testing. Although testing will not impact the patients treatment, it may have a significant impact on the patients children and other family members. It is medically reasonable and appropriate for the patient to undergo the requested genetic testing as it will provide significant future value for her children. Based upon the information set forth above, I have determined the requested genetic testing is medically necessary. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old female with bilateral knee pain. She was involved in a motor vehicle accident in July of 2004 and has had unresolved knee pain since that time. The patient requests MRI studies of both knees to identify the source of her persistent pain. The Health Plan has denied her request, stating there is no medical necessity for the requested diagnostic procedures.There are no evidence-based or physical findings indicating that MRI studies of the patients knees are medically warranted. If the patient has continued pain she would benefit from an orthopedic consultation. If, in the course of that examination the orthopedist finds abnormalities warranting further workup, then MRI studies may be appropriate at that time. However, based upon the information provided at this time there is insufficient evidence demonstrating that the requested diagnostic procedures are medically necessary. Therefore, 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 a body mass index (BMI) of 38.4. In addition, the patient has diabetes mellitus, hypertension, and joint and back pain. The patients provider has recommended the patient undergo Roux-en-Y gastric bypass surgery. In addition, the provider believes an open liver biopsy is indicated to monitor hepatic functional status. The Health Plan has denied authorization for the requested services on the basis that the patient does not meet medical necessity criteria for weight loss surgery.With a BMI of 38.4 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. Based upon the evidence provided, there is no medical necessity for gastric bypass surgery or a liver biopsy in this case. Accordingly, I have determined that the requested services are 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 43-year-old female diagnosed with attention deficit hyperactive disorder (ADHD) and Graves disease, previously treated with Ritalin SR 20mg twice daily.  She is specifically requesting Ritalin SR from her Health Plan, which has indicated it is not a formulary medication. The patient has contested the denial of Ritalin SR, indicating that because she felt stable and much more productive for the past six years with the Ritalin SR, she does not want her medication switched to the formulary medication, Metadate CD. In addition, she believes that her Graves disease poses an added risk and makes her particularly sensitive to side effects of various medications. Finally, she reports receiving medical advice to avoid generics and she notes failed prior trials of generic Ritalin and Cylert. The Health Plan believes there is no evidence that Metadate CD would be any less effective than Ritalin SR. Therefore, the Health Plan has denied authorization for Ritalin SR as not medically necessary.Though there may be no set evidence that one stimulant is necessarily more effective than another across a large populace of patients with ADHD, this does not detract from the evidence of differential benefit for any one patient. The submitted evidence documents the efficacy of Ritalin SR for this patient. The fact that the patient has been stable and productive for six years with Ritalin SR argues most favorably for continuing her medication as is. All told, I find that the requested medication, Ritalin SR, is medically necessary for treatment of the patients ADHD. Accordingly, the Health Plans denial should be overturned.