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

The patient is a 53-year-old male with a longstanding history of alcohol dependence. He was first admitted to acute inpatient hospitalization for alcohol detoxification where he remained for five days. He was also diagnosed with alcoholic cirrhosis.  The patient was referred for residential treatment and at the time of his admission he noted recent use of alcohol and never having been treated for alcohol abuse up to that point.  The patient had not received outpatient counseling nor attended Alcoholics Anonymous (AA).  During the admission process the patient was quoted as saying there was an extreme need for alcohol treatment.  He denied social or family problems and reportedly felt that he had not suffered any psychological or emotional problems in the last 30 days.   His course in residential treatment was unremarkable except that the patient apparently felt that he was ready to leave the program earlier than his counselor advised.  He remained in residential treatment from the Middle of July 2005 through the end of July 2005 and was discharged against medical advice. Given that the patient recognized the gravity of his drinking, at least from the standpoint of the deleterious effect on his physical health, it is unclear why he was not first referred to an outpatient program. There is no indication in the record of previous attempts at alcohol rehabilitation at the outpatient level. There did not appear to be any social, family, or emotional problems, and the marital relationship was apparently intact. The social supports available to the patient were entirely adequate for the successful pursuit of outpatient treatment.  All told, I have determined 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: Overturned Decision of Health Plan

The patient is a 13-year-old male with failing growth who has been denied authorization for growth hormone therapy. As of March 2006 the patients height was 134.1cm. A bone age study performed in February 2006 at the chronological age of 12 years 2 months revealed an estimated bone age of 11 years.  IGF-1 was 129. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.The patient has been dramatically falling off the percentile for height (50th to less than 3rd percentile), has been found to have a pathologically small pituitary gland, has had low levels of growth hormone dependent IGF-1 and IGFBP-3, and has been found negative for alternative explanations for his growth failure such as hypothyroidism, inflammatory bowel disease and celiac disease. As stated by the patients endocrinologist, provocative testing for GH levels would not contribute further to the diagnosis of GH deficiency. Growth hormone therapy is medically appropriate and indicated in this instance and should be authorized.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 59-year-old female with a 12-year history of severe sero-positive, anti-CCP positive, rheumatoid arthritis who has failed treatment with prednisone, Plaquenil, Arava, sulfasalazine, methotrexate (MTX), and Kineret.  The details of these failures are not explained in the provided records (i.e. toxicity or lack of response). The patient did respond to Remicade after she was titrated to a dose of 6mg/kg every four weeks. She then had to stop Remicade in August 2004 because the cost to her was prohibitive. Without Remicade there was a worsening of her arthritis, an increased steroid requirement, repeated local steroid injections, and a reported loss of employment. The patient was restarted on Remicade at the authorized dosage of 3mg/kg every eight weeks.  This therapy again failed and her provider has requested Remicade 6mg/kg every four weeks to gain control of her disease.  The Health Plan denied the request citing a lack of medical necessity.It is well known in the rheumatology community that many patients respond adequately to Remicade only after the dosage is increased, the treatment interval is shortened, or both.  This approach is the current standard of practice in the treatment of rheumatoid arthritis. The patient has previously demonstrated a dosage response at 6mg/kg every four weeks, and therefore the medically necessary dosage and frequency has been established for this patient. A recent report in Rheumatology confirms this dosage response.  Although the requested prescription of Remicade is medically appropriate and indicated, the use of Remicade should be accompanied by MTX or another immunosuppressive agent. The submitted records indicate the patient has failed MTX but it is not known whether this was due to toxicity or lack of response. It is clear that Remicade treatment must be accompanied by MTX (or by other immunosuppressive agents such as Imuran or Arava) to avoid the appearance of haca due to the immunogenicity of Remicade itself. Based upon the information set forth above, I have determined the requested prescription is medically necessary for treatment of the patients medical condition depending upon the concurrent use of MTX or another immunosuppressive agent. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has advanced hepatitis C-induced liver disease based on liver biopsy results. He failed daily interferon therapy in 1997, Intron A in 1998 and Pegasys in 2004. The patients provider has recommended the patient initiate treatment with Infergen and ribavirin. The Health Plan has denied authorization for the proposed therapy on the basis that it is not medically necessary.The use of Infergen and ribavirin in this clinical setting is medically appropriate and indicated. Infergen has been approved by the Food and Drug Administration for the treatment of patients who are non responsive to traditional hepatitis C therapy. The patient has failed all other available medications. As such, he is an appropriate candidate for the requested therapy. Accordingly, 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 33-year-old female who is 66 inches tall, weighing 326 pounds with a body mass index (BMI) of 52. She is requesting authorization for gastric bypass surgery. The patients comorbid conditions include hypertension, degenerative joint disease, depression, gastroesophageal reflux disease, and obstructive sleep apnea. She has completed a psychological evaluation and was found to be an appropriate candidate for weight loss surgery. At issue is whether gastric bypass surgery is medically necessary for treatment of her medical condition.With a BMI of 52 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. 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. Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 36-year-old woman who indicated she was bitten by a tick in 1998.  There is no record that she had Erythema migrans (the skin rash that is classical for early Lyme disease). She is noted by her provider to have had some of her symptoms since she was a teenager. The patient reports a variety of symptoms including nausea, fatigue, nerve pain, flu-like symptoms, poor memory, vertigo, confusion, limited sleep, joint and muscle pain, low temperatures, headache and pruritis.  Reported physical examinations and vital signs are unremarkable.There is no evidence in the record that the patient has Lyme disease. A single IgM Western Blot result is provided. This test was performed in April 2005 and is negative by CDC criteria.  No Babesia test results have been provided. The patients provider noted Lyme results as  equivocal in January 2005 and in a clinic note two weeks later noted +/- results for both Lyme and Babesia. The only abnormal test reported is the CD8/CD57 lymphocyte ratio. This is of uncertain significance and does not suggest Lyme disease. The patient has been treated with oral antibiotics including Zithromax, Cipro, Levaquin, Flagyl, Hydroxycholoquin, Ketek, and Tinidazole and with IV Rocephin. A request for reimbursement for previous antibiotic treatment as well as prospective authorization for an additional 12 weeks of IV Rocephin therapy. The Health Plan has denied this request indicating there is no evidence that the use of IV Rocephin beyond the initial four-week period is medically necessary.The evidence provided in this record does not establish a diagnosis of Lyme disease.   The CDC approach (screening test followed by Western Blot studies) remains the accepted route to a serological confirmation of Lyme disease. In this case, there is a negative IgM Western Blot.  The record does not include evidence of a IgG Western Blot or a screening test.   There is also no Babesia test data in the record. The patient has already received months of treatment with oral antibiotics and a month of IV Rocephin.   Because the diagnosis of Lyme disease was not substantiated the therapy at issue was/is not medically necessary. Even if there was convincing evidence of Lyme disease, there is no peer-reviewed data supporting more than 30 days of IV antibiotic treatment for Lyme disease in any form. Therefore, I have determined the therapy 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: Upheld Decision of Health Plan

The patient is a 42-year-old female with a presumptive diagnosis of narcolepsy and symptoms of hypersomnolence. She has been maintained on Provigil for over six years. The patient underwent a sleep study in September 2000, which revealed a mild, non-positional sleep breathing disorder consistent with mild upper airway resistance syndrome. There was no specific evidence of narcolepsy or obstructive sleep apnea. The patients request for authorization of Provigil was denied by the Health Plan citing a lack of medical necessity.The FDA approved indications for Provigil include narcolepsy syndrome, sleepiness due to obstructive sleep apnea and sleepiness due to shift work sleep disorder. Additional off-label uses include the treatment of attention deficit disorder, fatigue associated with chronic diseases, psycho-stimulant abuse, and depressive disorders. None of these indications apply to this patient as she is reportedly being prescribed Provigil for excess daytime sleepiness without an identified etiology; there is no evidence of narcolepsy.  Other treatment modalities including sleep hygiene interventions, increased exercise, and/or dietary modifications are available that might be explored. Additionally, an MSLT was previously recommended, but there is no evidence the testing has been completed. The potential side effects of Provigil are significant and include cardiovascular and psychiatric symptoms. Hence the risks associated with this medication are not outweighed by the patients subjective report of symptom improvement.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 47-year-old female who is requesting authorization for pterygium surgery.  The condition is causing her pain, inflammation and irritation. The patient has been using therapeutic eye drops without improvement in her signs or symptoms.  The consulting specialist recommends surgical excision with a conjunctival autograft and has submitted a request for authorization.  The Health Plan denied the request citing a lack of medical necessity.The consulting surgeon has recommended excision of the patients pterygium together with a conjunctival autograft.  This is appropriate therapy in light of the fact that the patient has considerable discomfort and has been using therapeutic eye drops without noticeable improvement.  The symptoms experienced by the patient do not constitute a cosmetic complaint, but rather a medical condition, which can be corrected with the proposed surgery.  Therefore, I have determined the requested procedures are 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 had pituitary surgery in June 2004. She is complaining of abdominal weight gain and problems with memory and thinking.  She had normal prolactin, ACTH and cortisol levels and normal thyroid function tests. An insulin tolerance test was performed and hypoglycemia did not induce a rise in growth hormone levels. The patients IGF-1 level was in the low normal range on two occasions.  Therapy with Nutropin, 0.5mg daily, was begun to bring her IGF-1 level into the mid normal range.  The patients provider plans to continue therapy for approximately six months and to monitor the patients symptoms.  The patients request for reimbursement and prospective authorization and coverage of Nutropin was denied by the Health Plan citing a lack of medical necessity. The patient had pituitary surgery in 2004.  She had subsequent symptoms of abdominal weight gain and memory and cognitive difficulties. The insulin tolerance test was indicative of a growth hormone deficiency, although growth hormone stimulation testing was not performed.  The patients IGF-1 level was low normal on two occasions; there are reported cases of growth hormone deficiency with normal IGF-1 levels in the literature. In light of all of these factors, a six-month trial of Nutropin, 0.5mg daily, is medically appropriate to see if the patients symptoms resolve. Therefore, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 56-year-old woman who has a history of left shoulder and forearm pain in addition to neck and back pain secondary to degenerative disc disease. The patients treating physician has recommended the patient undergo an open MRI of the left arm, cervical spine and lumbar spine. The Health Plan has denied this request indicating the requested diagnostic procedures are not medically necessary for evaluation of the patients condition.Based upon the information provided, there is no medical justification for an open MRI of the arm, and cervical and lumbar spine at this time. There is no significant neurological deficit or concern for tumor documented in the records provided. It does not appear the patient has recently been evaluated by an orthopedist. The Health Plans recommendation that the patient be evaluated by an orthopedist is medically reasonable and appropriate. After a full evaluation of the patient the orthopedist can determine if imaging studies should be performed. Therefore, I have determined the requested diagnostic procedures are not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 31-year-old woman who has plaque psoriasis that covered at least 50% of her body surface areas. Methotrexate, cyclosporine and phototherapy were ineffective or caused unacceptable side effects. She has received treatment with Raptiva since May 2005, which resulted in marked improvement with reduction in psoriasis to only 13% of her body surface area. The Health Plan has denied coverage for Raptiva on the basis that it is not medically necessary for treatment of the patients condition.Raptiva is a medically appropriate treatment for moderate to severe psoriasis resistant to other forms of treatment. Raptiva therapy resulted in remarkable improvement in this patients condition. In addition, methotrexate, cyclosporine and phototherapy were ineffective or caused unacceptable side effects. Given the patients documented response to Raptiva and her poor response to other therapies, continuation of Raptiva is medically reasonable and indicated. 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 48-year-old male who was diagnosed with metastatic renal cell cancer in January 2005. He was initially diagnosed following VATS and lung biopsy for a left pleural effusion, at which time he also underwent talc pleurodesis. His primary was identified as the right kidney and he underwent a right nephrectomy in March 2005. He was treated with systemic therapy for his metastatic disease with IL-2 and interferon, which was changed to Avastin and interferon in August 2005. The patient had a PET scan in September 2005 demonstrating uptake of the left lung, ribs, posterior neck and soft tissue adjacent to the maxilla. Treatment was then switched to sorafinib with the persistence of metastatic, though stable, disease. By report, his last PET scan revealed only a single mass in the left lung that demonstrated FDG uptake. His latest CT scan demonstrates mild enlargement of the left pulmonary lesion (3.1 x 3.2 cm in January 2006, which increased to 3.1 x 4.1 cm as of April 2006).The patient was discussed at a multidisciplinary tumor board at which time it was recommended that his enlarging left lung mass be treated. All other metastatic disease was felt to be stable, and it was felt worthwhile to treat this enlarging tumor. Options discussed were surgery and radiation therapy. The thoracic surgeon felt that the risks of surgery were too great due to the previous talc pleurodesis, and therefore radiation was preferred. The radiation oncologist recommended Cyberknife therapy. At issue is whether Cyperknife therapy is medically necessary for treatment of the patients medical condition.This patient who has metastatic renal cancer has been treated with a variety of systemic therapies (IL-2/IFN, IFN/Avastin and sorafinib). He has an enlarging metastasis of the left lung. A request has been made for Cyberknife therapy. Alternative therapies consist of surgical treatment, additional systemic therapy or other forms of radiation therapy.Given the metastatic nature of the patients disease, the goal of therapy is local disease control and palliation of this pulmonary lesion. However, the patient is currently asymptomatic and there is no role in treating the lesion with the goal of improving survival. Given the risks of re-operative thoracic surgery in this patient with prior pleurodesis, other non-operative measurements are more appropriate. Though radiation therapy is a reasonable modality, data on the use of Cyberknife in metastatic disease is limited. The two submitted reports show reasonable disease control rates, but there is no data related to renal cell cancer or any data comparing this modality to traditional external beam. Given the availability of other potential treatment modalities (e.g., traditional radiation therapy), the limited data on Cyberknife therapy, and the goal of symptomatic disease control in this asymptomatic patient, 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

A sixty-two year-old male with a spinal dural arteriovenous fistula is requesting authorization for treatment services at an out-of-network.  Reviewers Findings:  The reviewing physician found that it is essential the patient receive the highest level of care available as soon as possible, therefore, the requested services are medically necessary.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 21-year-old male who is status post knee surgery. He has requested reimbursement for a cold therapy unit that was used following the procedure for pain control. The Health Plan has denied the patients request on the basis that the efficacy of the cold therapy unit has not been established. The Health Plans denial should be upheld. A cold therapy unit to maintain temperature following knee surgery for pain control has not been proven to be effective in the peer-reviewed literature. To date, there is insufficient data establishing the efficacy of the device at issue. The patient could have been appropriately treated with standard modalities. Therefore, I have determined that the device 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 37-year-old female who has hand pain and limited mobility of her fingers. She has completed skilled physical therapy and is independent with a home education program. She has requested continued physical therapy for deep tissue massage with a physical therapist. The Health Plan has denied this request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.Ongoing physical therapy is not medically necessary for the patient as she has already completed a course of physical therapy and is independent with a home education program. Further skilled physical therapy would be for the purpose of maintenance and is not likely to improve the patients condition or function in a reasonable or predictable time period. In addition, ongoing physical therapy for chronic massage therapy and other passive modalities 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.