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

Physician 1: The patient is a 41-year-old woman with chronic back pain. A request has been made for an intradiscal electrothermal therapy (IDET) procedure. The Health Plan has denied this request on the basis that IDET remains experimental/investigational.There is no information available to warrant and support the use of IDET in the treatment of this patient. No long-term prospective study has shown significant long-term benefits, and the risks of the therapy are still unclear. In this community, when IDET has been used the results have been poor. As such, IDET cannot be recommended until the efficacy of the procedure has been established. 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 2: The patient is a 41-year-old female who had an injury to her back approximately four years ago. The submitted information indicates the patient had a positive discogram at L4-L5. Her pain is being managed on high-dose narcotics. The patients provider indicates the patient is not a surgical candidate. It has been recommended the patient undergo an intradiscal electrothermal therapy (IDET) procedure. The Health Plan has denied authorization for IDET on the basis that the efficacy of the procedure remains unproven.IDET at L4-L5 is not likely to be successful in this patient who had a positive discogram at levels L4-L5 and L5-S1. IDET remains an unproven procedure without clearly defined efficacy. IDET is not the standard of care and it is not in the mainstream of lumbar degenerative disc disease treatment, particularly when there is more than one disc involved. Review of the medical literature reveals several studies showed little to no efficacy associated with the IDET procedure. 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 is a 41-year-old female with chronic low back pain. She has failed conservative management and therefore, wishes to undergo an intradiscal electrothermal therapy procedure (IDET). The Health Plan indicates there is insufficient peer-reviewed evidence demonstrating the effectiveness of IDET for treatment of low back pain.Despite its widespread use, the efficacy of the IDET procedure remains elusive. Numerous peer-reviewed studies have failed to demonstrate its efficacy. At this time, IDET remains an unproven procedure. There is no substantial proof of its effectiveness for the treatment of chronic back pain. 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 now a 33-year-old female who has end stage renal disease, mild hypertension and a kidney transplant with rejection requiring her to go back on dialysis. She failed home peritoneal dialysis because of peritonitis. She is now medically stable on three-times-per-week hemodialysis. The patient wishes to dialyze at home. The Health Plan indicates home hemodialysis is not medically necessary for this patient.There is no description of a medical necessity, which would require this patient to dialyze at home. It is stated that she wishes to dialyze daily as opposed to the current three-times-per-week schedule. The medical justification for this is not clear, but common reasons for such a schedule are severe congestive heart failure, intractable hyperphosphatemia or uncontrolled hypertension. No medical evidence has been provided that would place this patient in the category of patients needing more than three-times-a-week dialysis. It is possible the patient wishes to dialyze at home for convenience.  The standard of care at this point is center-based dialysis, where the patient can be observed carefully and her dialysis regime can be adjusted under strict medical supervision.  Therefore, I have determined the requested home hemodialysis 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

This case involves a 15-year-old male who has been diagnosed with Aspergers syndrome. The patients parent is concerned that the patient may have been exposed to mercury or other toxins either in utero or during early childhood. A request has been made for authorization for laboratory testing to determine the presence of mercury or other toxins. The Health Plan has denied coverage for the requested laboratory testing on the basis it is not medically necessary for this patient.Though the possibility of mercury in immunizations as a cause of any of the autistic variants is remote, there is some evidence to suggest maternal mercury levels during pregnancy (i.e., from fish) may be a cause of autism. Laboratory testing of the levels of mercury and other toxins is a medically indicated and appropriate evaluative service for this patient. Therefore, I have determined the requested laboratory testing 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

This patient is a seven-year-old male with the diagnosis of autism who has received speech therapy since 2001. He has more recently been receiving speech therapy in conjunction with a behaviorist. The speech therapist has provided documentation from 2003-2005 regarding the patients progress. At issue is whether continued speech therapy is medically necessary.In reviewing the speech therapy progress reports and comparing goals and progress from 2003 to 2005 it is clear the patient is making progress in his speech and communication skills. Appropriate communication and social interaction is the first long-term goal and the patient has progressed from an inconsistent eye gaze with little to no verbalization and a vocabulary of less than 50 words to taking turns with up to 6 social exchanges. With regard to the second long-term goal of improved expressive language skills, the patient has gone from single-word gestures using only nouns to spontaneous two word semantic combinations. In the third long-term goal of improved receptive language skills, the patient has advanced from naming body parts to answering where questions.  These are real functional and speech related gains.It is important to note that in most therapy situations progress toward goals is viewed over weeks to months. Slower progress, over six months to a year for some skills, should be expected with autism, as is not just a speech disorder, but a behavioral disorder as well. The gains noted in this case are real gains and will have a significant impact on the patients ability to communicate in school, at home, and in the community.  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 48-year-old male who is status post multiple back surgeries. The submitted records indicate the patient is currently being medically managed with MS Contin. He has requested authorization and coverage for a spinal cord stimulator. The Health Plan has denied the patients request at this time, but has recommended a referral to a pain specialist for a second opinion.The Health Plans denial should be upheld. Upon review of the submitted documentation, it is not clear that the patients current pain management program would be significantly enhanced by implantation of a spinal cord stimulator. A second opinion evaluation by a board certified pain specialist is indicated prior to consideration of a spinal cord stimulator. The alternative services recommended by the Health Plan are medically reasonable and appropriate. As such, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a three-year-old male with developmental apraxia of speech (DAS). His delay is estimated to be 12 to 16 months and motor skill delays are significant. The goals for this patient are improvement of motor, articulation, and verbal skills. Speech therapy was recommended twice a week for 9 to 12 months. At issue is whether speech therapy is medically necessary for treatment of the patients condition.An extensive review of the literature revealed no studies providing a clear diagnostic standard for DAS. Similarly, there were no outcome studies, which objectively demonstrated that speech therapy improves DAS. The DAS website also acknowledges there is limited research available, particularly outcome-related data. The study cited above demonstrates there is no clear definition of DAS or specific criteria for its diagnosis. In fact, many physicians question the validity of DAS as a diagnosis. Regardless of whether this is a developmental or a neurological condition, there is no medical indication for treatment given the absence of a diagnostic criteria or evidence of effective treatment modalities. DAS is more appropriately addressed as an educational issue. As such, given the information provided, there is no medical justification for past or future speech therapy services.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: Upheld Decision of Health Plan

This patient is a 35-year-old female who is more than two-years post-operative from a gastric bypass for morbid obesity. She is seeking authorization for panniculectomy, abdominoplasty, and brachioplasty for excess skin secondary to an almost 200 pound weight loss. The Health Plan has denied authorization because there is a lack of documentation supporting the medical necessity of the procedures.The records provided include poor quality photocopies of photographs of the patient and a progress note and surgical authorization request from the board certified plastic surgeon.  The submitted information provides no objective evidence of medical necessity for the proposed procedures. Although some cases involving this much weight loss do necessitate skin reduction procedures, the records and photocopies provided in this case do not demonstrate that the proposed panniculectomy, abdominoplasty, and brachioplasty are medically warranted. Therefore, I have determined the requested procedures are 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 46-year-old female with a history of hypertension, diabetes mellitus, osteoarthritis, and degenerative disc disease. Office notes from 2003 indicate the patient had some limitation in her ability to perform activities such as housework and that certain activities such as walking increased her pain. The patients provider however, also noted that walking was of some benefit to the patient. An office note dated July 2005 states the patient was using a walker. The patient indicates she requires a power-operated vehicle (POV) to assist with ambulation and activities of daily living. The Health Plan has denied authorization and coverage for the requested POV on the basis it is not medically necessary.The submitted documentation does not sufficiently demonstrate that the patient is impaired in performing personal activities of daily living or that she has limited mobility within her home. Although a recent note indicates the patient is using a walker, the patients provider did not document any lower extremity weakness or frequent falls. As such, the patient does not meet medical necessity criteria for authorization of a POV at this time. Therefore, I have determined that the requested POV 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 51-year-old diabetic man with cellulitis of the left foot associated with an old recurrent ulcer related to an operative procedure performed in 1985. It does not appear to have been associated with osteomyelitis.  The patient was given Cipro followed by Levaquin. Follow-up cultures in July 2005 grew methicillin resistant staphylococcus aureus (MRSA). There was sensitivity to clindamycin, gentamicin, rifampin, tetracycline, trimeth/sulfa and vancomycin. Zyvox was then ordered by the patients podiatrist. At issue is whether Zyvox was medically necessary for treatment of the patients condition.The Health Plans denial should be overturned. Zyvox is accepted as an appropriate alternate to IV vancomycin. The studies referenced above support the use of Zyvox in the treatment of patients such as this patient. As such, the use of Zyvox in this instance was medically reasonable and appropriate and should be covered by the Health Plan. Accordingly, I have determined that the medication at issue was 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

In December 2003 this 38-year-old male patient underwent surgical reconstruction of his left anterior cruciate ligament (ACL). A standard hinged brace was used for approximately six weeks post-operatively. The patient then switched to a DonJoy brace.  The Health Plan indicates the patient could have been appropriately treated with a standard knee brace, and a specialized knee brace was not medically necessary.There is no class I data to suggest that the specialized knee brace at issue is more effective than a standard off the shelf type of hinged brace after an anterior cruciate ligament (ACL) reconstruction. There is no documentation of a limb deformity or any other compelling medical justification that would warrant the use of the DonJoy knee brace in this case. Therefore, I have determined that the specialized knee brace 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 58-year-old female who is status post gastric bypass surgery in 1998. She is currently at a weight of 232 pounds with a body mass index (BMI) of 36, and has multiple comorbidities. The patient is requesting authorization for revisional weight loss surgery. The Health Plan has denied this request on the basis that there is no documentation of dietary and lifestyle changes after the first bariatric surgery or evidence of excessive postoperative enlargement of the gastric pouch.Gastric bypass surgery has a slightly greater than 60% success rate, as measured by excess body weight loss at two to five years after surgery. A weight regain after gastric bypass is more often related to the operation itself and less frequently related to the patients lifestyle.The published data does not support the revision of a previous gastric bypass since, as a restrictive procedure, it may be of very little utility. A revision to the distal portion of the bypass has a significant risk for nutritional deficiencies. The only published data that supports revisional surgery after a failed gastric bypass dealt specifically with duodenal switch. Therefore, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 46-year-old female who has been receiving Pegasys and Copegus for the treatment of hepatitis C since February 2005. She has genotype 3 and has completed 24 weeks of therapy. The patients provider has recommended another 24 weeks of treatment with Pegasys and Copegus. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The treatment of patients who are genotype 3 with Pegasys and Copegus for longer than six months is not considered the standard of care. At the current time the Food and Drug Administration has not recommended 48 weeks of therapy for patients such as this patient. There is insufficient evidence that the requested therapy is likely to result in an improved clinical outcome. As such, continued use of Pegasys and Copegus is not medically warranted in this case.Based upon the information set forth above, 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 who has undergone two courses of Pegasys and Copegus for treatment of hepatitis C. Following the initial course of therapy the patient relapsed. Twelve weeks after the start of the second course of therapy it was determined the patient was non responsive. The patients provider has recommended the patient initiate treatment with Infergen and Copegus. The Health Plan has denied authorization for the proposed therapy on the basis it is not medically necessary.The use of Infergen and Copegus 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. Based on the information provided, the patient is an appropriate candidate for the requested therapy. 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: Overturned Decision of Health Plan

The patient is a 12-year-old male with an apparent diagnosis of Tourettes syndrome, bipolar disorder and oppositional defiant disorder. The patient is treated with psychotherapy and medical management. Reportedly, Catapres TTS-3 (clonidine) patches applied daily are more effective in controlling the patients tics and behaviors than any other clonidine regimen. At issue is whether a quantity of 28 Catapres TTS-3 patches every 28 days is medically necessary for treatment of the patients condition.Clonidine is an anti-hypertensive and has many possible side effects or adverse reactions, especially in children.  Topamax, Seroquel, Abilify and Prozac have also been prescribed for the patient. The patients current protocol of one Catapres TTS-3 patch per day has been in place for three years without a report of serious side effects. The patients parents apparently consent to this specific use of clonidine. The submitted evidence suggests the patients parents and his prescribing physician follow the patient very closely and believe the benefits of the patients current regimen outweigh the risks. As such, it appears that continuation of the patients current regimen is medically appropriate. However, it should be ensured the patient maintains a normal blood pressure for age, and the parents, or an appropriate caregiver, should monitor the patients blood pressure on a daily basis.Based upon the information set forth above, I have determined that the requested prescription is medically necessary for treatment of the patients condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 19-year-old male who was initially admitted to residential treatment in July 2003 due to persistent major depression and anxiety, which was later determined to be heavily anchored by a fairly resolute narcissistic character structure. The patient was treated with a range of psychotherapies as well as Wellbutrin 100 mg and Lexapro 10 mg per day. The consulting psychiatrist favored treating the patient primarily with therapy as opposed to medication. In August 2004, the psychiatrist stated he was not particularly optimistic about the potential for medications, given the clear psychodynamic aspects of the patients depression. A recommendation was made for discontinuation of Wellbutrin and Lexapro. The patient was subsequently moved to a transitional home affiliated with the residential treatment program, where he remained until December 2004.Chart notes as of May 2004 cite the patient as faring better, having had an all right month and, in comparison to the two prior months, it was definitely an improvement. He has begun to engage [in] this last month again with the program and staff. Notes from June 2004 state the patient had had a pretty good month. He has been stable in the program. During his stay at the transition home, the patient continued to receive a modicum of psychotherapy and also worked part-time while applying to various colleges. He was accepted to a music academy for an anticipated six-month course, which he planned to follow with attendance at a four-year college. Throughout his time in the transition home, the patient was noted as somewhat pessimistic and self-aggrandizing. However, he was able to consider attending college or traveling in Europe with his family.At issue in this case is whether the residential treatment services the patient received from August 2004 to December 2004 were medically necessary for treatment of the patients condition.Although the patients admission to residential treatment was appropriate given the presence of a narcissistic character structure, the submitted notes demonstrate the patient was stable as of August 2004. The patients condition was fairly static by that point. Furthermore, the level of care the patient received in the transition home does not appear to fall within the parameters of residential treatment per se. Specifically, the patient was seen in outpatient psychotherapy while working part-time and applying to college. This is tantamount to outpatient treatment except for the fact that the patient was not living at home. All told, there is no evidence residential treatment services were medically indicated from August 2004 onward.Based upon the information set forth above, 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.