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

The patient is a 66-year-old male and has neuropathic symptoms of painful foot and leg tingling. Spinal stenosis has been diagnosed. Lumbar laminectomy has been performed in the past. The patients HbA1C was normal, but fasting glucose was elevated. No glucose tolerance test results are cited. A podiatry evaluation for plantar fasciitis resulted in a diagnosis of neuropathic symptoms apparently from the back. NSAIDs, Neurontin, physical therapy, and spinal injections were tried without sustained relief. Recently, the patient received a trial of Lyrica. The patient and his provider indicate Lyrica has completely controlled his symptoms. At issue is whether Lyrica is medically necessary for treatment of the patients medical condition.The patient has symptoms suggesting polyneuropathy. Etiologic diagnosis is unclear. An elevated fasting blood sugar may indicate abnormal glucose tolerance, a risk for both diabetes mellitus and polyneuropathy, despite normal HbA1C. Based on the records provided, it does not appear the diagnosis of neuropathic symptoms from spinal stenosis has been confirmed by neurologic assessment. Treatment with Neurontin has been ineffective. The patient reports he has tried Lyrica with good relief.Response to treatment of pain from diabetic neuropathy often predicts response of pain from other sorts of painful neuropathy, which may not be well studied. Lyrica is approved for treatment of diabetic neuropathy, a condition often associated with painful burning or numb feet. Diabetic neuropathy is typically the only form of painful neuropathy studied in registration trials due to its high prevalence. The Health Plan recommends Neurontin, tricyclic antidepressants (TCA) or Cymbalta as treatment for diabetic neuropathy prior to consideration of Lyrica.The patient may indeed have glucose intolerance (pre-diabetes). A glucose tolerance test would be appropriate in this setting to further screen for mild or early diabetes. Additionally, the patient should be tried on a TCA such as amitriptyline or nortriptyline, or on Cymbalta. If a trial of a TCA or Cymbalta is ineffective or not tolerable, based on extrapolation from data on the treatment of diabetic neuropathy, as well as the patients good response to the trial of Lyrica, his request for the medication should be reconsidered by the Health Plan. However, based upon the information provided, I have determined the requested medication is not medically necessary for treatment of the patients medical condition at this time. Accordingly, the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 48-year-old woman with left leg pain and dermatitis associated with varicose veins. She has worn compression stockings for over two years without relief. A venous duplex exam showed no saphenofemoral junction reflux, but did show a perforating vein of the lower leg that refluxed into the great saphenous vein below the knee. The provider requests authorization for endovenous laser ablation treatment (EVLT) of the distal great saphenous vein and the incompetent perforating vein. The Health Plan denied the request citing a lack of medical necessity.The patient has met the requisite symptom severity and conservative therapy criteria for treatment of her varicose veins. However, endovenous laser therapy (EVLT) has been shown to be inferior to both endovenous radiofrequency ablation (RFA) and traditional surgical ligation and stripping. The study cited above found that treatment failure was twice as common with EVLT as with RFA. RFA has been shown to have efficacy similar to surgical therapy in a randomized study. In general, studies of EVLT have been limited to patients with proven saphenofemoral junction reflux. Appropriate therapy in this patient would involve ligation of the incompetent perforating vein, which appears to be responsible for the distal great saphenous vein reflux.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 28-year-old female with a history of large, bulging varicosities of the labia that became very painful with prior pregnancies and labial pain during her menstrual cycle. However, the patient is currently asymptomatic and does not have any large, bulging labial varicosities, only telangiectasia and 2mm to 3mm surface reticular veins in the groin region. The patients provider has submitted a request for authorization of sclerotherapy to the telangiectasias and reticular veins to prevent possible problems with future pregnancies and to prevent labial pain during the patients menstrual cycles. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.The patient has only superficial telangiectasias and reticular veins at the present time.  Sclerotherapy is appropriate for labial varicosities when the symptomatic vein can be visualized and directly injected, which is not the case in this instance. There is no evidence in the literature that injection of these small, asymptomatic vessels will effectively treat labial pain or prevent complications with future pregnancies. 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: Upheld Decision of Health Plan

The patient is a 59-year-old female who had a breast biopsy. She now has a puckered scar. She is seeking coverage for dermatologic visits for treatment of her scar. The Health Plan denied her request and recommended she consult a general surgery. At issue is whether the dermatologic visits at issue were/are medically necessary.The patients scar following her breast biopsy is puckered. It appears to have improved over time. Although the patient is concerned about the appearance of the scar, there is no evidence of complaints of pain, itching or physical disability. As such, the services of a dermatologist are not medically warranted in this case. The Health Plan has recommended the patient follow-up with a surgeon. Scar revision, if necessary, is within the scope of practice of a surgeon. Accordingly, I have determined the services at issue were/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 59-year-old female who had a bone mass density scan in December 2004 showing severe osteoporosis. She was placed on calcium and vitamin D as well as Actonel as anti-fracture treatment. A repeat bone scan was performed 12 months later while the patient was being treated with tamoxifen. The repeat test was ordered by her oncologist to see if changing her anti-cancer treatment from tamoxifen to an aromatase inhibitor might be harmful to her bones and increase her risk of fracture. The result showed a statistically significant additional loss of bone in her spine and a statistically significant gain in her hip. Based on these results the patients oncologist decided not to make the treatment change, as one of the potential new medications side effects was increased fracture risk. At issue is whether the repeat bone density scan was medically necessary.It is standard of care to perform a repeat bone density scan after 12 months if the T-score of any measured area is less than 3 SD. As such, the patient met medical necessity criteria for the repeat bone density scan in December 2005. Additionally, the patients oncologist makes it clear that the follow-up study affected his decision regarding the patients cancer treatment since changing the medication could have resulted in a worsening of her bone mass density and may have increased the vertebral fracture risk. Therefore, I have determined the bone scan at issue was medically necessary for evaluation 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 male diagnosed with prostate cancer.  His medical history indicates he had a PSA of 30.1 in September 2005 with an apparent delay in notification until April 2006 at which time his PSA was 32.2. Biopsy confirmed adenocarcinoma of the prostate and the patient began treatment with Casodex in June 2006. The patient was scheduled for radical prostatectomy in July 2006, but the procedure was aborted because an enlarged left pelvic lymph node was positive for metastatic disease. Lupron injections were subsequently initiated. In August 2006, the patients PSA was 2.1.  He consulted with a non-Plan radiation oncologist and a recommendation was made for proton beam radiation therapy to the prostate in conjunction with pelvic irradiation to 45Gy.The evidence submitted in support of the proposed proton beam radiation therapy is not entirely relevant. These papers discuss the efficacy of proton beam therapy, in limited disease prostate cancer. However, this patient has metastatic disease confirmed by biopsy of the pelvic lymph nodes. It appears the patient is being appropriately treated for his cancer and he has responded well, with his PSA decreasing from 30.1 (or 32.2) to 2.1. Consultation with the in-Plan radiation oncologist may be advantageous for follow up of the previous bone scan results and discussion of the potential benefit of conventional pelvic irradiation.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 35-year-old female, gravida 1, para 0, with a positive human papilloma virus (HPV) DNA probe. She underwent colposcopy with endocervical curettage (ECC) in August 2006. Biopsy revealed CIN III with abnormal vessels, or carcinoma in situ. The patient has reviewed the treatment alternatives with her provider and has submitted a request for total abdominal hysterectomy to the Health Plan. The Health Plan does not consider this procedure medically necessary, and has denied the patients request for authorization.Simply stated, hysterectomy (vaginal or abdominal) is the definitive treatment for CIN III with positive ECC. The patients choice of treatment is absolutely acceptable and consistent with the standard of care within the gynecologic community. 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 53-year-old man with progressive metastatic prostate cancer. He was diagnosed with stage IV cancer with metastases to bone. He has been treated in the past with multiple therapies including hormonal treatments and several chemotherapeutic agents. He is currently quite symptomatic from his cancer, and it has been proposed that he be treated with the chemotherapeutic agent Navelbine (vinorelbine). The Health Plan has denied authorization for the therapy on the basis that it is not medically necessary.Although Navelbine is not approved by the Food and Drug Administration for use in prostate cancer, there are a variety of reports indicating that there is activity with this drug for other types of cancer. Many studies explored the use of Navelbine in combination with other agents. However, there also studies involving Navelbine as a single agent, and it does appear to have some reasonable palliative efficacy. In one study (Oudard, et. al.) there was good palliative response in 71% of the evaluable patients. As such, there is sufficient data to support the use of Navelbine as medically reasonable and necessary in this setting.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 64-year-old female with a 16-year history of peripheral neuropathic pain who has failed treatment with multiple medications including tricyclic antidepressants, SSRIs, Neurontin, Cymbalta, Tegretol, Trazadone and Effexor. She has required significant amounts of narcotics for pain control. The patient was provided with samples of Lyrica and this medication has afforded excellent symptom relief and her quality of life has improved. The patients request for reimbursement and prospective authorization of Lyrica was denied by the Health Plan based upon a determination that the medication was/is not medically necessary.The patients peripheral neuropathy is severe and unquestionably refractory to standard treatments as numerous pharmacological agents have been tried and failed. The safety of Lyrica has been sufficiently tested in other clinical applications and it was found to be safe at doses up to 300mg twice per day. Painful diabetic peripheral neuropathy (DPN) is a model for a variety of other neuropathies, and historically medications that are helpful for DPN are also helpful for other peripheral neuropathic pain syndromes. In fact, treatment with Lyrica is fast becoming the standard of care for neurologists and pain specialists in situations such as this one. It is not surprising that the patient has shown an excellent response to Lyrica and continued treatment is medically indicated. Based upon the information set forth above, I have determined the medication 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 an 18-year-old female who recently completed an inpatient course of treatment for anorexia nervosa. She had a co-morbid diagnosis of depression and was treated with Zoloft and Provigil for mood augmentation. There is no record of a trial of antidepressant medications with a stimulating effect or trials of stimulants that have been FDA approved to augment mood. The patients request for reimbursement and continuing authorization of Provigil was denied by the Health Plan based upon a determination that the medication is not medically necessary.The FDA approved indications for the use of Provigil are clearly stated and they include narcolepsy, obstructive sleep apnea/hypopnea syndrome (OSAHS), and shift work sleep disorder (SWSD). Provigil has been associated with serious side effects including abuse/dependency and cardiac arrhythmias. Additional side effects included nervousness, anorexia, depression, anxiety and hypotension. Many alternatives exist to the off-label use of Provigil such as antidepressant medications that have a stimulating effect or stimulants that have been FDA approved for mood augmentation. There are no clinical indications for the use of Provigil with this patient that fall within the FDA guidelines. Therefore, I have determined 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: Upheld Decision of Health Plan

The patient is a 43-year-old female who has undergone gastric bypass surgery with a resultant weight loss of 150 pounds. She reports problems with skin rashes and odor, primarily in the area of her large pannus. There is no indication in the record she has been treated for skin conditions or functional limitations in the areas of her hips, thighs or buttocks. An abdominoplasty was reportedly authorized by the Health Plan and it was performed in October 2006. The patient is currently requesting authorization for excision of excess skin and subcutaneous tissue from her hips, thighs and buttocks. The Health Plan denied her request citing a lack of medical necessity.The records do not establish medical necessity for the requested surgery for the patients hips, thighs and buttocks. There is no documentation in the form of primary care or dermatology progress notes that describes ongoing clinically significant dermatologic problems or functional impairment in these areas. Surgical lipectomy should be reserved for patients that have failed optimal medical management which is not the case in this instance. The abdominoplasty that was performed in October 2006 will likely rid the patient of much of her excess skin, eliminate chronic rashes under the pannus and simplify her hygiene. The patient was not sick from the excess skin in the areas of her hips, thighs, and buttocks and this condition does not appear to jeopardize her health.  The requested procedures are desirable for aesthetic reasons, but they are not medically indicated.Based upon the information set forth above, 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: Overturned Decision of Health Plan

The patient is a 43-year-old woman with a several year history of chronic neck, shoulder and arm pain. She has previously failed treatment with Neurontin, Cymbalta, trazodone and multiple other medications. The record indicates she has also failed cervical spine surgery and has brachial plexus neuropathy. The patient was taking high doses of narcotic pain medications and finds that Lyrica, 75mg twice a day, has moderately reduced her pain and enabled her to decrease the narcotic medications. The patients request for authorization of Lyrica was denied by the Health Plan based upon a determination that it is not medically necessary.The patient has long-standing chronic pain with neuropathic features. She has failed to respond to the usual mediations and finds moderate relief with Lyrica. Lyrica is often utilized by neurologists and pain management specialists as a first-line agent for the treatment of a wide range of neuropathic pain syndromes. Continued treatment with Lyrica is beneficial to the patient and medically appropriate in this instance. 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 66-year-old male with type 2 diabetes mellitus (DM2). His blood glucose levels had previously been under good control on Actos, metformin and glipizide as evidenced by a hemoglobin A1c of 6.0%, excellent fasting blood glucose and occasional postprandial elevations of blood glucose according to his endocrinologist. The patient has macrovascular and mild microvascular disease and he is obese. He has reportedly been unable to lose weight with his current diet and exercise. In July 2006 his endocrinologist started the patient on Byetta for greater blood glucose control and to aid in his weight loss efforts and glipizide was discontinued. The patients primary care provider stated in his letter of October 2006 that the patient had lost close to 10 pounds and his provider wished to continue Byetta, presumably for further weight loss. The patients request for authorization of Byetta was denied by the Health Plan citing a lack of medical necessity. The patient appears to have had excellent control of his DM2 while taking Actos, metformin and a small amount of glipizide. Excellent control is defined by the American Diabetes Association as a hemoglobin A1c of less than 7% and by the American College of Endocrinology as a hemoglobin A1c of less than 6.5%. The patients hemoglobin A1c was 6.0% prior to starting Byetta. The Health Plan will cover Byetta for those patients not in good diabetic control despite compliance with their medication regime. Good control is defined by the Health Plan as a hemoglobin A1c of less than 6.5%, which is consistent with the recommendations of the learned medical societies. Byetta is not a weight loss medication and it is unlikely that the very small dosage of glipizide that the patient was prescribed contributed significantly to his inability to lose weight. 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: Upheld Decision of Health Plan

The patient is a 52-year-old male with a history of hypertension and asthma. He underwent spinal fusion surgery two weeks prior to hospital admission. He presented to the emergency room in October 2005 with shortness of breath and bilateral lower extremity swelling. His admission diagnosis was respiratory failure due to pneumonia/CHF. He was evaluated by pulmonology and started on intravenous antibiotics, intravenous steroids, oxygen, and regular nebulizer treatments. His chest x-ray demonstrated evidence of a density involving the posterior aspect of the right upper lobe and an infiltrate at the right base. A chest CT scan demonstrated no evidence of pulmonary emboli with evidence of diffuse interstitial fibrosis and air space consolidation involving the posterior segment of the right upper lobe, areas of pleural thickening of the left base, focal density on the left lower lobe, speculated density on the right and left upper lobes, and another nodule density in the lower lobe. An echocardiogram revealed normal LV function with mild pulmonary hypertension. His diagnoses were pneumonia/bronchospasm/diffuse idiopathic interstitial pneumonitis.  The patient has requested reimbursement for his continued hospitalization from October 2005 through October 2005. The Health Plan had denied this request indicating that the services at issue were not medically necessary.Review of the submitted medical documentation indicates that as of October 2005 the patient was medically stable. He was afebrile with an oxygen saturation of 98%. He was switched from IV medications to oral prednisone and oral antibiotics (Levaquin). He had complaints of weakness and constipation, but received no therapy that required inpatient hospital services. The additional two days of hospitalization were not clinically indicated, as the patient was stable for discharge by October 2005. Therefore, 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.