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

The patient is a healthy 35-year-old female whose family includes a father-in-law who has diabetes and hepatitis B infection. The patient does not have hepatitis B infection and would like to be immunized against hepatitis B and has requested authorization for the vaccination. The Health Plan has denied this request.The Health Plans denial should be upheld. The Health Plans guidelines are based upon the US Preventive Health Task Force guidelines and are also consistent with AASLD guidelines. Records provided do not demonstrate whether the patients father-in-law is HbsAg positive and at risk for spreading infection. In addition, the patient does not live in the same household as her father-in-law. Based upon the information provided, the patient would not be considered at high risk for hepatitis B infection and she does not meet nationally accepted guidelines for hepatitis B vaccination. Therefore, I have determined the requested vaccination is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 53-year-old female with long-standing knee pain. She has attempted physical therapy, acupuncture, and home exercises and continues to have persistent pain. She is seeking an MRI of her knees. The Health Plan has denied authorization for the requested MRI.Based upon the patients history and current condition, the requested MRI is medically indicated. The patient has attempted conservative treatment without success. There are a multiple number of ailments that could be responsible for the cause of her pain  all of which could be identified with an MRI. In addition, the patient may require surgical intervention but an MRI is needed to assist in determining the cause of the patients pain. Therefore, I have determined the requested MRI is 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 52-year-old male with chronic back pain who is requesting a bariatric adjustable bed. He states that he has tried physical therapy and epidural injections without benefit and that he can no longer sleep in a standard bed. His Health Plan has denied authorization for the requested equipment.From an orthopedic standpoint the requested equipment is not medically necessary or required to treat the patients condition. There are no long-term, prospective studies showing that there is any benefit in the use of a bariatric adjustable bed in the treatment of back pain. There is a great deal of variability with beds and their potential effectiveness is based entirely on patient preference. There simply is no evidence supporting the medical necessity of the requested equipment. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old male with a history dating to summer 2002. At that time, the patient indicates he visited Connecticut and acquired Lyme disease. He did not initially have an erythema migrans rash or other symptomatology until a few months later. He does not recall a tick bite while he was in Connecticut. His symptoms over the last two years include muscle twitching, PACs, fatigue, tremors, eye pain, and mental fog. Subjectively he indicates his symptoms have improved with extended antibiotic therapy.  A neurology consultation did not reveal a diagnosis for the patients presentation. Physical exams by three physicians did not show any joint effusions, limited range of motion in the joints or any objective neurologic findings. Laboratory evaluation includes a chemistry panel, CBC, Lyme Antibody, and Lyme Western Blot. Other studies include MRI of the brain, CT scan of the abdomen and pelvis, and lumbar puncture. The patients Lyme serology and CSF fluid analysis is negative. Other imaging is unrevealing. The patient has received multiple courses of various oral antibiotics with some subjective improvement, but no objective clinical difference. The patient is seeking additional long-term antimicrobial therapy.The patient has little evidence of active Lyme disease  either early or late stage. The diagnosis of neuroborreliosis is supported with a positive CSF, positive Western Blot and objective neurological findings. Lyme arthritis is diagnosed with a positive synovial fluid analysis, positive Western Blot, and objective physical examination findings. This patient meets none of the above criteria. Furthermore, there are no double blind, placebo-controlled trials published in peer-reviewed journals demonstrating the efficacy of prolonged antimicrobial therapy beyond four weeks or repeated therapy whether provided intravenously or orally. Moreover, there are studies in the peer-reviewed literature (see citations above) demonstrating no benefit to extended antimicrobial therapy in the treatment of Lyme disease.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, 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 who underwent a bariatric procedure with resultant massive weight loss. She is seeking authorization and coverage for removal of excess skin of the arms, breasts, thighs, abdomen, buttocks, and back. The Health Plan has authorized the removal of the abdominal panniculus for intertrigo but indicates a medial and lateral thigh lift, buttock lift, brachioplasty, and mastopexy are not medically necessary for treatment of the patients medical condition. The medical records and photographs submitted support the medical necessity for a mastopexy. There is documented evidence of intertrigo of the breast area that has been refractory to conservative management. Thus, a mastopexy is medically warranted to relieve the patients functional impairment. However, breast augmentation is considered cosmetic in this case and is not medically necessary. Furthermore, the submitted records and photographs do not provide compelling documentation of medical necessity for medial and lateral thigh lift, buttock lift, and brachioplasty. The patients skin problems in these areas do not appear to be significant. As such, these procedures are cosmetic in nature and not medically necessary for treatment of the patients medical condition.Based upon the information set forth above, I have determined that although the requested mastopexy is medically necessary for treatment of the patients medical condition, the requested medial and lateral thigh lift, buttock lift, and brachioplasty are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a sixteen year-old female with a history of depression, cutting behavior, eating disorder, polysubstance abuse, and suicidality are requesting authorization and coverage for residential treatment services.Reviewers Findings:  The reviewing physician found that there is no evidence that a comprehensive treatment plan or goals are in place, or that the patient experienced any significant activity.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 24-year-old female with a body mass index (BMI) of 46.5. Her comorbid conditions include hypercholesterolemia and hypertension. The patient has obtained psychiatric clearance for weight loss surgery. She wishes to undergo gastric bypass with duodenal switch. The Health Plan has denied this request indicating the patient does not medical necessity criteria for weight loss surgery. The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. The literature shows that duodenal switch has a superior long-term outcome when compared to Roux-en-Y gastric bypass. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly 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 morbidly obese.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 58-year-old female with a history of multiple cancers. In 1991, she was diagnosed with breast cancer and underwent bilateral mastectomies followed by chemotherapy. In 1993, she underwent hysterectomy and bilateral oophorectomy for a mucinous adenocarcinoma of the ovary. This was followed by intravenous as well as intraperitoneal chemotherapy. In 1996, she was found to have melanoma in situ of her back, which was widely excised. In May 2004, she was found to have cancer in the head of the pancreas, which was not resectable. Notes indicate the patient has a maternal great aunt with breast cancer and a maternal cousin with breast cancer. The patient seeks to have BRCA testing to determine if she carries a mutation of that gene, for which her two daughters could be tested for and their medical management affected.BRCA testing is a means of determining whether a patient carries a gene mutation. Carriers of a mutation have an extremely high risk of developing both breast cancer and ovarian cancer. Patients found to have such a mutation often consider preventive surgical removal of ovaries and/or breasts. Women felt to be at significant risk of carrying the mutation are either from families with a strong history of first-degree relatives with breast and/or ovarian cancer at a young age or who themselves have developed breast and/or ovarian cancer at a young age. This patient developed breast cancer at age 45 and ovarian cancer at age 47. 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 daughters and other family members. Furthermore, although the patients daughters are still under the age of 21 and it would controversial as to whether the daughters should be tested in the near future because it would be highly unlikely that oophorectomy or mastectomy would be recommended at their ages, it is medically reasonable and appropriate for the patient to undergo the requested testing as it will provide significant future value for her daughters.Based upon the information set forth above, I have determined the requested testing is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is an 18-year-old male with previously diagnosed major depression, recurrent as well as social and school phobia, which first became notable at age 7 and persisted to age 12. Some of his school and social phobia improved with the help of an antidepressant, whereupon it was discontinued by the sixth grade. However, the patient was noted to have a persistent lack of motivation and by his junior year of high school he had been at a total of eight schools. Thereafter, his depression became more severe, accompanied by lying about homework, being rude and defiant with authority, losing fifteen pounds, and needing to be hospitalized for depression and suicidal ideation. The first hospitalization occurred in January 2003. The patient had dropped out of high school though did obtain a GED. The patients depression has been described as attendant with low energy, lack of motivation, erratic sleep, moderate anhedonia, intermittent hopelessness, and suicidal feelings though no set plans for the latter. Treatment with medications such as Wellbutrin, Risperdal, Effexor, Zoloft, Geodon, Trazodone, and Lexapro were felt to be ineffective.Treatment at the residential treatment facility involved both schooling itself as well as individual psychotherapy. During this time the patient was treated with Wellbutrin and Lexapro, though the latter was eventually tapered away entirely by the end of his stay. He was seen both by his therapist as well as his psychiatrist as likely suffering from dysthymia. However, more importantly, the patients dominant character pathology was mostly in the realm of narcissism. The patient more consistently appeared detached and haughty, with a nearly assumed identity of the chronically depressed, almost as a means of self-promotion. Review of therapy summary notes shows the patient as having made progress during his treatment such that he was not quite as reflexively focused on feeling depressed and was seen as a bit more interpersonally proximate. As well, it is reported he scored an 800 on his verbal SAT and was now able to consider entering a university.Given the decline of this patients function over prior years, attendant with deepening of his depression, residential treatment was medically indicated. Though he was ultimately seen as not nearly as depressed as characterologically disordered, the latter is not only no less relevant but likely more enduring a problem for him. As such, a sustained therapy program such as the one provided at the residential treatment facility was greatly needed. In point of fact, the patients condition appears to have improved substantially as a result of treatment. He has achieved greater interpersonal proximity with less externalization of his difficulties. It is unlikely that the patient would have achieved such results at a lower level of care. Therefore, I have determined that the services at issue were 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 37-year-old female who recently experienced a massive weight loss. She has requested authorization and coverage for removal of excess abdominal wall skin. The Health Plan has denied this request on the basis that a panniculectomy is not medically necessary for treatment of the patients medical condition.The medical records provided do not demonstrate the patient meets medical necessity criteria for coverage of a panniculectomy. No photographic evidence has been provided to demonstrate the defect or intertrigo. Though the patient reports experiencing skin irritation under the pannus, there is no clinical evidence that the patient has a severe skin infection or ulceration that has been refractory to medical management. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 59-year-old morbidly obese female within the range of super morbid obesity. She has multiple comorbidities and has failed medical management. The patient has obtained psychiatric clearance for weight loss surgery. She has requested authorization and coverage for gastric bypass with duodenal switch. The Health Plan has denied her request on the basis that the duodenal switch procedure is not medically necessary for treatment of her medical condition.The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. The literature shows that duodenal switch has a superior long-term outcome when compared to Roux-en-Y gastric bypass. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Therefore, I have determined that 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 52-year-old man who was apparently diagnosed with stage I chronic lymphocytic leukemia (CLL) in March 2000. Based upon the information provided, it does not appear that he received any specific therapy for this condition. The patient also has a chronic pain syndrome, for which he was seen by a rheumatologist. He was started on Celebrex some years ago with symptomatic improvement. In August 2002, the patient was hospitalized for probable gastrointestinal bleeding, perhaps secondary to the Celebrex; at discontinuation of this drug his pain worsened and he was re-started at a lower dose.The patient states in his letter that his oncologists have indicated his pain is related to an immune mediated reaction related to his CLL. The Health Plan has denied authorization for continued use of Celebrex on the basis that it is not medically necessary for treatment of the patients medical condition.The materials provided do not include detailed information regarding the patients clinical history or current condition. The patient states Celebrex has been recommended by his oncologists for treatment of pain associated with CLL. Review of the medical literature reveals no evidence that Celebrex will improve any manifestations of CLL. As such, Celebrex is not medically indicated for treatment of CLL. Though it is very unlikely that the patient has any clinical problems related to stage I CLL, no evidence has been provided indicating the patient requires Celebrex on other grounds, e.g., rheumatologic issues. Therefore, I have determined that 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 17-year-old female who has a long history of behavioral health problems. On 11/20/03, the patient was admitted to an inpatient level of care. She was then stepped down to a residential level of care on 1/29/04. A request has been made for reimbursement for inpatient services received from 11/20/03 through 1/28/04 and for residential treatment services received from 1/29/04 through 4/9/04. The Health Plan has denied this request indicating the services at issue were not medically necessary.Review of the submitted clinical information demonstrates inpatient services were medically necessary. However, the clinical information does not demonstrate residential services were medically necessary. Prior to the inpatient admission, the patient had been receiving regular dietary and psychiatric counseling for at least a year. Despite this therapy, the patients condition was deteriorating with continued depression, self-harm, and acting out along with purging. The patients condition in November 2003 coupled with her treatment history warranted an inpatient admission. In fact, it appears the Health Plan recommended inpatient care for the patient. Records from the inpatient stay demonstrate improvement in the patients condition with stabilization and some level of insight. At the time of discharge from inpatient care, the patient was stable and records demonstrate residential care was not medically necessary. Based upon the documentation provided from the patients residential treatment, it is difficult to evaluate the patients clinical progress, as psychiatry visits were few and documentation brief. Furthermore, there is no objective clinical evidence demonstrating the patients condition was such that she required a residential level of care. Based upon the records provided, the patient could have been treated at a less intense level of care after discharge from inpatient care.Based upon the information set forth above, I have determined although inpatient care was medically necessary, residential care was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 61-year-old man with coronary artery disease. He underwent percutaneous transluminal coronary angioplasty in 1992. He received 100 chelating treatments. In 1993, he complained of effort angina. In August 2003, after complaints of chest pain, a nuclear stress test was performed. The patient was able to exercise 10 minutes and 27 seconds and achieve a maximum heart rate of 137 bpm. He reported a slight pressure sensation with exercise. The test was positive by EKG and nuclear criteria. Thereafter, his physician prescribed and administered 33 enhanced external counterpulsation (EECP) treatments. The Health Plan has denied reimbursement for the EECP treatments at issue on the basis they were not medically necessary for treatment of the patients medical condition.Analysis and Findings:In 1999, the Centers for Medicare and Medicaid Services (CMS) approved EECP as a reasonable and necessary treatment for certain Medicare beneficiaries suffering from stable angina pectoris refractory to medical and/or surgical therapy. The CMS approval provides coverage for EECP to Medicare patients who have been diagnosed with disabling angina (class III or class IV, Canadian Cardiovascular Society Classification or equivalent classification) who, in the opinion of a cardiologist or cardiothoracic surgeon, are not readily amenable to surgical intervention. The information provided in this case does not include documentation of medical or surgical management for the patients angina pectoris. In addition, objective testing indicates the patient does not meet medical necessity criteria for treatment. Therefore, there is no evidence demonstrating EECP was medically necessary for this patient.Based upon the information set forth above, I have determined that the treatments at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 38-year-old female with a multiplicity of seemingly unrelated symptoms. Equivocal improvement in the patients non-specific symptoms has been noted with growth hormone therapy. Therefore, the patient wishes to continue to receive growth hormone therapy. The Health Plan has denied coverage for growth hormone therapy indicating the requested therapy is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The submitted literature citations are not pertinent to patients such as this patient. A low IGF-1 is not an adequate test for adult growth hormone deficiency. For example, obese people have low IGF-1. An increase in IGF-1 would be expected with growth hormone injections. In addition, the patients GH stimulation test was normal. Furthermore, the laboratory tests are inconsistent, e.g., a high TPO followed by a normal TPO. Thus, there is no evidence that growth hormone injections have resulted in improvement in the patients condition. There is no medical indication for continued growth hormone therapy.  Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.