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

The patient is a 31-year-old woman who has extensive, severe psoriasis. She reportedly has had mildly elevated liver enzymes. The psoriasis has not responded to topical treatments. The patients dermatologist indicates that Soriatane is contraindicated in women of childbearing age. In addition, the patients dermatologist states that methotrexate is contraindicated in patients with abnormal liver enzymes and may cause hypertension. Furthermore, the patient indicates that the nearest ultraviolet treatment facility is inaccessible because of its distance from the patients home and work. The patients dermatologist has recommended Raptiva to treat the patients psoriasis. The Health Plan has denied the patients request indicating that the requested medication is not medically necessary.The Health Plans denial should be overturned. Raptiva appears to have a much more acceptable safety profile than methotrexate, Soriatane or cyclosporine. Furthermore, ultraviolet treatment is precluded in this case due to the distance of the nearest ultraviolet treatment facility. As far as pregnancy risk is concerned, cyclosporine, like Raptiva, is a category C medication. There is no evidence that Raptiva has a greater miscarriage or teratogenicity risk than cyclosporine. Furthermore, Soriatane and methotrexate are contraindicated in women who want to become pregnant. Thus, Raptiva appears to be a medically reasonable and appropriate alterative for this patient. Based upon the information set forth above, I have determined that 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 three-year-old male who has been diagnosed with childhood apraxia syndrome by a speech-language therapist. The patients birth history was within normal limits and no other neurological deficits are documented in the submitted records. The patients hearing was tested and was found to be within normal limits. The speech-language therapist has documented that the patients receptive language skills are within normal limits for his age. Review of the speech therapy progress notes reveals improvement in the patients speech. A request has been made for continued speech therapy. The Health Plan has denied the request on the basis that the patient is experiencing a developmental delay and therefore, speech therapy is not medically necessary.The Health Plans denial should be upheld. Upon review of current medical literature the definition of childhood apraxia disorder is not uniform and remains controversial. Childhood apraxia disorder is related to a nervous system disorder or underdevelopment. There is no literature or consistent neurologic finding to date to verify that childhood apraxia syndrome is an isolated disease. Therefore, under current definitions it appears the patients condition is considered a developmental delay rather than a medical condition. In light of this, treatment of the patients condition is not medically indicated.Based upon the submitted information, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1The patient is a 28-year-old man with a history of degenerative disc disease. The patient has low back pain and lower extremity pain. The patient has attempted conservative treatment including NSAIDs, muscle relaxants, physical therapy, and epidural steroids. The patient has requested authorization and coverage for nucleoplasty. The Health Plan has denied the patients request on the basis that it is considered investigational.Nucleoplasty is considered an investigational procedure and lacks established efficacy. Blinded-controlled studies have not established the clinical efficacy of this procedure. Nucleoplasty is not likely to be of greater benefit to this patient than other clinically available therapy. 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 2The patient is a 28-year-old man with a history of multi-level lumbar degenerative disc disease. The patient has experienced chronic back pain for 11 years. He has tried multiple treatment modalities without success. The patient wishes to undergo nucleoplasty. The Health Plan has denied the patients request on the basis that nucleoplasty is considered investigational.Nucleoplasty is not standard care for treatment of multi-level degenerative disc disease. There are no randomized, controlled trials demonstrating long-term efficacy of nucleoplasty. Furthermore, there is no peer-reviewed class I data to suggest that nucleoplasty is a more effective treatment option for this patients condition than standard therapies. 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 3The patient is a 28-year-old male with a history of chronic back pain with positive discogram at L3-4 and L4-5. The patient would like to avoid spinal fusion and has requested authorization and coverage for nucleoplasty. The Health Plan has denied authorization for the requested procedure on the basis that it is experimental in nature.There is no role for nucleoplasty in the treatment of this patient. There are no randomized, controlled trials demonstrating the long-term success of nucleoplasty in the treatment of discogenic chronic back pain. Nucleoplasty is without proven benefit in the treatment of this patients condition. There are no prospective controlled trials establishing the safety and efficacy of nucleoplasty for this category of patient. 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: Overturned Decision of Health Plan

A 33-year-old woman has a lesion of her lower right leg/ankle, which was biopsied by her primary care physician in September 2003. The diagnosis by pathology was superficial basal cell carcinoma. The patient has requested authorization for a consultation with a dermatologist for evaluation and treatment of her condition. The Health Plan has denied the patients request on the basis that the initial evaluation and treatment of dermatologic conditions as well as skin surveillance for skin cancer are within the scope of practice and clinical expectation of the patients primary care physician.Generally, dermatologists are better qualified and more knowledgeable and experienced in treating skin cancers and evaluating possible skin cancers. Though the Health Plan indicates that evaluation and treatment of dermatologic disorders, as well as skin surveillance for skin cancer, are within the scope of practice and clinical expectation of a primary care physician, there is no evidence of peer-reviewed studies supporting this contention. Consultation with a dermatologist for evaluation and treatment is medically reasonable and appropriate. Therefore, I have determined that the requested consultation is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old woman who reports tingling from head to toe following an automobile accident in October 2001. The patient has been evaluated by several physicians including an orthopedic surgeon and neurologist.MRIs of the cervical spine were performed in 2002 and 2003. The 2003 MRI showed straightening of the spine. There was no cord or root compression. There was minimal spinal stenosis at C4-5 and foraminal narrowing at C5-6 and C6-7. MRIs of the lumbar spine were performed in April 2002 and September 2003. There was bilateral foraminal stenosis and mild displacement of the right nerve root at L4-5. Mild foraminal narrowing was present at L3-4 and L2-3. MRI of the thoracic spine in September 2002 showed a posterior osteophyte at C6-7 with the thoracic spine otherwise negative. MRI of the brain in August 2003 was negative. EMG in August 2003 was normal for the upper extremities. There was decreased conduction velocity across the wrists, possibly representative of carpal tunnel syndrome. MRI of the chest in September 2003 was negative. Bone scan in December 2003 showed a scoliosis, otherwise negative. The patient has also been treated with various medications and physical therapy. The patient was examined by a neurologist in December 2003 who could not find an etiology of the patients symptoms. The patients primary care physician ordered a CT/body scan of the neck/thorax/abdomen and pelvis. The patient has requested authorization and coverage for a full-body CT scan.At issue is whether a full-body CT scan is medically necessary for evaluation of the patients medical condition.In general, there is no medical indication for a screening full-body CT scan. The American College of Radiology believes that there is insufficient evidence showing that whole-body CT screening prolongs life. The U.S. Food and Drug Administration concurs that whole-body CT screening has not been convincingly shown to detect disease early enough to avoid serious illness or premature death. According to Berland, et. al., whole-body screening cannot currently be justified based on medical, scientific or psychological grounds. Thus, there is no evidence that a full-body CT scan is medically indicated for further evaluation of this patient. Based upon the information set forth above, I have determined that the requested CT scan is 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 female toddler with port wine stain V2 distribution. She underwent six V-beam laser treatments with a pediatric laser expert. It has been noted that results of the treatment were partial and the response was not entirely satisfactory. The patients provider has indicated that she does not have any alternative therapy to offer the patient. The patient has been examined by another provider who has recommended C-beam pulsed dye laser therapy (PDL).An abundance of medical literature supports treating port wine stain early in life for best long-term results. In light of the fact that there are no further treatment modalities to offer this young patient, the requested therapy is medically indicated. While available data regarding C-beam PDL is limited, preliminary data suggests that C-beam PDL has the capability of providing an improvement for this patient. Given that other established alternatives have been exhausted, treatment with C-beam PDL is medically reasonable and appropriate. Based upon the information set forth above, I have determined that 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 48-year-old woman with Crohns disease. She has not responded to conventional medical therapy. These have included 6-MP, 5-ASA, thalidomide, and steroids. The patient was recently placed on methotrexate. She developed a lupus-like reaction to Remicade. The patient continues to be symptomatic. The patient has requested authorization and coverage for Humira. The Health Plan has denied the patients request on the basis that Humira is not medically necessary for treatment of the patients medical condition.Humira is anti-TNF alpha derived from human antibody. It has been approved by the Food and Drug Administration (FDA) for treatment of rheumatoid arthritis. Humira, like Remicade, can cause lupus-like reactions. There are ongoing studies involving use of Humira in treatment of patients with Crohns disease. Although Humira has not been FDA approved for treatment of the patients condition, its use by this patient is medically reasonable. The patient has exhausted all treatments options short of surgery. In this particular patient at this stage of her disease it is medically appropriate to proceed with the requested medication. Therefore, I have determined that 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 57-year-old female status post vertical banded gastroplasty. Her body mass index (BMI) is 30 with reported reflux esophagitis and solid intolerance. The patient has requested authorization for gastroplasty revision and conversion to Roux-en-Y gastric bypass. The Health Plan has denied the patients request indicating that Roux-en-Y gastric bypass is not standard of care for surgical treatment of GERD, gastritis, and esophagitis.  The patients current BMI in the absence of any comorbid criteria precludes any indication for gastric bypass surgery. The patient indicates that she wishes to undergo conversion to a Roux-en-Y gastric bypass so that she can consume normal, healthier meals; however there is a high incidence of solid intolerance after Roux-en-Y gastric bypass. Furthermore, there is a risk of protein malnutrition after Roux-en-Y gastric bypass since most patients are not able to tolerate eating meat. Thus, conversion to Roux-en-Y gastric bypass for treatment of the patients reflux esophagitis is not medically indicated in the absence of morbid obesity. If the patients GERD, gastritis, and esophagitis symptoms are severe enough, removal of the gastroplasty ring may be indicated to solve her reflux problems.Based upon the information set forth above, 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 32-year-old man with long-standing erectile dysfunction of uncertain etiology. The patient has responded to treatment with oral Viagra. The Health Plan has denied authorization and coverage for Viagra indicating that an organic causation has not been identified.This patient has erectile dysfunction of uncertain etiology, possibly vasculogenic. In the absence of identification of other more specific etiologies it is not unreasonable to assume venous leakage or neurogenic/psychogenic causation. In any event, treatment of this patients erectile dysfunction should be undertaken. The patient has already been treated with Viagra and it has proven to be an effective treatment for his dysfunction. Furthermore, regardless of the presumed source of erectile dysfunction, Viagra is considered a first-line therapy. Based upon this information, the patient should continue to receive Viagra for treatment of his erectile dysfunction. Therefore, I have determined that 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 63-year-old man who was diagnosed with gastric cancer in 1997. He had a subtotal gastrectomy in July 1997. He was then treated with chemotherapy, but suffered a recurrence in 1998. The patient underwent a complication gastrectomy, lymphadenectomy, and intraoperative radiation in July 1998. He had several complications including aortogastric fistula and upper abdominal bleeding. He had further upper GI bleeding episodes that were treated with surgery in 1999. Sometime after that, he was started on Procrit injections to maintain his hemoglobin.  The submitted information includes several hemoglobin determinations, including the following: 12/30/02: Hb 14.9; 3/26/03: Hb 11.7; 10/3/03: Hb 12.4; and 1/26/04: Hb 12.7. The patients iron studies have been normal. A request has been made for authorization and coverage for continued use of Procrit. The Health Plan has denied the request due to a lack of medical necessity.Procrit is an injectable form of erythropoietin given to raise the hemoglobin level primarily in patients deficient in natural erythropoietin. It is of value in patients with cancer who are receiving chemotherapy and is commonly used in such patients when they are anemic. Though there is some controversy as to what level of hemoglobin should serve as an indication for the use of Procrit, it is clearly not indicated with a hemoglobin above 12, as appears to be the case with this patient. Thus, there will be no benefit to this patient from the use of Procrit. Patients without a stomach have major difficulty in absorbing vitamin B12 and iron so they should be treated with these supplements. Should the patients hemoglobin fall, particularly down close to or below 10, then use of Procrit should be reinstituted.Based upon the information set forth above, I have determined that the requested medication is 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 10-year-old male with Tourettes syndrome, obsessive-compulsive disorder, anxiety, outbursts (likely related to Tourettes), dizziness, and sleep disorders. He has been treated with Prozac for his obsessive-compulsive disorder. The patient has difficulty following verbal commands in school. The patients intelligence quotient is 92, which is low normal. The patients physicians have recommended neuropsychological testing to evaluate the patient for a possible learning disability. The Health Plan indicates the requested services are not medically necessary for treatment of the patients condition.Upon review of the submitted evidence, it has not been demonstrated that the requested services are medically necessary. The alternatives offered by the Health Plan are medically reasonable and appropriate. The patient should be evaluated by a neurologist for evaluation and treatment of Tourettes syndrome. In addition, the patient should be examined by a psychiatrist for evaluation and treatment of possible obsessive-compulsive disorder. Furthermore, it appears that the school system can provide appropriate testing for purposes of optimizing educational intervention. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-three year-old male with a carcinoma is requesting authorization and coverage for a laryngoscopy.Reviewers Findings:  The reviewing physician found that a laryngoscopy is medically necessary to evaluate the patient for possible recurrence.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 59-year-old man who had experienced chest tightness for a number of years. He was referred to a cardiologist in 1997. A stress echocardiogram was normal. In 2003, the patient became concerned because he had chest tightness walking uphill. The patient was again referred to a cardiologist who noted the patients father had coronary artery disease. The age of onset was not noted. No other risk factors for coronary artery disease were found. The patients cardiologist recommended a stress myocardial perfusion study and an electron beam computerized tomography (EBCT). The former study was negative for exercise-induced ischemia. The EBCT scan total calcium score was 40.14.The patient has requested reimbursement for the EBCT scan. The Health Plan has denied the patients request indicating that the EBCT scan at issue was not medically necessary for evaluation of the patients medical condition.The Health Plans denial should be upheld. The appropriate test in this case was a stress myocardial perfusion study, which was performed with negative results. The addition of an EBCT scan was not medically indicated as an EBCT scan would not result in an improved health outcome. The American College of Cardiology/American Heart Association consensus statement recognizes that EBCT identifies a risk factor for the presence of coronary artery disease. It does not predict presence or severity of stenosis. Furthermore, the medical literature does not support the contention that an intervention on the basis of EBCT findings alters outcome. Therefore, I have determined that the EBCT scan at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old female with an extensive history of treatment for fibrocystic disease of both breasts necessitating bilateral mastectomies in 1995. She subsequently underwent revisionary procedures for capsular contraction of the reconstructed breasts. It has been proposed by the patients surgeon that the patient again undergo removal of the contracted implants, capsulectomy, and replacement of the implants. Signs and symptoms documented by the surgeon in his records and the accompanying photograph are pain and deformation of the breasts.The patient has had bilateral mastectomies and is symptomatic. The requested procedure is medically indicated and appropriate given the patients clinical history. Bilateral capsulorrhaphy/capsulectomy and replacement of breast implants in a previously mastectomized patient is a medically necessary reconstructive procedure. The requested procedure is not cosmetic in nature and is considered reconstructive as defined by California law and the guidelines of the American Society of Plastic Surgeons. 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.