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

The patient is a 46-year-old female with a longstanding history of irritable bowel syndrome (IBS). Zelnorm has relieved her constipation, bloating, and abdominal pain. The patient has requested authorization for a longer duration of Zelnorm therapy. The Health Plan has denied the request on the basis that continuation of Zelnorm is not medically indicated.Although the duration of the patients use of Zelnorm has exceeded FDA guidelines, IBS and constipation are lifelong conditions. The patients provider has indicated that the patient has not responded to any conventional medications. In addition, it has been noted that the patients symptoms returned once Zelnorm was discontinued. In this particular case, given the patients clinical condition and her past success with Zelnorm, continued use of Zelnorm may be medically indicated. However, this determination cannot be made because the information submitted does not contain the necessary recent history to determine whether the patient is experiencing any of the known complications from the medicine such as syncope, diarrhea, or symptoms of ischemic colitis. Absent a sufficiently detailed history, the prolonged use of Zelnorm is contraindicated. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if the patients provider submits documentation demonstrating the patient has no history consistent with known complications to Zelnorm, the Health Plans denial should be reconsidered because the patient has demonstrated a positive response to Zelnorm and no other medication previously tried was beneficial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 16-year-old female with a several year progressive history of antisocial acting out behavior including running away from home, truancy, periodic substance abuse, and oppositional defiance. The patient was apparently treated as an outpatient for a short time. A trial of Depakote resulted in equivocal results. The patients parents were unable to control the patients behavior and poor peer contacts. She was diagnosed by an outpatient psychiatrist as borderline personality disorder, rule out bipolar disorder, adjustment disorder, and disturbance of emotions and conduct. In August 2002, the patient was admitted to a residential treatment center. The patient has no apparent history of suicidal ideation or behavior or psychosis. A request has been made for reimbursement for residential treatment services received from 8/23/02 to 12/31/02. The Health Plan indicates the submitted clinical information does not support the medical necessity of treatment at the residential level of care.Based upon the submitted records, at the time of the patients admission to the residential treatment center in August 2002 the patient was out of control due to her pathology. In view of the patients condition at that time, the patient was in need of residential treatment services for evaluation and stabilization. Review of the documentation provided demonstrates that the patient required containment, structure, and treatment. However, after thirty days at residential level treatment the patients condition had stabilized and transfer to a partial hospitalization program would have been medically reasonable and appropriate. There is no evidence that as of 9/23/02 the patient posed a threat to herself or others. The patient was cooperative and able to participate in treatment. Thus, as of 9/23/02 the patient could have been appropriately treated in a partial hospitalization program followed by intensive outpatient treatment. Based upon the information set forth above, I have determined that residential treatment services were medically necessary for treatment of the patients medical condition until 9/23/02. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 63-year-old man with a well-documented diagnosis of very symptomatic chronic urticaria. Treatment with Benadryl, Claritin, Allegra, and other over-the-counter antihistamines was ineffective. Treatment with Zyrtec was effective. The patient experienced immediate relief of his symptoms with Zyrtec. The patient wishes to continue use of Zyrtec. The Health Plan indicates the submitted information does not demonstrate that Zyrtec is medically necessary for treatment of the patients urticaria.Zyrtec is medically necessary for treatment of the patients condition. The submitted information indicates the patient is currently using Zyrtec and is stable on the medication with no adverse effects.  In addition, there is evidence that Zyrtec has proven effective for this patient. Furthermore, there is documented evidence that other antihistamines have not been effective. Continued use of Zyrtec is medically reasonable and appropriate and indicated in this case. 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: Overturned Decision of Health Plan

The patient is a nine-year-old male who was evaluated by his podiatrist from early March 2003 through April 2003. Numerous diagnoses were made including fasciitis, flat feet, varus, and abnormal pronation. During an evaluation in February 2004, the patients physician noted the patients feet were turning inward and the patient had pain in his heels. A podiatry consultation was recommended. The Health Plan has denied authorization for the consultation on the basis that it is not medically necessary.There are numerous differential diagnoses for heel pain including but not limited to plantar fasciitis, infra-calcaneal bursitis, apophysitis, stress fracture to calcaneus, calcaneal bone cyst, calcaneal bone tumor, and avascular necrosis of calcaneus. In light of the extensive differential diagnoses for heel pain an extensive podiatry evaluation of the patient is medically reasonable and appropriate. It is possible that the patients heel pain and flat feet are mutually exclusive. A podiatry evaluation is needed to determine the etiology of the patients pain. 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 six-year-old male with a history of febrile seizures. The patient also has developmental and social delays and has been diagnosed with expressive language delay, oral motor difficulties, mild phonological disorder, and moderate developmental apraxia of speech. The patient underwent a developmental evaluation in 2002, which reflected multiple components of developmental delay with both sensory issues and fine and gross motor issues. The patient had many of the components of pervasive developmental disorder, but did not meet the criteria for pervasive developmental disorder. Subsequently, the patient was diagnosed with the above language disorder by his speech therapist. It appears the patient has received approximately eight months of speech therapy. A request has been made for additional speech therapy. The Health Plan has denied authorization for additional speech therapy on the basis that it is not medically necessary. In light of the evaluation by the patients developmental psychologist, which reveals a spectrum of delays it is unlikely the patients speech issues are related to his seizures (especially febrile seizures). The available clinical evidence seems to indicate the patient has a speech delay that is developmental in nature. Therapies for developmental delays are not medically necessary and are typically appropriately provided through means other than individual therapy. As such, the submitted evidence provides no medical indication for speech therapy at this time. Therefore, I have determined that the requested therapy is not medically necessary for the 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 five-year-old male who has been diagnosed as having ADHD, hyperactive type. Pervasive developmental disorder - not otherwise specified, and mental retardation have been ruled out. The patient was initially treated with Adderall immediate release with positive response. The medication was later switched to Adderall XR (long-acting), which was given only once per day. The patient continues to have positive response to Adderall therapy. The patient has not been tried on any other psychostimulant. A request has been made for authorization of Adderall XR. The Health Plan has denied the request on the basis that Adderall XR is not medically necessary. Though the submitted records indicate the patient has had a positive response to Adderall XR it has not been established that Adderall XR is medically necessary for treatment of the patients ADHD. The records demonstrate the patient had significant positive response to immediate release Adderall. There is no documentation of significant rebound on the immediate release version of Adderall. Furthermore, Adderall XR has not been approved for use in children under the age of six. Moreover, the submitted documentation does not demonstrate the patient has experienced complications that would warrant use of the long-acting version of Adderall. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for the 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 51-year-old male with a history of severe chronic pain of the low back, shoulders, neck, and joints after a near fatal accident. The patient also states that he has been HIV positive for 14 years and hepatitis C positive for 5 years. The patient has been tried on numerous narcotic medications including Percocet, Percodan, Norco, Duragesic patch, OxyContin, MS Contin, morphine sulfate, and Actiq. The patients most recent medication regimen appears to have been Percocet 2 tablets every four hours and Duragesic patch 100mcg per hour in addition to Actiq, which was prescribed in June 2004. It appears the patient is also taking Valium and Restoril.The patient states that the only narcotic that has provided pain relief is Actiq. The Health Plan has denied authorization for Actiq on the basis that it is not medically necessary for treatment of the patients medical condition.This patient with severe musculoskeletal pain involving his low back, shoulder, and neck, is seeking additional narcotic medication (Actiq) after indicating that his current regimen of Duragesic patch and Percocet does not control his pain. The patient seems to be requiring increasing doses of narcotics in treating his chronic, severe, non-cancer pain. Actiq is currently indicated for severe breakthrough cancer pain. Actiq has potentially serious side effects; its use in this clinical context in the absence of breakthrough cancer pain is not medically warranted. 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: Upheld Decision of Health Plan

This 63-year-old man has prostate cancer. He experienced a rise in PSA from 4.0 in June 2001 to 11.5 in November 2003. Biopsies from the left side revealed Gleason score of 5+4=9 in 5/6 core biopsies. Biopsies from the right side revealed Gleason score of 5+4=9 in 6/6 core biopsies. Based upon Partins Tables, the risk of capsular penetration is 41%, the risk of seminal vesicle involvement is 15%, and the risk of pelvic lymph node involvement is 38%. The urologist staged the patient as T2c while the radiation oncologist recommended two to three years of neoadjuvant hormone therapy (NHT) along with radiation therapy to the prostate and regional lymphatics followed by a boost of radiation to the prostate gland. The patient wishes to receive intensity modulated radiation therapy (IMRT) rather than 3-dimensional conformal radiation therapy (3D CRT). The Health Plan has denied authorization and coverage for IMRT on the basis that it is not medically necessary.IMRT is a more precise therapy compared to 3D CRT. IMRT can deliver 8000 cGy to the prostate, while 3D CRT can deliver 7200 cGy to the prostate. However, it is likely that the patients cancer is not limited to his prostate. There is a 38% chance of lymph nodes being positive. Thus, it is not sufficient to treat the prostate only. Presently, diagnostic imaging is incapable of outlining the lymph nodes in the pelvis and therefore, IMRT will be useless for these potentially involved targets. IMRT is superior to 3D CRT only when the disease is confined to the prostate. There is a strong likelihood that the cancer involves the patients pelvic lymph nodes as well. For patients such as this patient, 3D CRT is just as effective without any change in the prognosis.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the 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 36-year-old female with a body mass index (BMI) of 40 and comorbid conditions including urinary stress incontinence, gastroesophageal reflux disease, and depression. In addition, it has been noted that the patient has a history of migraine headaches. It does not appear the patient has obtained psychiatric clearance for weight loss surgery. The Health Plan has denied authorization and coverage for gastric bypass on the basis that it is not medically necessary.With a BMI of 40 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery and is particularly important in this case given the patients history of depression and migraine headaches. Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 64-year-old morbidly obese woman who is seeking panniculectomy for a large pendulous panniculus. She was seen and evaluated by her dermatologist and her plastic surgeon in June 2004 for her pannus. After examining the patient, the plastic surgeon documented the discussion of the patients morbid obesity and the many comorbidities that presently put the patient at risk for any operative procedure. The patient wishes to undergo a panniculectomy. The Health Plan has denied the patients request on the basis that the requested procedure is not medically indicated.The patient is an elderly and morbidly obese woman with severe comorbidities of diabetes, hypertension, hypothyroidism, hyperlipidemia, and osteoarthritis. The complaint of circulation decreasing to her lower extremities is not noted to be present in the submitted notes but could be secondary to another comorbid condition, i.e., peripheral vascular disease. The submitted photographs and clinical notes reveal no evidence of untreatable intertrigo or rash. The patients providers recommendation to treat the patients morbid obesity is medically reasonable and appropriate. A panniculectomy is not medically indicated at this time. 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 22-year-old woman with a body mass index (BMI) of 47. She has comorbid conditions including hypertension. The patient has obtained psychiatric clearance for weight loss surgery. She wishes to undergo gastric bypass. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 47 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. 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: Overturned Decision of Health Plan

The patient is a 34-year-old woman with longstanding problems with her right knee. The patient has undergone two prior surgeries. She is status post anterior cruciate ligament (ACL) reconstruction and now requires a revision of this surgery. A request has been made for a continuous passive motion (CPM) unit postoperatively. The Health Plan has determined that a CPM unit is not medically necessary for the patients postoperative rehabilitation.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. In the case of this patient, she clearly experienced a benefit from use of a CPM unit following her prior surgery. In addition, the patient has a history of motion and stiffness problems that developed after her first knee surgery. Furthermore, there are no significant risks posed by use of a CPM unit. Given the patients history, her prior problems, and her success with use of a CPM unit in the past, a CPM unit is medically reasonable and indicated for the patients successful postoperative rehabilitation. Based upon the evidence set forth above, I have determined that the requested equipment 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 female who is 15 months status post right mastectomy for breast cancer with 7 of 19 positive lymph nodes harvested at lymphadenectomy. She underwent postoperative chemotherapy and a course of radiation therapy, which ended in December 2003. The patient sought reconstruction of her chest wall deformity and was evaluated by a plastic surgeon who recommended a TRAM flap reconstruction. The patient sought a second opinion from the plastic surgeon who had placed her breast implants ten years earlier. He suggested the use of a latissimus dorsi myocutaneous flap with an implant to match the remaining left breast. The patient is considering a left breast mastectomy because of fear of bilateral disease. The Health Plan has denied authorization for the latissimus dorsi flap repair on the basis that it is not medically necessary. The TRAM flap reconstructive procedure has been authorized.The procedures proposed for the patients breast reconstruction post mastectomy, post radiation therapy (expander/implant, TRAM flap, and the latissimus dorsi flap/implant) all are negatively impacted by the post radiation changes to the respective vascular pedicles or local tissue. The choice of procedure is essentially guided by the knowledge of the patients treating surgeon. There is no objective evidence that the requested procedure is more advantageous than the procedure recommended by the patients treating surgeon and authorized by the Health Plan. The procedure authorized by the Health Plan is medically reasonable and appropriate. 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: Upheld Decision of Health Plan

The patient is a 61-year-old woman with a long-standing history of neck pain. The patient has undergone treatment with traction, chiropractic, and physical therapy. The patient has requested authorization for additional physical therapy visits. The Health Plan indicates the patients condition has significantly improved since she began physical therapy. Therefore, the Health Plan has determined that additional physical therapy is not medically necessary for treatment of the patients neck pain.Review of the submitted medical records shows the patient has reached a plateau in terms of range of motion. As of 12/11/03, strength was noted as 5/5 and sensation was noted as independent. There has been no reported change in functional status since 10/2/03 and pain complaints are unimproved since that time. Hence, the patients progress has reached a plateau. It appears the patients therapists request for physical therapy once per week is for the purpose of maintaining the patients condition. The patient has already been instructed in a home program. Given the patients long history of neck pain it is not anticipated that she will benefit from additional physical therapy. Therefore, 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.