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

The patient is a 58-year-old male who has been experiencing recurrent vertigo, unsteadiness, disequilibrium, and ataxia since 2000. The patient reports significant disequilibrium and unsteadiness. An MRI documented cerebellar atrophy. Otoscopy revealed both external auditory canals were clear and tympanic membranes were visible an intact. Microscopic examination was normal. The patient underwent a computerized dynamic posturography resulting in a composite score of 40. Vestibular rehabilitation was then recommended. A request has been made for reimbursement for the computerized dynamic posturography, which the Health Plan has denied.The Health Plans denial should be upheld. There are no recent articles to establish computerized dynamic posturography as a sensitive or specific tool in diagnosing the cause of disequilibrium. Additionally, there is no available data regarding the health outcome effects of treatment decisions based on dynamic posturography. Thus, the clinical usefulness of computerized dynamic posturography remains unproven. Its use in the management of this patient was not more beneficial than established alternative tests. Accordingly, I have determined a computerized dynamic posturography was not medically necessary for evaluation 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 53-year-old female with a history of obesity (55 and weighing 189 pounds with a body mass index of 31), and tendonitis. She has no documented history of diabetes, sleep apnea, hyperlipidemia, hypertension or arthritis. The patient has requested authorization and coverage for the medication Xenical. The Health Plan has denied this request indicating the requested medication is not medically necessary for treatment of the patients obesity.The Health Plans denial should be upheld. With a BMI of 31 and no significant comorbid conditions, the patient does not meet medical necessity criteria for Xenical. Additionally, there has been no submitted documentation indicating the patient has tried and failed lifestyle interventions such as diets, exercise programs, or behavior modification for weight control. Other treatment options including structured diet programs, nutritional counseling and physician supervised low calorie/exercise programs along with behavioral modification, would be medically appropriate prior to consideration of prescription pharmacotherapy. 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

The patient is a 23-year-old male who requests circumcision. His request is based on a desire for more sensitivity of the penis and reduced pain during intercourse. His examination by the urologist demonstrated a normal penile foreskin and glans penis. The patients past urologic history includes a repair of ureteropelvic junction obstruction of the kidney three years ago. There is no evidence the patients history of ureteropelvic junction pyeloplasty is relevant to his current complaints. The Health Plan has denied coverage for circumcision citing lack of medical necessity.There is no medical indication for circumcision on an adult male who is not having difficulty with phimosis or complications thereof. The urologists examination of the patient demonstrated no such medical indication. The penile exam was normal. Furthermore, though the patient wishes to undergo the procedure in part to increase sensitivity, there are some reports that circumcision can blunt rather than enhance sensitivity. For these reasons, 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 48-year-old male who has a diagnosis of multiple sclerosis with associated chronic fatigue and pain. He received physical therapy. The patients provider recommended continued physical therapy three times a week. The Health Plan has denied coverage for physical therapy the patient received, as well as authorization for additional physical therapy on the basis such services are not medically necessary. The Health Plans denial should be upheld. Physical therapy was being used for maintenance with no functional improvement goals expected. There is no medical indication for additional therapy. The patient should have a clear understanding of a home program based on the amount of supervised physical therapy he has received and should be able to participate in an independent program. Therefore, I have determined the medical necessity of the therapy at issue has not been established. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 12-year-old male with a diagnosis of autism who has been receiving speech therapy since June 2002. According to documents provided, he has made significant gains in speech during that time. He is now age appropriate for expressive and receptive language skills. He continues to show deficits in problems solving, pragmatic language skills, and verbal language processing. At issue is whether continued speech therapy for the deficits documented is medically necessary.In reviewing the speech therapy reports, I find sufficient documentation that this patient continues to make gains in therapy that warrant continued therapy. Social speech and communication are not solely determined by expressive and receptive language; rather, age appropriate communication also relies on problem solving and pragmatic language skills. Although the literature does not document well the benefits of one-on-one speech therapy for pragmatic speech delay, the patient has experienced significant progression in these areas as documented by the patients therapist. It is well documented in speech therapy texts and developmental pediatrics texts that improvement in speech therapy for a diagnosis of autism is measured in years rather than months. Thus, I find the progress shown in this patient and the expected improvements to be reasonable and predictable. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should continue to receive speech therapy twice weekly with re-evaluation in six months.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 50-year-old female in good health with the exception of hemodynamic stable mitral valve prolapse. She requires extraction of impacted molars. Her cardiologist indicates she is a low risk for significant coronary artery disease and mitral valve regurgitation, which requires antibiotic prophylaxis prior to oral surgery. There is no information from the oral surgeons office indicating anything unusual concerning extraction of the patients teeth. The patient is seeking authorization for inpatient hospital and general anesthesia services in association with her oral surgery. The Health Plan has denied this request.Based upon the information provided there is no cardiovascular of other medical condition which would require the use of hospital based general anesthesia for the proposed oral surgery. This type of oral surgery for a person with stable mitral valve prolapse would best be performed in the office setting. Therefore, I have determined 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: Upheld Decision of Health Plan

The patient is a 42-year-old female who is 59 weighing 238 pounds with a body mass index (BMI) of 35. She has comorbid conditions including diabetes, obstructive sleep apnea, gastroesophageal reflux disease (GERD), and hypertension. The patient has requested authorization and coverage for gastric bypass surgery. The Health Plan has determined gastric bypass surgery is not medically necessary for treatment of the patients condition.With a BMI of 35 and her comorbid conditions, the patient does not meet medical necessity criteria for weight loss surgery. There is potential that conservative care including dietary regimen, appropriate exercise, and behavioral support and modification could be effective in assisting the patient in weight loss. Therefore, given the risks and morbidity associated with gastric bypass surgery, further attempts at weight loss should be undertaken prior to consideration of surgery. Accordingly, I have determined that the requested procedure 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 46-year-old female who is 51 weighing 240 pounds with a body mass index (BMI) of 45. She has comorbid conditions of hypertension, asthma, and osteoarthritis. She is status post Nissen fundoplication. She has been approved for bariatric surgery on the condition that she loses weight preoperatively and attends support group meetings. She has not complied with these conditions. Based upon the information provided, she has not been evaluated by a bariatric surgeon since 2004. In addition, it is unclear when the patient underwent a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.With a BMI of 45 and comorbid conditions the patient meets accepted criteria for consideration of weight loss surgery. However, the patient has not been evaluated by a bariatric surgeon in almost a year and it is unclear when she underwent a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Because of the time which has passed the patient should be re-evaluated by a bariatric surgeon and undergo a psychological evaluation. If these evaluations indicate the patient is an appropriate candidate for surgery  surgery should be authorized. If these evaluations indicate surgery is contraindicated  surgery should not be authorized.Regarding the Health Plans 10% weight loss requirement, 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. Furthermore, the report cited by the Health Plan as demonstrating benefit to preoperative weight loss refers to a preoperative weight loss of 5% not 10%.Based upon the information set forth above and because of the time which has passed the patient should be re-evaluated by a bariatric surgeon and undergo a psychological evaluation. Therefore, the Health Plans denial should be upheld at this time. If these evaluations indicate the patient is an appropriate candidate for surgery  surgery should be authorized. If these evaluations indicate surgery is contraindicated  surgery should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 60-year-old female with metastatic breast cancer. She underwent gamma nail to the left hip. The patient also has persistent anemia. She has progressed well in the hospital with less than 120 minutes of occupational and physical therapy daily. She requires contact guard assist to ambulate and minimum assistance with transfer. She is able to ambulate more than 250 feet. She needs standby assistance or is independent with ADLs. It appears her pain is under control. The patient has requested coverage for additional acute rehabilitation services. The Health Plan has denied the request on the basis the requested services are not medically necessary.Review of the submitted documentation does not demonstrate the patient requires intensive occupational/physical therapy at an acute rehabilitation level. It appears the patient is stable for transport to another facility for radiation. The patients medical needs are not at an inpatient level, except for hydration. She does require frequent monitoring and rehabilitation for her hips. These services can be provided at a skilled nursing facility that is equipped to monitor her frequently. As such, the services authorized by the Health Plan are medically reasonable and appropriate.Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 69-year-old male with diabetes, hypertension, heart disease and severe peripheral vascular disease. He also has a worsening ischemic/neuropathic heel ulcer. Angiogram confirmed severe disease below the knee with no distal target vessels, heel ulcer 4 x 4 cm in size, and necrotic tissue requiring antibiotics.The patient was examined by a vascular surgeon who recommended a below the knee amputation. He then consulted an out-of-plan vascular surgeon who has offered a popliteal dorsalis pedis bypass. It appears the patients current condition is non-healing arterial insufficiency/neuropathic ulceration. The patient wishes to avoid amputation and therefore, has requested authorization and coverage for a popliteal dorsalis pedis bypass. The Health Plan has denied coverage for the requested procedure on the basis it is not medically indicated for treatment of the patients condition.The patient has severe peripheral vascular disease and ischemic/neuropathic heel ulcer. A report by the patients radiologist and the in-plan vascular surgeon confirm no distal targets for bypass. Therefore, a below-the-knee amputation was offered. The out-of-plan vascular surgeon has offered a distal bypass though noted the angiogram was of poor quality. Approximately 10% of vascular patients have unreconstructable disease. This decision is based on the subjective opinion of the vascular surgeon. However, when no apparent named distal vessels are seen on angiogram, a distal bypass is unlikely to be successful. A large heel ulcer even with a well functioning bypass often requires coverage with a myocutaneous flap. Based upon the information provided, the requested procedure is not likely to be of benefit and therefore, is not medically necessary. However, a second opinion from an in-plan vascular surgeon using higher quality views of the angiogram would be medically reasonable and appropriate prior to below-the-knee amputation. 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 52-year-old female who has a history of two caesarian sections, hysterectomy, diverticulitis and colostomy. She has an abdominal pannus with scar tissue. The patient reports experiencing skin rashes and recurrent yeast infections. She has requested authorization and coverage for a panniculectomy, which has been denied by the Health Plan.The Health Plans denial should be upheld. The information submitted does not demonstrate the patient meets accepted criteria for authorization of a panniculectomy. Although the patient has an abdominal pannus, there is not documented evidence of intertrigo or panniculitis that has failed to respond to conservative therapy. Furthermore, there is a lack of evidence demonstrating significant functional impairment. Therefore, 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: Overturned Decision of Health Plan

The patient is an HIV-positive 48-year-old male under the care of an HIV care physician who has requested recombinant human growth hormone (rhGH) to treat severe fat redistribution syndrome of HIV (also referred to as visceral adipose tissue accumulation or lipodystrophy). The patient has visceral fat accumulation (lipohypertrophy) as well as facial and peripheral lipoatrophy and has experienced improvement on growth hormone treatment. At issue is whether continued growth hormone therapy is medically necessary.Lipodystrophy is a recognized condition in patients with HIV. The cause is unknown; it is believed to be multifactorial, with HIV infection, insulin resistance and antiretroviral medications all playing some role. To date, there is no FDA approved treatment for this condition; however, results of clinical trials of human growth hormone have been promising. Liposuction is often ineffective and cannot be performed on intra-abdominal fat and the fat often quickly reaccumulates anyway. While diet and exercise may help, they do not reverse the condition. Metformin and testosterone replacement may also play a role, but have not been proven effective.The results of a placebo-controlled, double blind trial with 245 HIV patients testing rhGH in abnormal visceral adipose tissue accumulation show significant improvement in patients who received rhGH. There are also numerous pilot studies that suggest it may be the most effective treatment thus far, and there are many reports of dramatic improvement in certain patients with lipohypertrophy.The weight of the evidence in placebo-controlled trials published in peer reviewed journals, as well as expert opinions published in review articles and numerous preliminary abstracts, suggests that human growth hormone is likely to be effective for treatment of the patients severe visceral fat accumulation.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 52-year-old female who has recurrent Stage IIIC ovarian cancer. She is status post treatment with carboplatin, paclitaxel, gemcitibine, Doxil, Xeloda, Hexalen, topotecan and altretamine. The patient has a 6cm cul-de-sac mass at the greater gastric curvature. A recent chest CT was normal. There is no evidence of ascites or mention of retroperitoneal lymphadenopathy. The patient has consulted a provider who has recommended tumor debulking surgery. The Health Plan has denied authorization and coverage for the proposed procedure on the basis it is not medically necessary for treatment of the patients condition.Of the remaining treatment options, resection of the deep pelvic mass is the most appropriate. The patient is in a difficult situation having failed first line platin-taxane chemotherapy in only six to eight months and having received many other agents in short order. The proposed procedure, while not curative, is medically appropriate and indicated to forestall likely gastrointestinal obstruction. Postsurgical use of radioactive P32 is not recommended due to suspected maldistribution. Oral etoposide may be appropriate after surgical debulking. Based upon the information set forth above, I have determined that the requested surgery 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 woman with recurrent/refractory ovarian cancer. She was originally treated in November 2002 for Stage III disease with a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy and partial colectomy with primary re-anastomosis. She received adjuvant chemotherapy of alternative regimens of gemcitabine/carboplatin and carboplatin/paclitaxel as part of her enrollment in GOG 182. She developed recurrent disease in March 2004 manifested by a rising CA125 and has undergone additional chemotherapy consisting of gemcitabine/cisplatin, followed by Doxil, then Xeloda, then Hexalen, and finally topetecan, with no further therapy since April 2005. Her most recent CT scan of 5/5/05 demonstrated likely recurrence along the greater curve of the stomach, jejunum, and in the pelvis adjacent to the rectum. In addition, a very low-grade localized partial bowel obstruction due to the jejunal recurrence is noted. The patient consulted an out-of-network provider who recommended debulking surgery with retrieval of tumor for chemosensitivity assay and subsequent chemotherapy based on the results of this assay. The Health Plan indicates the proposed surgery can be performed by an in-network provider.The patient wishes to have tumor debulking surgery performed by an out-of-network provider. The Health Plan indicates the proposed surgery can be performed by an in-network provider. There is no evidence that medically appropriate surgical care is not available in-network. Furthermore, there is no evidence the outcome of surgical services performed by the out-of-network provider will be superior to the results obtained by the in-network provider. Since appropriate care is available in-network, it is not medically necessary that the patient obtain surgical services from an out-of-network provider. As such, I have determined 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: Upheld Decision of Health Plan

The patient is a 44-year-old female with chronic pain secondary to reflex sympathetic dystrophy of her left shoulder. She is requesting coverage for Actiq. Treatment has included lidoderm patches, Actiq lozenges, nortriptyline, Gabitril, nerve blocks, physical therapy and cognitive behavioral therapy. The patients provider indicates the patient can no longer use Darvocet, Bextra, Vicodin and Percocet due to severe nausea and abdominal pain. The patient has requested authorization and coverage for continued use of Actiq. The Health Plan has determined the requested medication is not medically necessary for treatment of the patients condition.Actiq is a short-acting narcotic with clearly limited indications. Actiq is approved for cancer related chronic pain syndromes refractory to the usual narcotic and other pain management techniques. It is not intended for use in other pain syndromes. There is no evidence Actiq is medically indicated for this patient. 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.