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

The patient is a 67-year-old female with a non-healing ulcer of the left ankle. She has a possible history of scleroderma. The patient has requested coverage for Regranex for treatment of the ulcer. The Health Plan has denied the request on the basis that the requested medication is not medically necessary.The Health Plans denial should be upheld. The use of Regranex in non-diabetic ulcers has not been studied and is considered an off-label use. The treatment alternatives offered by the Health Plan such as Granulex and Santyl are medically reasonable and appropriate options for wound care. A trial of Granulex and Santyl is indicated before treatment with Regranex is pursued. 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 37-year-old female who has experienced progressively severe crumbling of her right first toenail for at least three years. This condition has been unresponsive to anti-fungal creams. Her physician has recommended treatment with Lamisil. The Health Plan has denied this request indicating Lamisil is not medically necessary for treatment of the patients condition. In light of the presence of severe crumbling of the toenail, the patients condition is medical rather than cosmetic in nature. However, there is no evidence that the patient has undergone fungus culture or KOH prep, which is indicated prior to use of Lamisil. 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 documentation of a positive KOH prep or fungus culture is provided, the patients request for Lamisil should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 63-year-old female who has a history of symptomatic reticular varicose veins and telangiectasia. She also has a family history of varicose veins. The patients provider recommended sclerotherapy injections, which she underwent on 7/15/04 and 8/26/04. She has requested reimbursement for the injections at issue. The Health Plan has denied the patients request stating the injections at issue were not medically necessary for treatment of the patients medical condition.The patient has telangiectasia and reticular veins. These findings are not sufficient to justify sclerotherapy. Sclerotherapy of telangiectasias and reticular veins is usually performed for cosmetic reasons and repeat injections are required over the years. The documented evidence does not demonstrate sclerotherapy is medically warranted.  Therefore, I have determined that the injections at issue were 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 74-year-old female with a long-standing history of lower back pain due to scoliosis. She is status post several spinal surgeries with relief only resulting from the first surgery in the 1960s. Her most recent spinal surgery occurred in January 1980 and she has been treated with intramuscular (IM) morphine sulfate since that time. She has been unable to tolerate Demerol, Duragesic patch, and MS Contin secondary to side effects. She apparently does not have side effects from the IM morphine sulfate, which she takes 15mg/ml morphine (0.5 to 2ml) every 3-6 hours as needed. The patient is currently requesting authorization and coverage for self-injectable morphine sulfate. The Health Plan has denied the patients request on the basis that the requested medication is not medically necessary.Review of the submitted information indicates the patient has been treated for the past 25 years with IM morphine sulfate for her severe intractable lower back pain. Despite her severe kyphoscoliosis and back pain she was able to remain functional using IM morphine therapy. The patient had been maintaining a narcotics contract from her pain physician over the years. There is no documentation of any adverse side effects from the treatment. In light of the effectiveness and duration of the treatment, continued use of IM morphine sulfate is medically appropriate and indicated. However, the patient needs to continue to be on a narcotics contract for as long as she requires morphine therapy and should be followed by a pain specialist.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: Overturned Decision of Health Plan

The patient is a 56-year-old female who has failed conventional medical therapy. She has arthritis as a component of her comorbidities and is taking NSAIDs. 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 the patients request on the basis that duodenal switch 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 13-year-old female with a relative idiopathic short stature with somewhat low levels of IGF-1, but a normal growth hormone (GH) response to provocative testing. She has advanced normally into puberty and since April 2004 has been given Lupron in an attempt to delay puberty as well as therapeutic GH. A positive growth response by October 2004 was observed. The patients pediatric endocrinologist contends that a neurosecretory GH deficiency may be present. The patients height potential should be 56-57 as judged from the mid-parental heights, but her predicted height from a recent bone age was near 51.  Based upon the notes provided, the patient was growing above the 10th percentile for height and had gained some 13 pounds in weight prior to beginning hormonal therapies. From September 2003 to March 2004 the patient grew at a rate of 6.4cm/year. During six months of GH therapy (April 2004  October 2004) the patient grew at a rate of 7.6cm/year and gained another five pounds.A request has been made for authorization and coverage for GH therapy. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary.Whereas it appears clear the patient is likely to be shorter than her mid-parental height would otherwise suggest, she had been growing above the 10th percentile without GH therapy. Furthermore, she is taking Lupron to delay the advancement of her puberty and thereby hoping to extend her growth period. It remains problematic to what extent therapeutic GH would increase her final height if continued. The growth response data over the early months of GH therapy are not impressive. In light of these results, I have determined further use of GH therapy is not medically warranted. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 57-year-old male with an acoustic neuroma, apparently post-neurosurgery, with significant residual neurological deficits. The patient requires mechanical devices in order to function.  The patient experiences frequent falls. He was seen and treated by a neuro-otologist in 2003 and 2004. In addition, it appears the patient has left-sided deafness, impaired vision, and substantial loss of coordination. He has obtained a POV and lift and has requested reimbursement for the equipment at issue.  In many cases patients with an acoustic neuroma experience severe neurological deficits and require major rehabilitation and mechanical aides. Based upon the records provided, the patient is severely handicapped and cannot functionally ambulate or safely and effectively operate a manual wheelchair. He requires mechanical aides that are necessary for his ability to function. Though rehabilitative services may eventually help him become less dependent on mechanical devices, the evidence provided demonstrates the equipment at issue is medically necessary at this time. Therefore, I have determined that the equipment at issue is medically necessary for the patients mobility. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 34-year-old female with mastodynia and upper and lower back pain. She has not responded to anti-inflammatory agents and codeine over a six-month period. The patient has been evaluated by her primary care physician and her gynecologist. Her gynecologist recommended referral to a plastic surgeon for alleviation of the symptoms related to her large breasts. The plastic surgeon evaluated the patient and sought authorization for breast reduction surgery. The Health Plan has determined the requested procedure is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence documents the patients symptomatology and failure of conservative therapy. The photographs and documentation from the patients primary care physician, gynecologist, and plastic surgeon provide medical justification for the requested procedure. Breast reduction surgery is medically appropriate and is likely to alleviate the patients symptoms. 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 an 11-year-old male who is of short stature. The patient was referred to a pediatric endocrinologist who recommended the patient receive growth hormone therapy. The Health Plan has denied authorization for growth hormone therapy indicating it is not medically necessary for treatment of the patients condition.  The submitted information does not demonstrate growth hormone therapy is medically necessary for this patient. There are no records from the patients primary care physician explaining the reason for the referral to pediatric endocrinology. Furthermore, it appears the submitted evidence includes contradictory growth velocity information. The information provided does not establish that growth hormone therapy is medically appropriate or indicated for this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 17-year-old female with a history of multiple surgical procedures, orthodontic therapy, and speech therapy for bilateral cleft lip and cleft maxillary alveolus. Currently, the patient has a dental malocclusion, maxillary deformity with asymmetry, and absent dentition in the region of the alveolar clefts. A request has been made for authorization and coverage for repositioning surgery of the upper jaw. The Health Plan has denied the request on the basis that the requested surgery is not medically necessary.Maxillary osteotomies and bone graft are proposed for staged reconstruction of the patients maxilla with complete bilateral alveolar clefts. Closing and grafting the clefts will eventually allow dental arch reconstruction with dental implants. The proposed orthognathic surgery is the most appropriate next step for this patient in the sequence of reconstructive events and is medically indicated. Therefore, 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

A 48-year-old woman has had severe pustular psoriasis for at least two years. The information provided indicates the patient has attempted treatment with topical steroids, tacrolimus, urea, Soriatane, and ultraviolet light. According to both the patient and her dermatologist ultraviolet light has been beneficial. The patient states traveling 20 miles three to four times per week is a hardship for her since she works nights. She has requested authorization and coverage for a narrow band ultraviolet B light home unit. The Health Plan has determined the requested equipment is not medically necessary for treatment of the patients medical condition. The submitted information indicates the patient has failed treatment with topical steroids, tacrolimus, urea, and Soriatane. Ultraviolet therapy is the only form of treatment that has been effective for this patient and is medically indicated. However, it has not been established that the patient requires an ultraviolet B home unit. There is no evidence the patient is homebound and unable to receive ultraviolet B therapy as an outpatient. Thus, the requested equipment is a convenience item and therefore, not medically indicated. Therefore, I have determined the requested equipment 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 56-year-old female who underwent a vitrectomy for treatment of a macular hole. Following surgery, face down head positioning was required. The patients physician recommended the use of a vitrectomy support system to allow the patient to maintain the correct position for proper healing. The patient is requesting reimbursement for the vitrectomy support system. The Health Plan has denied the patients request indicating the equipment at issue was not medically necessary.Post-op face down head positioning is considered to be a very important part of the vitrectomy. Retinal specialists believe the success rate is higher if the patient maintains a high percentage of his or her time in a face down posture. Long periods of time with the bubble out of position increase failure rate and increase the possibility of lens damage with subsequent cataract formation. It is very difficult for patients to maintain a face down position without assistance. A device such as the vitrectomy support system is considered part of the therapy. Therefore, I have determined that the equipment at issue was 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 33-year-old female who was diagnosed with vulvodynia in 2003. She was treated by her gynecologist with topical estrogen, anti-inflammatory creams, antifungal preparations and Elavil, all without apparent success. The patient was referred to an out-of-network provider who specializes in the treatment of vulvodynia. The out-of-network provider instituted treatment with manual therapy and a pudendal block, which has resulted in considerable relief of her pain. The patient has requested authorization and coverage for a referral to a physician who specializes in vulvodynia. The Health Plan has determined the requested referral is not medically necessary for treatment of the patients medical condition.Vulvodynia is an enigmatic disorder, which falls into the broad spectrum of pelvic pain and perhaps into the even broader spectrum of chronic systemic pain disorders. Since the etiology of vulvodynia is unknown and likely to be multifactorial, successful treatment is at best difficult to achieve. In the case of this patient, the correct diagnosis took some time to be made and the patient was then treated with the most appropriate therapies, i.e., topical estrogen, anti-inflammatories, antifungals, and Elavil. All of these medications were ineffective in alleviating the patients pain. At that point, she was referred to an out-of-network provider who specializes in pelvic pain disorders. The provider felt that the patients vulvodynia was caused by myofascial trigger points of the left pelvic floor. He recommended a left pudendal block and manual therapy techniques. Both the patient and the provider felt that the patients symptoms improved with this therapy.As with any chronic pain patient, it is important that the patient be treated by a pain specialist so that she is not receiving uncoordinated care from multiple physicians in multiple specialties. Success of the treatment is dependent upon the targeted (and often unique) therapies for chronic pain and the confidence that the patient has in the specialist. As this patient appears to be obtaining relief with treatment from the out-of-network specialist, the requested referral is medically appropriate and indicated for her continued benefit. Therefore, I have determined that the requested referral 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 50-year-old male who underwent bilateral mastectomy for gynecomastia including liposuction and removal of a mass in the right upper lateral chest wall. The patient has requested reimbursement for removal of breast tissue. The Health Plan has denied the patients request indicating that the available documentation does not demonstrate that the excess tissue was breast tissue as opposed to adipose.There is no information in the preoperative evaluation and work-up to indicate that gynecomastia was causing functional difficulties for this patient. The surgical procedure itself consisted entirely of suction/power-assisted lipectomy without en-bloc excision of typically hard, fibrous male breast tissue, which is consistent with true gynecomastia. The material removed was fat; no pathological evaluation of the tissue was performed. In the absence of pre-operative medical documentation and work-up of functional difficulties resulting from the stated gynecomastia, the procedure at issue was cosmetic in nature. Therefore, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old male who reportedly had rosacea and pre-cancerous skin lesions. Though a letter from the patients provider indicates the patient has rosacea and precancerous skin lesions there is no indication the patient underwent previous therapies for treatment of rosacea. The patient has been treated with liquid nitrogen for pre-cancerous lesions. He underwent laser therapy in July and August 2003 and has requested reimbursement for this therapy. There are many possible treatments for rosacea and actinic keratosis including topical medication, liquid nitrogen, and laser or light therapy. While use of laser therapy is an acceptable treatment for rosacea and actinic keratosis, the submitted evidence does not demonstrate the patient required such treatment. The provided laser therapy notes do not document clinical findings or reason for treatment. As such, there is insufficient evidence that the patient required the therapy at issue. Therefore, I have determined that the therapy at issue was 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 10-year-old male who was diagnosed with Prader-Willi syndrome (PWS) at the age of eight months. His current growth velocity at age 10 is 16cm/year. In addition, the patient is Tanner Stage 2 and his IGF-1 level is 142. The patients physician indicates the patient has evidence of growth failure dropping from the 95th percentile at age 9 to the 80th percentile by age 10. The physician also states the patient has premature adrenarche and bone age advancement, which compromises his ability to attain his genetic potential of 172.5cm. The physician has recommended Genotropin growth hormone (GH) therapy to preserve the patients height projection and improve muscle mass and function. The Health Plan has denied authorization and coverage for GH therapy on the basis that it is not medically necessary for treatment of the patients medical condition.The Food and Drug Administration (FDA) has approved the use of GH for children with PWS, applying in its determination the data provided in the various submitted articles. In its determination the FDA did not approve GH therapy in PWS solely on the basis of its height promoting effect (which the FDA acknowledged as sufficient), but rather on the multiple benefits of this treatment intervention on these patients, including the beneficial effects of growth hormone on body composition, muscle bulk and tone, respiratory function, cholesterol levels, bone mineral density, etc. Furthermore, the FDA did not require proof of growth deficiency for GH therapy to be implemented in patients with PWS. As such, the use of growth hormone therapy for treatment of this patient is medically appropriate and indicated and should be authorized. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a fourteen year-old obese female with comorbidities including arthritis, psychological issues, and hyperinsulinemia is requesting authorization and coverage for a referral to an endocrinologist.  Reviewers Findings:  The reviewing physician found that due to the patients lack of response to medication and attempted dietary and exercise activity intervention, it is essential that the patient be closely monitored by experts in caring for adolescents with morbid obesity and associated comorbidities.  The Health Plan denial was overturned.