Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1This patient is a 37-year-old woman who sustained a compression fracture at L-1 in December 2003 after being thrown from a horse. The patient reports problems with constant pain, although a back brace has provided some benefit. The patient has requested authorization for kyphoplasty. The Health Plan has denied the request indicating that the requested procedure is experimental in nature.The patient is a young woman without osteoporosis. This patient has not tried bracing and has only attempted medical management for a short time. The medical literature suggests that younger persons with compression fractures heal and do very well with bracing for three months. The literature does not support kyphoplasty over conservative management in the patients age group. As such, 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 37-year-old woman who sustained a compression fracture at L1 two months ago. She has persistent pain. The patient has requested authorization for kyphoplasty. The Health Plan has denied her request indicating that kyphoplasty is considered experimental in nature.Kyphoplasty has been utilized increasingly over the years. The procedure is designed to alleviate pain and occasionally restore height to the vertebral body. This patient, with a L1 compression fracture and persistent pain, would be a candidate for kyphoplasty if she does not respond to medication, rest, and time. 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 at this time. However, if documentation is provided that the patient has failed continued attempts at conservative management, then the patients request for kyphoplasty should be reconsidered.  Physician 3The patient is a 37-year-old woman with a traumatic compression fracture. The patient is young and healthy with no signs of osteoporosis. She has requested authorization for kyphoplasty. The Health Plan has denied the patients request.No controlled perspective studies exist to document intermediate or long-term safety and efficacy of kyphoplasty in single or multiple compression fractures. There is no evidence that shows that kyphoplasty actually increases the height of the vertebrae or restores alignment. Additionally, the patient is a young, healthy woman without osteoporosis. Given these factors, kyphoplasty is not medically indicated for this patient and is not likely to result in greater benefit than conservative therapy.Based upon the information set forth above, 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. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 63-year-old female with a history of degenerative disc disease as well as degenerative arthritis of the lumbar spine. She underwent discectomies at L4-5 and L5-S1. Following surgery, the patient has apparently had persistent or recurrent symptoms with lumbar pain and radiating pain to both legs. Treatment with ibuprofen provided no relief at 600mg and Celebrex 200mg was started in November 2003. This was said to provide greater benefit, with improvement in radiating pain but persistence of right buttock pain. The submitted information indicates that the patient is sensitive to medications but this is not documented in the provided clinical records. Nor do the submitted records note prior use of NSAIDs other than ibuprofen. The patient has requested authorization for Celebrex. The Health Plan has denied her request.Given the patients history of degenerative disc disease and degenerative joint disease of the spine, MRI documentation, history of discectomies, and continuing symptoms, the use of anti-inflammatory agents is both appropriate and medically necessary. In this context, the use of Celebrex is appropriate, given its reported effectiveness and lack of side effects in this patient. This is particularly true given the likely need for long-term treatment for degenerative spinal problems, which are not likely to resolve. However, there is no evidence that Celebrex or other Cox-II inhibitors are more effective than traditional NSAIDs. The advantage of Cox-II inhibitors lies in their lower incidence of symptomatic or dangerous GI effects, such that patient compliance is greater, leading to an overall greater net benefit over time (their lack of platelet inhibition offers an advantage for patients requiring anticoagulant therapy, as well). No evidence has been submitted indicating that the patient has had significant GI history, required long-term steroid treatment, or has failed NSAIDs other than ibuprofen. As such, I have determined that the use of Celebrex 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, the patient should receive trials of up to two relatively GI-safe NSAIDs (such as nabumetone and etodolac) to determine if the patients response is equal to that with Celebrex, with equal tolerability. If either the benefit is less or the degree of tolerability is less, then the patients request for Celebrex should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 47-year-old woman with a chondral defect in the medial femoral condyle. A request has been made for an osteochondral autograft transfer system (OATS) procedure to fill in the defect. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the patients chondral defect.Given that the patient has an isolated lesion in the condyle that is not too large, she is an ideal candidate for the OATS procedure. The OATS procedure is used frequently to fill in small defects of the condylar weight-bearing surface. Furthermore, the patient does not have significant arthritis and the defect appears small enough that the OATS procedure is medically reasonable and appropriate. 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 35-year-old man with hyperhidrosis. The submitted information does not indicate that conservative treatment has been attempted. The patient has requested authorization for bilateral curettage of axillary dermis. The Health Plans denial is medically reasonable and appropriate. The requested surgery is not the standard of care for treatment of the patients condition. No evidence has been provided that the patient has tried and failed conservative treatment. Non-surgical measures including the use of antiperspirants should be exhausted before axillary curettage is considered. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 55-year-old woman with Lyme disease and chronic foot pain. The patient has undergone surgery, though her pain persists. She has tried multiple medications to relieve her pain. The patient requests authorization for Celebrex. The Health Plan has denied the patients request indicating that Celebrex is not medically necessary for treatment of the patients foot pain.The patients medical condition requires the use of Celebrex, as it is the only medication that helps relieve her pain. Based upon the submitted documentation, the patient has tried Bextra, Relafen, and Vioxx, but found that these medications were ineffective or caused intolerable side effects. Celebrex has been effective for this patient without causing significant side effects. 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 31-year-old female status post massive weight loss after gastric bypass surgery for morbid obesity. The patient underwent a panniculectomy for a large panniculus and is seeking further procedures to remove the massive amounts of redundant skin. The procedures she is seeking are: brachioplasty, thigh lift, and breast lift. No evidence of any breast evaluation has been submitted; thus, it is unclear whether the appropriate procedure in this case would be a breast lift or a breast reduction. The Health Plan has denied authorization for a referral to a plastic surgeon indicating that the requested procedures are not medically necessary for treatment of the patients condition.No evidence has been provided which demonstrates that brachioplasty and thigh lift procedures are medically necessary for treatment of this patients excess skin. As such, these procedures are considered cosmetic in nature and are not medically indicated. However, the patient indicates that she experiences back pain due to the size of her breasts. The submitted information does not note the condition of the patients breasts or back. Therefore, the patients request for a breast procedure may be medically indicated depending upon the results of an evaluation by a plastic surgeon. Based upon the information set forth above, I have determined that the requested referral to a plastic surgeon for evaluation of the patient for a breast procedure is medically necessary. However, the requested brachioplasty and thigh lift procedures are not medically necessary. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 64-year-old man with arthritis of the hip who is requesting minimally invasive hip replacement surgery. The Health Plan has denied the patients request on the basis that the requested procedure is not medically necessary for treatment of the patients condition.The patients medical condition requires hip replacement. The standard procedure involves a fairly large incision. Some surgeons are now performing the procedure with annular incisions, some with incisions of one to two inches in length and special instruments for such small openings. To date, it has not been shown that there is any increased benefit from smaller incisions on a long-term basis. Furthermore, there are reports of complications with smaller incisions due to an inability to visualize the entire hip. The submitted information does not demonstrate that the patient requires minimally invasive hip replacement surgery. Although the requested procedure involves a smaller incision, the surgery itself is identical to routine hip replacement. Thus, 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 47-year-old woman with a body mass index (BMI) of 36. She has comorbid conditions including gastroesophageal reflux disease and sleep apnea. She has requested authorization for gastric bypass surgery. The Health Plan has denied the patients request.With a BMI of 36 and her comorbid conditions, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery do not outweigh the potential benefits of the procedure. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a four-year-old female with a proximal femoral focal deficiency (PFFD), Type D. Her right leg is approximately 16 cm shorter than the left, externally rotated, and the enrollee has a very short thigh. The patients mother is seeking authorization for a Super Hip procedure. The Health Plan has denied this request.The patient requires treatment. There are a number of procedures and therapies available for the patient. The procedure requested by the patients parent is reasonable and indicated for the patient. There is sufficient evidence that the requested procedure will benefit the patient and that it is the treatment of choice for this patient. Therefore, I have determined that the requested procedure is medically necessary for treatment of the enrollees medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 46-year-old woman who saw a physician in August 2003 for treatment of fingernail fungus. The patient indicates that some of her fingernails are partially separated from the nail bed and are very painful. The patients provider has prescribed the medication Lamisil. The Health Plan has denied authorization for Lamisil on the basis that it is not medically necessary for treatment of the patients nail condition.The patient indicates that she has partially separated fingernails, which have caused significant pain and therefore, functional impairment. The patient should be evaluated by a dermatologist as soon as possible and undergo a direct microscopic examination and/or fungus cultures. If the tests are positive for fungus, Lamisil is medically indicated for three months provided that CBC and chem panel results, including liver function tests, are normal.Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition pending an evaluation by a dermatologist. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 24-year-old female with a BMI of 46. She has comorbid conditions including hypertension. She wishes to undergo gastric bypass. She has undergone a formal psychological evaluation and has been found to be an appropriate candidate for weight loss surgery.With a BMI of 46 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. In addition, the patient has undergone a psychological evaluation and is considered an appropriate candidate for 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.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 46-year-old woman with a long history of back pain who is status post lumbar fusion. The patient is followed by a pain management specialist. The patient has been receiving physical therapy and takes Norco and Duragesic for pain management. In addition, the patient has used Actiq. The patients request for authorization of Actiq has been denied by the Health Plan.The Health Plans denial is medically reasonable and appropriate. The patients provider has indicated that the patient has used Norco for breakthrough pain in place of Actiq. While Actiq has been approved by the Food and Drug Administration (FDA) for pain due to cancer, it has not been approved by the FDA for back pain or non-malignant conditions. Furthermore, review of the submitted information indicates that the patients pain can be controlled with maximization of long-acting medications and with other short-acting medications as needed, such as Norco. Therefore, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage of robotic-assisted laparoscopic radical prostatectomy. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees prostate cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee requested authorization and coverage of the medication Bextra. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee requested authorization and coverage of a consultation for possible bilateral reduction mammoplasty. The Health Plan denied the request indicating that the requested consultation is not medically necessary for evaluation of the enrollees pain. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested consultation is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee requested authorization and coverage of skin excision and revision abdominoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees excess skin.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 16-year-old female enrollee requested authorization and coverage of Rocephin IV therapy through homecare. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees possible Lyme disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee requested authorization and coverage of bilateral endoluminal radiofrequency ablation (also known as venous closure). The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees varicose veins.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee requested authorization and coverage of a CT scan of his neck and back. The Health Plan denied the request indicating that the requested CT scan is not medically necessary for evaluation of the enrollees neck and back pain. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested CT scan is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a four-year-old male enrollee requested authorization and coverage of continued speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees autism.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of the medication Zestril. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees hypertension.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage of optic nerve surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees left eye proptosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage of scar revision. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees suprapubic keloid scar.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.