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

The patient is a 39-year-old female who has experienced chronic pelvic pain since approximately 1989. She had been evaluated by her primary care provider and several specialists without receiving a clear diagnosis or effective treatment for her pain.  In 2003 the patient experienced some relief with a trial of neurontin and was then referred to her current provider who diagnosed pudendal neuralgia. She was begun on a course of PT and injection of trigger points. Although the patients symptoms seemed to wax and wane, in general she experienced a marked improvement in her pain with PT, as evidenced by her decreasing pain medication requirement and her ability to resume activities such as sitting, driving, exercising, coitus and working part-time.  In December 2005 the patient had an accidental fall which appeared to exacerbate her pain and cause somewhat different symptoms which were subsequently addressed in her PT. Currently, the patients pain is described as manageable and she is able to sit for four hours with moderate discomfort and is able to work part-time. The patient has requested authorization for continued PT to treat her pelvic pain.  The Health Plan denied her request based upon a determination that continued therapy is not medically necessary.A critical issue seems to be whether the patients continuing PT falls into the category of long-term maintenance or whether it should still be considered therapeutic, and as such medically necessary. A  Maintenance Program is defined by the Health Plan as one that begins when the therapeutic goals of a treatment plan have been achieved or when no additional functional progress is expected to occur. In this case, the patient has not achieved her therapeutic goals as she still experiences pain (especially when attempting to increase her activity level), continues to have considerable functional limitations such as discomfort with prolonged sitting and has only resumed working on a part-time basis.  Moreover, in his letter of August 2006 her provider indicated the patients condition continues to improve and that a full recovery is expected with continued therapy. As it appears there is still an opportunity for functional improvement, continued PT should be considered therapeutic rather than maintenance at this point in time. Therefore, I have determined 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: Upheld Decision of Health Plan

The patient is a 36-year-old female with pelvic pain who has had two pregnancies, tubal ligation, total vaginal hysterectomy (2003) and a laparoscopic diagnosis of endometriosis (1993). The records also indicate a diagnosis of depression. The patient presents with a four-month history of severe pelvic pain. She desires pelvic laparoscopy, but her in-Plan provider would like her to have a more definitive evaluation including a consultation with a pelvic pain specialist that is within the Health Plan. The patient self-referred to a non-Plan gynecologist who suggests she will benefit from laparoscopy with possible resection of deep endometriosis. The patients request for authorization of laparoscopy of the pelvis performed by a non-Plan provider was denied by the Health Plan based upon a determination that the requested services are not medically necessary.Diagnostic evaluation and management of chronic pelvic pain (CPP) presents a challenge for the treating gynecologist. CPP may be caused by or related to both gynecologic and non-gynecologic disorders. This ambiguity of symptoms and etiology complicates treatment and an interdisciplinary approach is often needed for optimal management. Although this patient may ultimately require a laparoscopy, she has not yet been adequately evaluated and in-Plan resources have not been fully utilized. The Health Plans recommendation for an in-Plan referral to a chronic pelvic pain specialist is a medically appropriate course of treatment prior to surgical intervention.  Based upon the information set forth above, I have determined the requested services are not medically necessary for evaluation of the patients medical condition at this time. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 24-year-old female who had moderate to severe plaque psoriasis covering 20% to 25% of her body surface area. UVB therapy and various topical, prescription, psoriasis medications have not been effective. The patient has a strong family history of kidney disease and reportedly plans to become pregnant within three years. Since she began treatment with Enbrel in May 2006 her psoriasis has improved to the point where it covers only 1% of her body surface area. As of August 2006 the Enbrel dosage has been reduced to 50mg every other week. The patient now requests reimbursement and on-going coverage for further treatment with Enbrel. The Health Plan does not consider the medication medically necessary and has denied authorization and coverage.The patient has a strong family history of kidney disease, hypertension and liver disease which places her at a higher risk for developing these conditions. As such, treatment with methotrexate and cyclosporine is contraindicated. The patient is also in her child-bearing years and expresses a desire to become pregnant in the next three years. Soriatane should not be prescribed under these circumstances. The patients treatment with Enbrel is medically indicated and has resulted in significant improvement. The treatment should be continued under the supervision of her provider. Based upon the information set forth above, I have determined the medication at issue was/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 63-year-old female requesting authorization for bariatric surgery without meeting the Health Plans weight loss requirement. In December 2004 her weight was 234.7 pounds with a body mass index of 41.5. The Health Plan required a 10% weight loss which established a goal weight of 211 pounds for authorization of weight loss surgery. After cessation of smoking, the patient gained additional weight and now must lose 49 pounds. The patients co-morbid conditions include obstructive sleep apnea, hypertension, osteoarthritis and depression. She has completed a psychological evaluation and was deemed a good candidate for weight loss surgery. The patient has requested authorization for bariatric surgery based on a modified preoperative weight loss requirement. The Health Plan denied her request indicating bariatric surgery without meeting the weight loss requirement is not medically necessary.With a BMI of 41.5 (now 46) and comorbid conditions such as obstructive sleep apnea, hypertension, osteoarthritis and depression, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for her. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. 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.  Additionally, there is no data supporting the premise that preoperative weight loss improves outcomes. The psychological evaluation indicates the patient is an appropriate candidate for the surgery.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: Overturned Decision of Health Plan

The patient is a seven-year-old female with cystic fibrosis who is status post jejunal atresia with resulting short gut syndrome, malabsorption and failure to thrive. Presently, she is showing good weight gain on nocturnal Pediatric Vivonex feedings via gastrostomy tube. The patients mother is requesting authorization and coverage for this nutritional product. The Health Plan denied her request based upon a determination that Pediatric Vivonex is not medically necessary.The American Academy of Pediatrics, Committee on Nutrition set forth the following national standard for nutritional intervention in its policy statement of May, 2003: All foods for special dietary use with accepted benefit for treatment of a medical condition should be reimbursed as a medical expense, provided the costs are over and above usual foods. Individual and family financial barriers to obtaining these foods should be removed. This recommendation pertains to any medical condition for which specific dietary components or the restriction of specific dietary components is necessary to treat a physical, physiological, or pathologic condition resulting in inadequate nutrition.The patient in this case is a child with chronic disease, congenital in origin, which has resulted in malabsorption and failure to thrive. The nighttime infusions of Pediatric Vivonex may not represent the entirety of her caloric intake, but it is evident that oral feedings alone do not provide sufficient calories to sustain normal growth, weight gain, and good health. In a pediatric patient such as this one with malabsorption secondary to cystic fibrosis and short gut syndrome, maintaining adequate growth and weight gain is a primary medical concern. Other nutritional products were tried previously and resulted in chronic diarrhea with no significant weight gain. The trial of Pediatric Vivonex prescribed by her pediatric gastroenterologist has resulted in an impressive increase in weight without untoward side effects. It is clear that continued nutritional support with this product is essential for the patient.Based upon the information set forth above, I have determined the requested nutritional product 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 28-year-old female with a history of moderate to severe asthma who has been treated with multiple high dose steroid regimens, long-acting beta agonists, leukotriene modifier, and methylxanthine. She still requires frequent rescue medication. Her last injection of steroids occurred in April 2005. It appears her last use of oral steroids was in August 2005. The patients FEV1 was 1.97 (67%) in May 2006. Her allergic component is treated with diphenhydramine because she experienced angioedema with fexofenadine and loratadine.The patients provider indicates her IgE level was 57 IU/mL in August 2003 and 45 IU/mL in December 2005 and she had a positive skin test. The patient has been previously treated with laser sinus surgery.At issue is whether Xolair is medically necessary for treatment of the patients condition.Review of the submitted clinical information indicates Xolair is medically indicated for this patient. She had a decreased FEV1, elevated IgE, positive hypersensitivity skin test, and has required multiple doses of steroids (oral and injectable). In addition, the patient is on multiple classes of asthma medication, some of which she receives in the form of samples. The patient is an appropriate candidate for Xolair and as such, the medication should be authorized.For the reasons set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 17-year-old female who was apparently diagnosed with attention deficit hyperactivity disorder (ADHD) and alcohol abuse. A few stimulants were tried with minimal benefit. A SPECT scan was performed apparently to clarify the patients diagnosis and suggest further treatment. The Health Plan has denied reimbursement for the SPECT scan on the basis that it was not medically necessary. Although SPECT scanning is often useful in cases involving brain trauma, there was no clinical indication for its use in this setting. A SPECT scan was not medically necessary for evaluation of the patients condition. Standard of care in the community is to involve patients in a 12-step work for sobriety and try various combinations of medications and behavioral modification techniques to improve behavior and ADHD symptoms. The findings of the SPECT scan did not contribute to the diagnosis or treatment of the patients symptomatology. Therefore, I have determined that the SPECT scan at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 60-year-old woman with knee pain. She had good relief of pain with intra-articular hyaluronan injections. A request has been made for authorization for a repeat series of injections. The Health Plan has denied this request on the basis that the requested injections are not medically necessary.The patient received a series of intra-articular hyaluronan injections and her pain improved for at least six months. She is a surgical candidate with severe arthritis in her knee. She is attempting to postpone surgery as long as possible. There is no contraindication to another series of injections, especially given the benefit of the previous series. A repeat series of intra-articular hyaluronan injections is appropriate to alleviate pain and postpone surgical intervention. Therefore, I have determined the requested injections are 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 58-year-old female who was treated with physical therapy following hip replacement surgery. Her symptoms included hip slippage, decreased strength and pain while climbing stairs. A physical therapy treatment program was established for the patient that included instruction in a home program. She was discharged from physical therapy after 26 sessions, 15 of which included biofeedback.  The patients request for reimbursement for the biofeedback was denied by the Health Plan citing a lack of medical necessity.The initial physical therapy evaluation and progress notes indicate a plan to improve strength, posture, closed chain proprioception and hip stability. Various therapeutic modalities were employed such as a hip stabilization exercise program, manual and active stretching, therapeutic exercise, balance and gait training, ice, and biofeedback. It appears the patient gained strength and was more comfortable with stairs by the end of her therapy. The role of biofeedback in this treatment plan however, was not clearly documented. There are no baseline parameters given with which to track the patients progress with this particular therapy. Additionally, the utility of biofeedback has not been established for the treatment of the type of symptoms experienced by the patient. Therefore, I have determined 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: Upheld Decision of Health Plan

The patient is a 58-year-old female with a history of chronic constipation and difficult defecation. She has had an extensive GI workup which by her account demonstrated colonic stricture, as evidenced by limited passage of the colonoscope and barium enema studies. She has been given a diagnosis of colonic inertia. More recently, the patient has had symptoms of vaginal pain/pressure, lower abdominal/back pain and dyspareunia; she has become concerned that she has endometriosis. A CT scan showed a mildly enlarged heterogeneous uterus consistent with small fibroids as well as normal adnexa and the patients pelvic exam was also described as normal. The patient had been offered a partial colectomy by the surgeon; however, she has requested a laparoscopy to rule out endometriosis as the cause of her symptoms. The Plan gynecologist felt that it was unlikely that the patient had endometriosis and that the risks of laparoscopy would outweigh the benefits. The patients request for authorization of a diagnostic laparoscopy was denied by the Health Plan citing a lack of medical necessity.Although there exists some possibility of endometriosis involving the bowel, the treatment of such would be colectomy; similar to a previous surgical recommendation. If the surgeon believes that a partial colectomy is currently indicated and the patient consents to this surgery, her interests would best be served by first undergoing exploratory laparotomy with both a colorectal surgeon and a gynecologist present. If endometriosis of the bowel is responsible for her symptoms, the patient could then receive the appropriate surgical treatment. At this time, a diagnostic laparoscopy would serve no useful purpose and therefore is not medically indicated. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 16-year-old-female with severe OCD symptoms for which treatment records begin in 2004. The possibility of a pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDA syndrome) was also raised as an etiology due to the rapid onset of the disorder. The patient has been treated with traditional medications to control the OCD behaviors and has also been seen by a psychologist who has offered cognitive therapy. The patient, her therapist and her parent all request more intensive outpatient treatment since the patients OCD behaviors are such that she cannot drive a car and has difficulty with her academic and social functioning. Her current psychologist indicates his patient schedule cannot accommodate three to four sessions per week with the patient. The patient and her parent have expressed concerns that her severe OCD and major functional impairments will negatively impact her ability to prepare for college. The familys request for authorization for the intensive outpatient cognitive behavioral therapy program was denied by the Health Plan based upon a determination that the services are not medically necessary.The patient is unique in the severity of her symptoms and the lack of a significant response with the combination of medications and cognitive therapy. She is in a critical phase of her life and faces the challenges of continuing her education and possibly living away from home. Her symptoms are almost incapacitating and her treating psychologist does not have the available time to offer her the intensive treatment that was recommended. The patient has a fair to good prognosis for decreasing the symptoms with the intensive outpatient cognitive behavioral therapy program. Psychiatric follow-up will also be important for this patient to optimize medication management. The severity of the patients condition is uncommon and is creating significant social and functional impairments for her during the late adolescent period of her life. At present, the intensive outpatient program is medically appropriate and presents the least restrictive treatment alternative. Based upon the information set forth above, I have determined the requested services are 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 53-year-old female who has a body mass index (BMI) of 36. Her comorbid conditions include hypertension, exertional dypsnea, hypoglycemia, joint pain, sleep apnea and urinary stress incontinence. She has requested authorization for gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary.Based on the patients BMI of 36 and her comorbid conditions, she 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 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 27-year-old female who underwent bilateral functional endoscopic sinus surgery, inferior turbinate reduction and septoplasty in March of 2000 to treat symptoms including nasal airway obstruction and nighttime headaches that were unresponsive to medical therapy. The operative report from that surgery indicates that pre-operatively there was a sharp rightward deviation of the nasal septum. This was repaired by separating the septum from the maxillary crest, taking the crest down and moving the septum to the right, supposedly to midline. The patient did well postoperatively for a few months, but then had recurrence of her original symptoms. She states that my septum leaned to one side and could be pressed flat with little effort on the top of my nose.  The patient sought further care in December of 2005 based on her continued nasal airway restriction. She was found at that time to have a leftward septal deviation, partial turbinate reduction, a dorsal hump and loss of tip support. In January 2006 she underwent septorhinoplasty with an ear cartilage graft placed for tip support and infracture of the turbinates. The operative report is sparse, but it appears osteotomies were done and the dorsal hump and the widened tip were addressed. The patient relates her symptoms have improved after this surgery. The Health Plan denied the patients request for reimbursement indicating the nasal surgical procedures were not medically necessary.The patient underwent revisional nasal surgery with the intent of correcting her continued nasal airway restriction. This was accomplished to her satisfaction and a portion of the surgery would be considered a functional correction. This would include the revisional turbinate reduction (CPT Code 30130), the septoplasty portion of the septorhinoplasty (not previously billed separately; included in CPT Code 30420) and the anesthesia procedure (CPT Code 01999). However, the portions of the surgery where the surgeon uprighted the pyramid and smoothed the top and trimmed the alar cartilages but very conservatively to take care of her widened tip were not medically necessary and the grafting (CPT Code 21235) and septorhinoplasty (CPT Code 30420) were cosmetic procedures.Based upon the information set forth above, I have determined that a portion of the procedures at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.