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

The patient is a 58-year-old woman who sustained a severe fracture to her foot requiring open reduction internal fixation. Postoperatively, the patient utilized a continuous passive motion (CPM) machine for approximately two months. She has had an excellent recovery. The Health Plan approved a CPM machine for 21 days of use. According to the Health Plan, use of the equipment beyond the authorized period was not medically necessary for the patient.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM therapy. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the machine was felt to be of benefit following surgical treatment of the patients severe foot fracture. Use of the CPM machine was medically indicated beyond the 21 days authorized by the Health Plan. After using the CPM machine for 53 days, the patient regained mobility and stamina, required very little physical therapy, and was able to return to her normal routine. The patients use of the CPM machine for the period of time at issue was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a seven-year-old male with a diagnosis of Aspergers syndrome who has been receiving speech therapy since 2003 for receptive and expressive speech delays. He has made gains according to his therapist who has recommended ongoing speech therapy to address pragmatics and social speech, vocabulary, following directions and transitions between activities. A request has been made for reimbursement for speech therapy services the patient received from January 2005 through May 2005. The Health Plan has denied coverage indicating the therapy received was not medically necessary.Upon review of the monthly speech therapy progress notes and the session notes there are subjective descriptions that suggest the patient is making progress. However, the objective goals have remained essentially unchanged over a six-month period.  Progress to goals was minimal except for objective number one with a change from a 65% accuracy level to a 70% accuracy level. The speech therapy reports do not objectively identify significant improvement over the timeframe addressed. 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: Overturned Decision of Health Plan

The patient is a 19-year-old male who has had severe extensive psoriasis for the past two years. The psoriasis, at its worst, covered 81% of his body surface and was severely painful. Cyclosporine had to be discontinued because of severe headaches. His dermatologist stated that methotrexate and Soriatane are contraindicated because of a history of liver problems. The manufacturers protocol for ultraviolet therapy states that this treatment is contraindicated if the patient has psychological problems. Coverage for Enbrel was denied by the Health Plan in 2004. Coverage for Raptiva was recently denied by the Health Plan as not medically necessary.The treatment alternatives required by the Health Plan are contraindicated according to this patients medical history. Severe headaches from cyclosporine rule this drug out. Additionally, the patients provider indicates the patient has a history of liver problems. Although there may be no objective evidence of liver disease currently, the patient would be at risk for liver problems from methotrexate or Soriatane.  Furthermore, the manufacturer of the UVA equipment warns against that therapy for patients with psychological problems. The Health Plan has denied coverage for Enbrel. At this point, it is imperative that this patient be treated for his extensive and severe psoriasis. Therefore, 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: Overturned Decision of Health Plan

The patient is a morbidly obese male of 59 years with a body mass index (BMI) of 41.8. His comorbidities include diabetes mellitus, hypertension and joint pain. The patient has completed a psychological evaluation with a positive recommendation for the surgery. It appears he has attempted weight loss with both supervised and unsupervised programs. The Health Plan has denied authorization for bariatric surgery stating there is incomplete documentation of the patients participation in a six-month supervised weight loss program, and therefore medical necessity for the surgery has not been established.With a BMI of 41.8 and comorbid conditions such as diabetes mellitus, hypertension and joint pain, 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 this patient. 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 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 best long-term outcome for the obese. Based upon the information set forth above, I have determined that the requested surgery 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 59-year-old female with progressive vitiligo of the hands. She has undergone treatment with Excimer laser. The patient received 16 treatments resulting in 10-25% repigmentation. Serology for various autoantibodies was positive. A request has been made for reimbursement for the Excimer laser treatments the patient received. The Health Plan has denied this request on the basis that the therapy at issue was not medically necessary for treatment of the patients condition.Excimer laser is an efficient method for delivering narrow band UVB to individual lesions in a number of skin disorders including vitiligo. The therapy is at least 95% as effective as traditional UVA or UVB therapy. Furthermore, there are studies indicating that the number of treatments required is significantly less than that of UVA or UVB therapy. Given the progression of the patients vitiligo and the location of the lesions, laser therapy was medically reasonable and indicated. Therefore, I have determined that the therapy at issue was 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 10-year-old male with the diagnosis of Aspergers syndrome. He currently attends a special school and has attended a camp and group sessions to improve his socialization over the last two years. A review of the notes from the peer-involved group therapy demonstrates initial progress and improvement in most of the target areas with an apparent plateau. The parents request that the Health Plan provide coverage for this group socialization program, but the request has been denied on the basis that the therapy is not directed toward acute mental health issues and is not medically necessary.Though a review of the literature suggests that socialization with behavioral modification can be helpful in Aspergers syndrome, in this case the patient has been receiving peer-involved group therapy for several years and seems to have reached a plateau. Given the documentation provided, continued therapy was not medically warranted beyond July 2005.  Additionally, such therapy has historically been included as part of the students school curriculum through the IEP program. Therefore, I have determined the therapy at issue was/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 58-year-old woman who is requesting reimbursement for a series of Hyalgan injections given for clinically significant osteoarthritis of the left knee.  She had her first series of Hyalgan injections several years ago as well as two arthroscopic surgeries.  The patient had a recurrence of her left knee pain in August 2004 and completed a second series of five Hyalgan injections on the recommendation of her provider.  The Health Plan has denied the patients request for reimbursement for the Hyalgan injections as they have determined that a repeat series of injections was not medically necessary.After one series of Hyalgan injections has been given for an arthritic knee, the standard treatment alternatives include NSAIDs, cortisone injections, physical therapy, etc.  There is insufficient evidence in the current literature to support the theory that a repeated series of Hyalgan injections will improve outcomes for arthritic knees over those achieved with standard treatment alternatives. 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: Overturned Decision of Health Plan

The patient is a 58-year-old female with a body mass index of 41.8. She has documented comorbid conditions. She has also been diagnosed with myasthenia gravis. The patients primary care provider indicates the patient has been on steroids at times for control of her symptoms. At issue is whether gastric bypass surgery is medically necessary for treatment of the patients morbid obesity. With a BMI of 41.8 and comorbid conditions the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that weight loss surgery will be beneficial for this patient. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the 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 best long-term outcome for the obese. Based upon the information provided, weight loss surgery is medically necessary to treat the patients morbid obesity. There is concern, however, about the use of steroids for treatment of the patients myasthenia gravis. Steroid use can predispose the patient to gastric ulcers, and once Roux-en-Y gastric bypass is performed the stomach can no longer be accessed for examination and intervention if there is a problem. Therefore, the patients providers should determine whether the use of steroids would preclude Roux-en-Y gastric bypass in favor of the duodenal switch procedure.   As 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 39-year-old woman who has been treated for psoriasis with Raptiva with beneficial results. Prior treatment with topicals and UVA was unsuccessful. Methotrexate and cyclosporin are contraindicatd because of a family history of pulmonary fibrosis. The patient recently changed health insurance plans and Raptiva is not a formulary medication under her current plan. The Health Plan will authorize Enbrel for the patient. The patient is concerned about the side effects of Enbrel and therefore wishes to continue treatment with Raptiva.  Review of the relevant medical literature does not demonstrate that Raptiva is safer than Enbrel or carries a lower risk of side effects.  According to the Food and Drug Administration approval, Raptivas side effects include: immune hemolytic anemia, immune thrombocytopenic purpura, arthritis, and worsening of psoriasis (sometimes to the point of hospitalization for generalized erythroderma).With both Raptiva and Enbrel there may be an increase in serious infections, a theoretical increased risk of malignancy, rare occurrence of demyelinating disorder, new onset or exacerbation of seizure disorder, and rare occurrence of tuberculosis (TB). A TB skin test is essential prior to the use of either drug. Only Raptiva treatment requires frequent testing for platelet counts.Because scientific evidence demonstrates that Enbrel is a medically reasonable and appropriate alternative to Raptiva, I have determined 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: Overturned Decision of Health Plan

The patient is a 49-year-old female who has a long history of temporomandibular joint pain and myofascial pain involving the muscles of mastication. In April 2005, she consulted an out-of-plan provider and was treated with a dental occlusal orthotic termed NTI. She is currently experiencing a good result with that treatment and has had periodic adjustments of the device as her dental occlusion shifts. The patient was evaluated by an in-plan provider in August 2005 who recommended changing her treatment plan to include the use of a different type of orthotic splint. The second treatment plan would also involve the use of anti-inflammatory medication. The patient has requested authorization and coverage for continued treatment with the out-of-plan provider. The Health Plan indicates appropriate services are available in-plan and therefore, has denied authorization for the requested services.The patient is currently doing well with the treatment she has been receiving from the out-of-plan provider, using an orthotic device of his choosing. To discard her current successful treatment regimen and embark on another treatment plan that involves a different type of orthotic device and incorporates the use of anti-inflammatory medication is somewhat risky. It is not known if the results the patient achieved with the out-of-plan treatment can be replicated with the new treatment plan proposed by the in-plan provider. As such, it is medically reasonable and appropriate to allow the patient to continue to be followed by her out-of-plan provider. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 78-year-old male who underwent cardiac transplant for class III-IV congestive heart failure. He has multiple comorbidities including carotid artery disease, pancytopenia, prostate cancer, asthma and proteinuria. He was accepted as a candidate for an alternate donor heart and the transplant procedure was performed in June 2005. The patient has request reimbursement for this procedure. The Health Plan has denied this request on the basis that the patient did not meet generally accepted medical criteria for transplantation.Review of the submitted clinical evidence demonstrates that the patient had end-stage heart disease that had become refractory to medical therapy. Though the patient had multiple medical problems, he did meet transplant criteria for inclusion in the alternate donor transplant program. An alternate donor transplant was performed in June 2005. Based on the patients condition at that time, an alternate donor transplant was medically necessary for the treatment of the patient. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This case concerns a 13-year-old female with Crohns disease and growth arrest. She was part of a one-year growth hormone (GH) study for children with Crohns disease.  Her treatment ended in February 2005 and she grew 6.8cm during the one-year study.  The enrollee had a period of no growth before GH therapy was initiated and similarly stopped growing after GH therapy was discontinued. The mothers height is 54 and fathers height is 60.   The Health Plan has determined GH therapy is not medically necessary and has denied authorization and coverage.Although GH therapy has not yet reached the standard of FDA approval for Crohns disease, there is growing support in the literature for its use for that indication. In addition, the patients response to GH therapy has been dramatic and convincing in this instance.  Although there were conflicting reports regarding oral steroids, her growth did in fact cease when GH therapy was discontinued, minimizing any possible connection between her growth acceleration and the discontinuation of oral steroids, if indeed they were ever taken. The growth charts attached clearly documented a positive response to GH therapy during the yearlong treatment and they also document a lack of growth both before and after the study. In light of these results, continuation of GH therapy is medically appropriate.Based upon the information set forth above, 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: Overturned Decision of Health Plan

The patient is a 40-year-old male with psoriasis, which has become progressively more extensive. Ultraviolet light treatment resulted in significant pain. Soriatane was ineffective and was discontinued due to elevated liver enzymes. The patients liver enzymes remain elevated. The patients dermatologist and primary care physician have recommended treatment with Enbrel injections. The Health Plan has denied coverage for Enbrel on the basis that it is not medically necessary.Methotrexate is absolutely contraindicated in patients with any evidence of liver dysfunction. In the early days of methotrexate treatment for psoriasis there were fatalities from liver failure as well as cases of permanent morbidity from liver damage. Furthermore, cyclosporine can result in liver damage, and hypertension and/or renal disease are not uncommon complications. As such, cyclosporin is not recommended and at the most, should be used for only a few months because of the potential side effects. Enbrel has none of the above-mentioned side effects and can be used on an ongoing basis. In light of the patients elevated liver enzymes, Enbrel is the most appropriate treatment for this patient and should be authorized.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: Upheld Decision of Health Plan

The patient is a 49-year-old female who has continuing chronic abdominal pain.  The source of the pain has not been identified despite an aggressive workup including colonoscopy and prior exploratory laparoscopy.  She has also been diagnosed with constipation and IBS. She would like a diagnostic laparoscopy to be performed in the hope that the reason for her pain can be determined and she can be appropriately treated.  The Health Plan has denied authorization for the requested surgery on the basis that it is not medically necessary.The exploratory laparotomy performed in 2003 found no herniations or acute gastrointestinal conditions, and the surgery was limited to lysis of adhesions.  The patients current symptoms do not suggest that a surgical condition now exists, or that there is a need for a second surgical intervention. Diagnostic laparoscopy would not be the recommended treatment for this patient.  Therefore, I have determined the requested surgery 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 32-year-old female who had gastric bypass surgery in 2001 resulting in significant weight loss. She underwent a panniculectomy in 2003 and bilateral breast reduction surgery in 2004.  The patient has experienced a weight gain of 44 pounds over the past two years.  She is also experiencing a recurrence of snoring, dyspepsia, and joint pain. In November 2004, an upper gastro-intestinal series showed an intact gastric remnant without evidence of leakage. The patient has requested authorization and coverage for gastric bypass revision, which has been denied by the Health Plan.The indications for revisional weight loss surgery are to correct complications of the original operation or to alleviate side effects. Although the patient is gaining weight, studies have identified no anatomical abnormalities following the gastric bypass procedure. Weight regain after gastric bypass is not a rarity. Creating a smaller pouch, reducing the size of the gastrojejunostomy anastomosis, or conversion to a distal bypass are proposed methods of revising the gastric bypass. All of these procedures will expose the patient to significant risk of complications and are likely to result in failure. 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: Upheld Decision of Health Plan

This patient is a 16-year-old male with a diagnosis of fragile X syndrome who has been receiving speech therapy secondary to global speech delays. He has been receiving speech therapy in the school system in a group setting and has also been receiving individual speech therapy in the private setting. The private speech therapist is recommending continued speech therapy once per week.  The Health Plan has denied authorization for past and future speech therapy citing a lack of medical necessity.In reviewing the speech therapists evaluation from April 2005 in comparison with the evaluation from September 2002, there is little documentation that the patient has made functional gains in his speech. The primary emphasis of the therapy is on expression of emotion and answering yes or no questions. At age 16, these are goals that cannot be achieved within a reasonable and predictable time period.  It appears cognitive issues are affecting the attainment of these goals and progress cannot be anticipated in a reasonable amount of time. The patients pragmatic/social language skills are being treated in a group setting within the school system. The submitted documentation does not demonstrate the medical necessity of past and future speech therapy in this case.Based upon the information set forth above, 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.