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

The patient is a 48-year-old woman with bilateral knee pain due to osteoarthritis. She was given Synvisc injections in April 2005 and again in December 2005. She underwent injections in each knee and good results were indicated by her orthopedist.  The patient has requested reimbursement for the cost of the therapy.  The Health Plan denied the request based on a determination that the therapy was not medically necessary for treatment of the enrollees knee pain.The patient had her first series of Synvisc injections in April and had good relief for over six months.  In light of her previous response to the therapy, a second series was medically appropriate.  The second series was again successful, and her orthopedist reported that the patient was able to decrease her pain medications by 50%. Therefore, I have determined 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: Overturned Decision of Health Plan

The patient is a 25-year-old female who had gastric bypass surgery in 2002. Her pre-bypass weight is not recorded. The records reflect a weight loss of 110 to 165 pounds with a weight in December 2005 of 195 pounds and a BMI of 30.5. One provider noted a target weight of 160 to 170 pounds. The patient does not want to wait to lose more weight because of the severity of her complaints. She complains of chronic skin infections, rashes, pimples and boils in the abdomen skin. She has constant skin irritation in the axilla from skin-on-skin rubbing and contact. She requests coverage for a panniculectomy, brachioplasty, breast reduction, thigh lift and buttocks lift. She has seen at least two plastic surgeons that agree with the panniculectomy, but want her to lose additional weight from her recorded 216 pounds in May 2005 and 220 pounds in June 2005. The patients personal notes and the notes of her health care providers all reflect symptoms from the significant weight loss. The patient has requested authorization and coverage for panniculectomy/abdominoplasty, brachioplasty, breast lift and reduction, thigh lift, and buttock lift.  The Health Plan denied the request based on a determination that the requested procedures are not medically necessary.The record provided for review included 20 pages of color photographs of the patient. They indeed show significant erythema in the groin creases, axillary region and under the breast folds, but no demonstratable skin irritation is seen in the lower back/buttocks regions. The treatment records do indicate that topical antifungal agents were prescribed, but the patients complaints continued to such a degree that she has indications for surgery as described in the position paper from ASPS.  It says in part Resection of redundant skin and fat folds is medically indicated if panniculitis or uncontrollable intertrigo is present. Chronic or recurrent skin infections may occur. A large overhanging pannus may cause lower back pain and interfere with ambulation and personal hygiene. It goes on to state, in female patients with ptotic breasts after massive weight loss, macromastia may be present and associated with postural backache, upper back, neck and shoulder pain. Intertrigo and related dermatitis may also be present. Reduction mammoplasty is indicated in these patients. Also, stated in the position paper is Resection of upper arm and thigh tissue is performed to improve the patients comfort and appearance. With the exception of the buttock lift, this patient has signs and symptoms sufficient to qualify all of the requested surgeries as reconstructive and not cosmetic in nature.Based upon the information set forth above, I have determined the majority of the requested procedures are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned with one exception (buttock lift).
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 61-year-old male with a history of alcohol abuse who has been hospitalized twice in the last eight months.  He participated in skilled rehabilitation following each of his acute hospital discharges.  The patient reports a fall in December 2005 and difficulty with transfers thereafter.  Apparently a hospital bed was delivered several months ago, and never picked up by the vendor.  The patient does not have a bed of his own and has requested authorization of the hospital bed for an additional six months.  The Health Plan has denied his request based upon a determination that the hospital bed is not medically necessary.Upon review of the information there is no documented medical necessity for the requested hospital bed.  The patient has some instability of gait due to chronic alcoholism for which he uses a walker or cane.  It was noted that his transfers required stand-by assistance (SBA) at the time of discharge from the hospital in December 2005. There is no documentation of impairment in bed mobility.  Furthermore, the documentation indicates the patient has no regular bed, but he could function as well as he does with the hospital bed if he had a regular bed.  The enrollees primary complaint is that he cannot transfer from the floor where he sleeps to an upright position.  This however, does not constitute medical necessity for a hospital bed.  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

This case involves a 52-year-old male with a right knee injury that occurred in February of 2005. He was diagnosed with an anterior cruciate ligament (ACL) tear at the time of the injury. The patient elected to forgo surgical reconstruction and has done well as long as he avoids activities where he would experience difficulty with the knee. At this point in time, the patient would like to resume some of his previous sporting activities. He and his orthopedist agree that a knee brace is needed to avoid reinjuring his knee. The patient has requested authorization for a Don Joy Defiance knee brace. The Health Plan has denied his request based upon a determination that the requested DME is not medically necessary.The June 2005 note from the patients orthopedist states the patient has instability with pivot/incline walking, a Grade II Lachman and a positive pivot shift. Although the December 2005 orthopedists note indicates there is no day-to-day instability, that observation should be considered in light of the patients activity limitations. He stated that he avoids walking on uneven ground and generally walks very carefully.  He no longer participates in sporting and recreational activities that would stress his knee joint. Furthermore, the patient does not want surgical reconstruction. As the patient does have a confirmed laxity with instability on pivot shift activities, a functional knee brace is medically necessary to prevent instability with more vigorous activities.  The L1886 or an L184 would meet the patients needs, however the additional polycentric knee joints, carbon graphite frame, or heavy knee joint included in the DonJoy Defiance knee brace are not medically necessary.Based upon the information set forth above, I have determined a portion of the requested DME is medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old man with bilateral arthritis of the hips, left worse that right. He has researched alternatives to total hip replacement and has submitted a request for metal-on-metal hip resurfacing arthroplasty to his Health Plan.  The Health Plan does not consider this procedure medically necessary, and has denied the patients request for authorization.Metal-on-metal hip resurfacing is not currently the standard of care for severe osteoarthritis, as there is not sufficient peer-reviewed data establishing the long-term efficacy and durability of the procedure. Given the patients age, there is no evidence to suggest that hip resurfacing is a better or more effective procedure than conventional total hip replacement. In comparing the surgical options, total hip replacement remains the standard of care for treatment of severe hip joint disease.  Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition.  As such, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 68-year-old woman who has severe lichen planopilaris and scarring alopecia of the scalp. Treatments with topical corticosteroids, intralesional kenalog, oral Plaquenil and oral Cellcept have all been unsuccessful. The condition has worsened and the inflammation has become more severe. The patients dermatologist prescribed Elidel cream and Clobetasol lotion. The patients request for authorization of the Elidel cream was denied based upon the Health Plans determination that it was not medically necessary to treat her scalp condition.Lichen planopilaris is an inflammatory process that involves the skin and hair follicles of the scalp. It is often associated with severe inflammation that may result in significant pain and scarring alopecia. In this patients case, the inflammatory process is severe, as is the hair loss. Elidel cream was prescribed by her dermatologist only after other anti-inflammatory treatments had failed. The recommended treatment with topical Elidel is a reasonable next step and medically appropriate as a further attempt curtail or stop this disease. 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: Upheld Decision of Health Plan

The patient is a 47-year-old female, who sought treatment for a severe rash around her eyes with reported pain, swelling, and visual disturbance of several months duration.  Her provider noted dry skin around the eyes and a possible contact dermatitis.  He also noted the patient was unwilling to discontinue cosmetics. The patients provider indicated that contact testing might be appropriate, but did not pursue it. He utilized a radio-allergo-sorbent-test (RAST) to specifically identify the patients IgE response to inhalants, drugs and foods in order to determine if she was allergic. A local steroid was prescribed and the patient was advised against cosmetics.  The RAST panel was negative and there is no additional follow up included in the record.  The patient has requested reimbursement for the cost of the diagnostic services.  The Health Plan denied her request based on a determination that the diagnostic services were not medically necessary for evaluation of her skin condition.The history and physical exam of the patient is not consistent with contact sensitivity.  If the patients provider wished to investigate an allergic response, a total IgE level would have been appropriate.  If positive, it would then be reasonable to pursue more extensive IgE testing for inhalant allergy, but not food or drug allergy. It is not the standard of care to order comprehensive IgE testing without first conducting 72-hour contact testing for a standard battery of contactants and the specific suspect contactants. Therefore, I have determined the diagnostic services at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 35-year-old female with right leg varices and great saphenous vein (GSV) reflux on duplex exam.  She underwent sclerotherapy in December 2004 and apparently had some relief of her pain symptoms, although she did not have her GSV reflux addressed. Following the sclerotherapy, the patient had some residual pain and later developed scarring and local recurrence of a varicose vein.  The patient seeks authorization for removal of the varicose vein and revision of the scar. The Health Plan denied her request based upon a determination that the procedures are not medically necessary.The patient has a right thigh varix that was treated with sclerotherapy and has now reoccurred along with a scar and recurrent pain. She also has GVS reflux and incompetence that has not been treated.  In this clinical context, the isolated treatment of varices (sclerotherapy or phlebectomy) is not medically appropriate. Because this patients GSV reflux was never addressed, (i.e. venous closure, EVLT, or stripping) it is not a surprise that the varix recurred.  The scar that accompanied the varix is not only unsightly but is also likely to contribute to her lower extremity pain. Until the GSV reflux is addressed, a clear determination as to the source of the patients leg pain cannot be made.  It is not likely that the isolated varix and scar on the right thigh are the only contributing factors. In summary, the request for an isolated varix excision (phlebectomy) and scar revision is not medically necessary or appropriate at this time. If the patient has her GSV reflux addressed and continues to have pain at the site of the varix, phlebectomy may then be appropriate and medically necessary. Based upon the information set forth above, I have determined the requested procedures are 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 36-year-old male with diabetes mellitus type II, who is obese, insulin resistant and dyslipidemic.  He appears to have been untreated from 2000 until July of 2005. In July 2005 the patient started on Actos tablets and Lantus insulin with initial improvement in his hemoglobin A1c from 12.2% to 11.5%.  By September 2005 his A1c dropped to 9.1%.  The patient was also noted to have postprandial blood sugars in the 180 mg range; significantly above the American Association Of Clinical Endocrinologists recommendation of 140 mg. Byetta injections of 5 mcg twice a day were added to his diabetic regimen by his endocrinologist. Within six weeks the patient reported fasting blood sugars of less than 100 mg and postprandial levels around 120-30 mg. Because the Health Plan denied further authorization for the prescribed Byetta, the patients endocrinologist provided additional samples.  The patient has requested authorization for the prescribed medication but his request was denied by the Health Plan based on a determination that Byetta was not medically necessary for treatment of his type II diabetes.The patient is insulin resistant, requiring as much as 100 units of Lantus insulin to achieve basal control and he is also obese. He has had an excellent early response to Byetta at the starting dose of 5 mcg twice per day and would be expected to have an even better response with the full maintenance dose of 10 mcg twice per day.  The Health Plan did not recommend an alternative to the Byetta that would achieve the same level of improvement without causing substantial weight gain, which is a contraindication in diabetes mellitus type II.Although the FDA has not approved Byetta for use with Actos and/or Lantus insulin (or insulin of any type for that matter), available data demonstrates the likely effectiveness of Byetta when used in combination with Actos. Additionally, the response demonstrated by the patient supports the theory that the combination of basal insulin and Byetta is an ideal treatment program for patients with diabetes mellitus type II.Based upon the information 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 46-year-old woman who underwent gastric bypass in 2004 and has since had a considerable weight loss.  She has excess skin in the abdominal area and a panniculus.  Reports of back pain and skin irritation related to her condition are noted in the record. The patient has requested authorization for abdominoplasty and panniculectomy.  The Health Plan has denied her request based upon a determination that the surgical procedures are not medically necessary.  The records provided document a weight maximum of 216 pounds in May 2004 pre-bypass and a weight minimum of 124 pounds in September 2005, which indicates a documented loss of 92 pounds. However, the Health Plans requirement of a 100-pound weight loss should not be considered the primary reason for denial of the requested surgery. The Health Plan also requires that the panniculus hang at or below the level of the pubis.  This criterion is not met as photographs show that the hanging skin does not even reach the pubis, and there appears to be more lateral, rather than midline draping.  Photographic evidence of a chronic recurring skin condition refractory to appropriate medical therapy is also required. There are no photographs presented showing any irregularity of her abdominal skin and, there are no doctors notes recording treatments related to an on-going skin condition. Based on the photographic evidence and the lack of any demonstratable complaint related to her pannus, I have determined the requested procedures are cosmetic and 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 who is 53, weights 254 pounds, and has a body mass index (BMI) of 45. She also has significant comorbid conditions. It is not known if the patient has received psychological clearance for weight loss surgery, but her provider indicates she is psychologically ready for surgery. The patient otherwise meets the NIH guidelines for weight loss surgery. The Health Plan has denied coverage for laparoscopic adjustable gastric banding (Lap Band) based upon their determination that it is not medically necessary for treatment of the patients medical condition.The long-term success of the Lap Band when measured in terms of maintaining excess body weight loss (EBWL) is inferior to the gastric bypass or duodenal switch operations. The limited result of the procedure does not come with limited risk. The Lap Band website reports that in a three-year follow up study of 299 patients with the Lap Band, 88% had post operative complications ranging from nausea and vomiting and reflux to stomach-band outlet blockage.  In this study one-fourth of the patients had their Lap Bands removed.Based upon the information set forth above, 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

The patient is a 49-year-old male with a diagnosis of schizoaffective disorder who was admitted to a partial hospital program (PHP). He presented for admission to PHP with a one-month history of increased auditory hallucinations, confusion, and self-destructive thoughts. He also had increased paranoid delusions and generalized disorganization in his thinking. His medications included Clozaril, Risperdal, Seroquel, lithium, Effexor-XR and Zoloft. By December 2005 the patient had stabilized to his previous level of functioning.  The patients wife requested reimbursement for services provided after December 2005 and on-going PHP authorization.  The Health Plan denied this request based upon a determination that the services were not medically necessary after December 2005.A review of the record demonstrates that the patient was neither suicidal nor homicidal during the time he was in the PHP. By December 2005 his psychosis had decreased and he was stable. There were no adjustments made to his medication regimen.  He could have been managed in an outpatient treatment program with medication management on an as necessary basis. I agree that by December 2005 he had derived the maximum benefit possible from the PHP and there was no reasonable expectation of improvement. Therefore, I have determined the services at issue were/are 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 woman with chronic migraine, chronic hip pain, insomnia and excessive daytime somnolence (EDS) who is requesting coverage for Provigil. She tried Provigil and finds it resolves her symptoms and substantially improves her quality of life. She apparently has been unable to reduce her other medications due to an increase in her chronic pain.  The patients request for authorization and coverage of Provigil was denied by the Health Plan based upon a determination that it was not medically necessary.The patient has excessive daytime somnolence likely related to a primarily sleep disorder and sedating medications including OxyContin, Neurontin, and Topamax. She has been taking Provigil for several months, and the medication has afforded her substantial improvement in her ability to manage her pain, to maintain her cognitive functioning, and to perform effectively at work.  While Provigil is not FDA approved for medication related EDS, it is widely used in this clinical setting by psychiatrists, neurologists, and pain management specialists.  Based on the information 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.