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

The patient is a 10-year-old male with autism who has been receiving occupational therapy and individual speech therapy for many years. He also has a history of seizure disorder, sensory integrative dysfunction symptoms and dyspraxia. The patients therapist notes that progress has been difficult secondary to the patients behavioral and mood issues. The therapist has documented some gains in speech specifically with sight words, and the use of two to four word phrases. The patients therapist has recommended a decreased frequency of two therapy sessions per week. At issue is whether continued speech and occupational therapy is medically necessary for treatment of the patients autism.Upon review of the submitted records, there appears to be an inconsistency between the therapy goals listed in the July 2004 evaluation and those in the progress report dated 1/25/05. There is no evidence in the submitted materials that the patient achieved the goals established in July 2004. Furthermore, several goals in the January 2005 report are related as much to the home program as to the actual therapy. Based upon the documentation provided, there is insufficient evidence the patient has made significant progress with therapy. As such, it is unlikely the patient will experience clinical benefit from continued therapy. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old male with diabetes mellitus type 2 that is poorly controlled (A1C of 8%) with 70/30 insulin. Based on the records provided, the patient has apparently not been seen by an endocrinologist. His primary care physician has recommended insulin pump therapy. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. There is no evidence other alternative oral and/or insulin therapies have been tried by the patient. There are multiple alternative therapies to the patients current program including Novalog/Humalog insulin, bedtime NPH insulin, and the combination of oral agents and insulin. Additionally, there is no indication whether the patient has been compliant with his insulin injections, home glucose monitoring or diet. Furthermore, it does not appear the patient has undergone a specialty consultation with an endocrinologist. For these reasons, I have determined that 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: Upheld Decision of Health Plan

The patient is a nine-year-old female with a history of receptive speech and expressive speech language delays. She shows no other symptoms consistent with autism as documented by the neuropsychologist and developmental pediatrician. The patient shows no fine motor delays as documented by her occupational therapist. She has been receiving speech therapy since the age of three and a half. The patients therapist documents continued delay and is recommending continued therapy. At issue is whether speech therapy is medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Based upon the information provided, there are no medically based issues warranting additional therapy. The primary issues are educational in nature as documented in the speech therapy letter dated 6/1/05 and in the daily notes. Most of the submitted clinic notes document problems with vocabulary, grammar and homework. In the absence of a more specific diagnosis, additional speech therapy is educational in nature and not medically indicated. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a seven-year-old female with a diagnosis of autism and developmental delay who has been receiving therapy since February 2002. Additionally, the patient has received Lovas therapy eight hours per week and participates in a weekly playgroup as well as a special day class. The patients speech therapist documented receptive speech at 28 months in the 2002 evaluation and at 30 months in the 2004 evaluation. Expressive language skills were documented at 16 months in 2002 and 28 months in 2004. Behavioral/pragmatic language skills assessment documented improvement in tolerance during sessions from 15 minutes to 30 minutes. The submitted records do not discuss pragmatic language in a social setting. The patients therapist has recommended two hours per week of speech therapy. The Health Plan indicates the patients records do not demonstrate speech therapy from 1/7/03 to 7/26/04 was medically necessary. Therefore, the Health Plan has denied reimbursement for these services.In reviewing the available progress reports and session notes it appears the patient has achieved little progress during the period at issue. It could be argued the few documented gains are related to maturity. The objective testing provided for expressive and receptive speech demonstrate minimal gains over a two-year period. The improved attention to task could also be attributed to maturity. Little evidence has been provided that pragmatic communication skills have improved. Furthermore, objective standardized test results have not been provided to document improvement in communication skills. As such, there is insufficient evidence demonstrating speech therapy was medically warranted in this case.Based upon the information set forth above, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 50-year-old female with small varicose veins. The patient was initially evaluated by a plastic surgeon who indicated the patients veins were too small to treat. The patient was subsequently seen by a dermatologist who believed the patients veins were too large to treat. It was recommended the patient undergo a trial of compression stockings. The patient then consulted another plastic surgeon who recommended and performed sclerotherapy. The Health Plan has denied coverage for sclerotherapy on the basis it was not medically necessary.The Health Plans denial should be upheld. The patient reported aching varicose veins without leg fatigue or significant lower extremity edema with prolonged standing. Based upon these symptoms, a trial of conservative therapy was the most appropriate treatment modality for this patient. There was no medical indication for sclerotherapy at the time the patient underwent the procedure. Therefore, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 30-year-old male with complaints of daytime hypersomnolence and fatigue. He reports snoring, waking up gasping for air, and difficulty going to sleep and staying asleep. The patient has an Epworth Sleepiness scare score of 10. An overnight polysomnography study obtained in December 2004 documents mild upper airway resistance, but no significant obstructive sleep apnea. Overall sleep efficiency was 85.3%. Apnea/hypopnea index (AHI) was 4.9. Oxygen saturation dropped from a baseline of 97% to a low of 93%. At the time of this study, the patient was 57 weighing 160 pounds. Therapeutic treatment options based upon the results of the polysomnogram included weight loss (if applicable), use of oral appliances, application of surgical techniques (if clinically indicated), and a second overnight sleep study for the purpose of CPAP titration. Another overnight polysomnography CPAP report was obtained. CPAP was titrated to 10 cm of water where all sleep disordered breathing events (apneas, hypopneas, and snoring) were eliminated. Sleep efficiency was 76%. The patient has requested authorization for a CPAP machine. The Health Plan indicates the patient does not meet medical necessity criteria for authorization of the requested equipment.Overnight polysomnography is used to evaluate sleep disordered breathing and diagnose significiant obstructive sleep apnea. The patients polysomnography results do not meet criteria for authorization of the use of CPAP for obstructive sleep apnea. The patient has an AHI of less than 5 with no associated comorbidities; as such, use of a CPAP device is not clinically indicated. Therefore, I have determined that 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: Upheld Decision of Health Plan

The patient is a 41-year-old woman with acne vulgaris. She had a chemical peel performed by a dermatologist with beneficial results. Treatment with doycycline, topical Retin-A micro gel, and sulfacetamide lotion was not effective. The patient and her dermatologist have requested reimbursement for the chemical peel procedure. The Health Plan indicates chemical peels are a cosmetic procedure, and therefore, has denied the request for reimbursement.The Health Plans denial should be upheld. Chemical peels are not medically necessary for the treatment of acne vulgaris. There are other treatment modalities, which were likely to be effective in this case including oral erythromycin, oral ampicillin, oral sulfur, topical Cleocin, topical benzoyl peroxide, topical erythromycin, Tazovac cream, Finacea, topical Differin, and Benzaclin. There is no evidence the use of a chemical peel was medically warranted for this patient. Therefore, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a partial responder to anti-viral therapy for chronic hepatitis C, but was unable to achieve a sustained viral response, resulting in relapse within 12 weeks of concluding a year-long course of optimal therapy. A request has been made for further treatment with Peg-Intron and ribavirin. The Health Plan has determined the requested therapy is not medically necessary.The treatment of patients with hepatitis C not achieving a sustained viral response is controversial and remains unproven at this time. Re-treatment is being advocated by some, but there exists no controlled trial or other compelling evidence that would make this approach the standard of care or medically necessary. While this may change in the future, currently there is insufficient evidence of success with the proposed management strategy. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 59-year-old woman with symptoms of low energy, aching all over, and difficulty with concentration. She has requested authorization for growth hormone (GH) therapy for presumed adult GH deficiency (AGHD) based on a low IGF-1 and the response to an Arginine/GHRH stimulation test. An MRI of the brain revealed a partially empty sella. The patients provider has recommended the use of growth hormone therapy. The Health Plan has denied coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients condition.There is no evidence of AGHD in this patient. The diagnosis is usually made based on the clinical context, which is suggestive of some disorder of the hypothalamic-pituitary axis. There is no significant pituitary lesion. Furthermore, partially empty sellas are a common incidental finding on brain imaging studies. The patients endocrinologist has posited no other pituitary trophic hormone deficiency. The patients symptoms are sufficiently non-specific, and GH stimulation tests sufficiently inaccurate, that it is possible to have a false positive diagnosis, unless the clinical context in which the testing is performed is compelling. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 44-year-old male with recurrent prostatitis with apparent flare-up, including symptoms of dysuria. The patient was treated with Cipro. In 2003, the patient had perineal aching radiating to his penis, groin, and right testis with post-void discomfort, worse after sexual intercourse. There were findings of myofascial pelvic floor pain with tender pudendal nerve. Electrodiagnostic testing revealed prolonged latency (conduction time) of the left pudendal nerve, consistent with the diagnosis of pudendal nerve entrapment. A report from the patients treating physician indicated the patient responded well to physical therapy and pudendal nerve blocks, but still had some nerve sensitivity. The patient continued to receive electromyography biofeedback therapy and physical therapy services from his provider at least until 2004. The patient has requested reimbursement for these services. The Health Plan has denied the request indicating that the services at issue were not medically necessary.The patient has had chronic pelvic pain syndrome, a condition of sometimes vague causation and one that is often difficult to treat effectively. One cause for the problem is prostatitis, which the patient had apparently had for many years. The patients urological evaluation is not documented. The patient also has documented pudendal nerve entrapment. Review of the submitted records indicates the patients condition was appropriately treated with the course of pudendal nerve block injections that he received. There is no objective medical evidence that physical therapy or biofeedback had any significant effect on the patients condition. Based upon the information provided, there was no clinical indication for continued services. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 29-year-old female with a body mass index (BMI) of 49. She has many extensive comorbidities and has failed medical management. The patient has requested coverage for gastric bypass with duodenal switch. The Health Plan has denied the request on the basis the requested procedure is not medically necessary.The Health Plan has authorized medically appropriate treatment for the patient. Roux-en-Y gastric bypass is an accepted form of weight loss surgery for patients such as this patient. The patients obesity is likely to respond to Roux-en-Y gastric bypass. As such, use of the duodenal switch procedure is not medically warranted in this case. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 32-year-old female with degenerative disc disease with involvement at L5-S1. The patient has undergone conservative treatment without sustained relief. She is requesting authorization for artificial disc replacement at L5-S1. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental without established long-term efficacy. The best-published results reveal outcomes equivalent to fusion. However, the majority of studies show a failure rate of 35%. Furthermore, the long-term safety profile is unknown. In addition, there are other treatments available. For these reasons, I have determined 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.Physician 2: The patient is a 32-year-old female with degenerative disc disease. She has had intermittent pain since she was involved in an automobile accident. She is status post nucleoplasty with increased pain. Her provider believes the L5-S1 disc is responsible for the patients pain and is recommending artificial disc replacement with the Charite disc. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, I have determined 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.Physician 3: The patient is a 32-year-old female with degenerative disc disease. She is seeking authorization for artificial disc replacement utilizing the Charite disc. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial, the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 63-year-old hypertensive male with a history of cough possibly related to use of benazepril (Lotensin). His hypertension is controlled on a combination of Toprol XL and Norvasc. The Health Plan indicates the patient does not meet criteria for authorization of Norvasc. Therefore, the Health Plan has determined Norvasc is not medically necessary.The patient has a documented history of intolerance to benazepril due to cough. The patients blood pressure is in control on a combination of a beta and calcium channel blocker, Norvasc. There is no documentation of a trial of other calcium channel blockers such as Plendil or Sular. These medications are likely to be equally effective as Norvasc. As such, there is insufficient evidence demonstrating Norvasc is 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 32-year-old female with chronic pain associated with myofascial pain, and nephrocalcinosis. She is status post C1 laminectomy and suboccipital craniectomy. The patient and her physician are requesting authorization for Actiq to help control the patients chronic pain. The Health Plan has denied the request on the basis that Actiq is not medically indicated for treatment of the patients chronic pain.Actiq is a short-acting narcotic with clearly limited indications. Actiq is approved for cancer related chronic pain syndromes refractory to the usual narcotic and other pain management techniques. There is no evidence suggesting the patient requires Actiq or that other indicated pain relief medications and therapies are ineffective or contraindicated for the patient. Therefore, 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 52-year-old man who has painful onychomycosis of the toenails. His dermatologist recommended oral Lamisil, after a failed treatment of Lamisil cream. Because he was concerned about side effects he declined oral medication and requested Penlac solution. The Health Plan has denied coverage for the requested medication on the basis it is not medically necessary.Medically appropriate treatments for fungus nail infections include oral antifungals, fungoid solution, and Penlac solution. The submitted records indicate the patient wishes to avoid the side effects associated with oral Lamisil. Though Penlac solution is not as effective in the treatment of onychomycosis as Lamisil tablets, it has shown some success and the risk of systemic side effects is less than minimal. As such, Penlac solution is medically appropriate for treatment of the patients condition and should be authorized. Accordingly, 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 39-year-old female who has a pannus following gastric bypass surgery. She notes irritation and rash outbreak during warm months of the year when topical therapy is not applied. In addition, the patient reports low back pain. The patients physician has recommended an abdominoplasty for treatment of the patients symptoms. The Health Plan has denied the request indicating an abdominoplasty is not medically necessary for treatment of the patients condition.Review of the patients photographs and clinical notes reveals a pannus with evidence of rash, but no signs of ulceration. The pannus does not appear to hang below the level of the pubis. The patient indicates that she has applied topical ointments and creams at times. Daily application of such over-the-counter preparations is necessary, and should prevent dermatitis and rash when applied in an aggressive and consistent manner. Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.