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

The patient is a 53-year-old woman with a 42-year history of type 1 diabetes mellitus. She is being managed by an endocrinologist on an insulin pump. In March 2003, the patients Hgb A1c was 7.1%. The submitted medical records include evidence of mild reflux esophagitis and chronic duodenitis with villous atrophy, thought to be secondary to celiac sprue based on biopsies performed three years ago. A consultation note from the patients transplant surgeon dated 8/22/03 notes only cataracts and retinopathy involving the left eye in the review of systems. The patient wishes to undergo pancreas-only transplantation. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary for treatment of the patients medical condition.Patients who receive only a whole body pancreas transplant face a higher risk of dying compared to patients awaiting the same procedure. In light of the associated risks of morbidity/mortality, it must be demonstrated that optimal medical management has failed before pursuing pancreas-only transplantation. Based upon the submitted information, there is not sufficient evidence that the patients metabolic status and microvascular status warrant pancreas-only transplantation. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if the patients treating physicians provide evidence of frequent, acute and severe life-threatening complications such as ketoacidosis or severe hypoglycemia, rapid progression of microvascular disease, and failure of frequent monitoring of intensive insulin therapy with multiple doses, then the patients request for a pancreas-only transplant should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 58-year-old female with a long-standing history of smoking.  However, the patient quit smoking approximately 15 years ago. The patient underwent a CT scan of the chest on 7/13/99, which was negative. Chest x-rays performed on 9/9/03 and 9/17/02 were negative except for evidence of chronic obstructive pulmonary disease on the latter exam. CT scans of the coronary arteries performed on 2/28/01 and 7/18/02 were negative. A helical CT scan of the lungs performed on 3/26/04 was also negative. The patient has requested reimbursement for the most recent helical screening CT scan of the chest.Currently, there are several on-going clinical trials evaluating the efficacy of screening CT scans of the chest for lung cancer. This patient may qualify for one of these studies. However, earlier detection of lung cancer by screening CT scans of the chest has not yet shown to decrease mortality from lung cancer and is currently not the standard of practice. Thus, helical screening CT scans of the chest are of unknown efficacy at this time. Therefore, I have determined that the CT 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 61-year-old male with a history of hypertension, allergic rhinitis, and long-standing moderate to severe asthma. The patient has been followed closely by his allergist. According to a note dated 11/6/03, the patient was started on Advair 100 twice daily. By 10/27/03, the patient was maximized to Advair 500 twice daily. Singulair was started on 11/27/03 because the patient continued to require albuterol two to three times per day.An IgE level was obtained on 11/21/03, which showed a level of 459 U/L. Skin testing showed that the patient had reactions to multiple grasses, trees, weeds, cat, dog, dust mites, and mold. The patients allergist indicated the patient should start Xolair therapy. Subsequent notes from the patients provider on 12/15/03, 1/12/04, 1/29/04, 2/18/04, 3/17/04, 3/31/04, and 5/5/04 showed that the patient had been on Advair 500 and Singulair 10 mg over this five-month period.The Health Plan has denied authorization for Xolair indicating there is a lack of documentation of maximal use of inhaled beta-agonist and corticosteroids. At issue is whether the requested medication is medically necessary for treatment of the patients medical condition.Xolair is indicated in patients with moderate to severe asthma, positive skin test reactivity to aeroallergens, and an IgE level greater than 30. Xolair is useful in patients who are on maximal doses of inhaled steroids and leukotriene modifier drugs and still have poorly controlled asthma. Use of systemic steroids such as Prednisone should be avoided because of a myriad of adverse effects, especially in this patient who already has hypertension with a history of an episode of steroid-induced diabetes. The submitted records indicate the patient had been on maximal inhaled corticosteroid use and leukotriene modifier for five months. The last office note of the patients provider showed the patient had to be started on theophylline because the use of Xolair had not yet been authorized. The Health Plan indicates there is no documentation that the patient had been on maximal therapy for more than three months. However, the patients providers records are sufficient to document medication use. Furthermore, the use of Xolair is medically indicated in this patient as his asthma is not controlled on his current regimen.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 36-year-old male with a history of chronic daily headaches status post head trauma two-and-a-half years ago. Numerous diagnostic tests have been performed but the etiology of the patients headaches is unclear. The patient has been tried on prophylactic agents, which have not been very successful in ameliorating the patients headaches, and triptans used as abortive agent have been of marginal success. The patient was authorized to undergo two trials of Botox injections, which occurred on 7/30/03 and 9/16/03. According to the patients provider, the first course of Botox injections resulted in pain relief for two weeks, but the second course of Botox injections resulted in no pain relief. The patient requests authorization for additional Botox injections. The Health Plan has denied the patients request on the basis that Botox injections are not medically necessary.There is insufficient evidence in the peer-reviewed literature to support Botox injections for the treatment of chronic daily headaches in this patient. Furthermore the patient already received two courses of Botox injections and only the first course of injections provided pain relief (and only for two weeks). In light of the lack of evidence supporting the Botox therapy and the patients lack of response to previous Botox injections, further Botox therapy is not medically indicated. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 41-year-old female with multiple myeloma serologically relapsed following induction chemotherapy and allogeneic transplantation. She is somewhat intolerant of thalidomide and has an increasing M-spike. She is in good clinical condition. The patient has requested authorization for a cancer treatment protocol offered by an out-of-network provider involving melphalan and Velcade.The proposed treatment protocol is medically appropriate for this patient and should be authorized. Myeloma patients who have progressed following or during melphalan chemotherapy may respond again to remarkably lower doses when given in combination with arsenic trioxide or Velcade. As such, the proposed treatment protocol is medically reasonable and indicated for patients such as this patient. Therefore, I have determined that the requested protocol 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 55-year-old male with a body mass index (BMI) of 38.9 and comorbidities including diabetes mellitus, hypertension, and sleep apnea. He has requested authorization for gastric banding weight loss surgery. The Health Plan has denied the patients request on the basis that the gastric banding procedure is not medically necessary.Gastric banding is not considered standard of care. Furthermore, gastric banding surgery is known to have higher complications and greater risk than other weight loss procedures. This patient can be appropriately and effectively treated through other weight loss procedures. The gastric band procedure is not medically indicated for treatment of this patients obesity. 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: Upheld Decision of Health Plan

The patient is a 32-year-old female with grade II oligoastrocytoma. She is also status post awake craniotomy and tumor resection in June 2000. The patient now has a recurrent tumor in an area that was previously unresectable. A request has been made for a second awake craniotomy with brain mapping. The patient has requested a referral to an out-of-plan neurosurgeon for a second awake craniotomy with brain mapping. The Health Plan indicates that the procedure is available in-plan.The Health Plans denial should be upheld. The Health Plan has offered medically appropriate and indicated services. Although the previous awake craniotomy was performed by an out-of-plan provider, it is not medically necessary for the same provider to perform the second awake craniotomy. The Health Plan has authorized the procedure and has appropriate staff available to perform the procedure. There is no evidence that the in-plan providers lack the skill or expertise to perform the procedure. Therefore, I have determined that the requested referral 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 15-year-old male with a history of bipolar disorder and polysubstance abuse. He was admitted to residential treatment after a three-day hospitalization following a suicide attempt. Treatment in residential care included Trazodone, Lithobid, and Risperdal. The patients last measured lithium level returned at a value of 1.0.A request has been made for continued psychiatric residential treatment services. The Health Plan indicates the submitted information demonstrates that as of 6/7/04 continued psychiatric residential treatment services were not medically necessary.The Health Plans denial should be upheld. The submitted information provides no evidence that the patient is acutely ill from affective or aggressive standpoints. Additionally, based upon the information provided the patient was not actively suicidal by the point of 6/7/04. As of 6/7/04, the patients condition stabilized to the point that residential treatment services were no longer medically indicated and transition to a partial hospitalization program would have been medically reasonable and appropriate. Therefore, I have determined that the requested services are not medically necessary for the 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 44-year-old female with a body mass index (BMI) of 61, which is diagnostic for super morbid obesity. The submitted records indicate the patient has asthma and familial lymphedema. It does not appear the patient has obtained psychiatric clearance for weight loss surgery. The patient wishes to undergo gastric bypass surgery. The Health Plan has denied authorization and coverage for gastric bypass surgery on the basis that it is not medically necessary.With a BMI of 61 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients super morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorization of weight loss 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 depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 51-year-old woman with long-standing knee pain. She has failed conservative treatment including rest, medication, injections, and physical therapy. The patient underwent an arthroscopy and continues to have pain. She was found to have arthritic changes at the time of the surgery. The patients provider has recommended the patient receive Synvisc injections. The Health Plan indicates there has not been an adequate trial of prescription anti-inflammatories following surgery. The patient is a candidate for Synvisc injections. The submitted records demonstrate the patient has persistent pain despite conservative and surgical attempts to relieve her discomfort. She may eventually require knee replacement. Non-steroidal medication that failed to provide relief preoperatively is not likely to benefit the patient postoperatively. The requested therapy is medically reasonable and appropriate in this clinical setting. Therefore, I have determined that 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 woman with a history of sudden onset of vertigo occurring 5/24/2003. She also had a history of migraine headaches, which do not appear to always coincide with the episodes of vertigo. The patient also has had complaints of neck and back pain, stress, and vision problems. There is a significant diagnosis of benign paroxysmal positional vertigo and also a later possible diagnosis of Menieres disease.At the time the patient sought treatment from an acupuncturist her symptoms were vertigo, dizziness, unbalanced headaches, poor concentration, fatigue, weakness, and ear ringing. In his letter/report of 11/20/03, the patients acupuncturist reports a favorable response to clinical treatment, as do his chart notes for the treatment dates. The only exception is on 11/10/03 when there was an increase in symptoms due to the onset of menses. Currently, it appears that the patients chief complaint is vertigo, which is greatly affecting her quality of life, both personal and professional. She cannot drive for periods over 10-15 minutes, must walk with her head down so she can watch her feet to maintain balance, and must slowly and cautiously move her head. The patient has requested authorization for continued acupuncture treatments. The Health Plan indicates that acupuncture is not medically indicated for treatment of the patients vertigo.Upon review of the submitted medical records, it appears the patient has had a number of examinations/tests to determine the cause of her vertigo symptoms without much success. These include neurological consultations (two), otolaryngology consultation, MRIs (two), a color flow Doppler, and an outpatient consultation. The results of these examinations/tests were essentially normal. She has been prescribed medication and physical therapy, which she states have been of no help. Dizziness is one of the conditions that is commonly treated with acupuncture. In addition, acupuncture is used to treat depression, stress, and headache/migraine, all of which the patient has experienced. The patient reported no benefit from traditional treatments; in fact, she indicated some of the medications caused her symptoms to increase. She has reported a good response to non-traditional medicine (acupuncture/herbs) in that her symptoms have decreased and are not as severe and she is sleeping better. In light of the failure of standard therapies and the patients favorable response to acupuncture, continued acupuncture treatments are medically appropriate and indicated.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive eight acupuncture treatments followed by re-evaluation by her acupuncturist and primary care physician.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 24-year-old woman with a body mass index (BMI) of 55 and comorbid conditions. The patient has requested authorization for the duodenal switch procedure. It does not appear the patient has obtained psychiatric clearance for weight loss surgery. The Health Plan has denied the patients request indicating that the duodenal switch procedure is not medically necessary. The Health Plan has authorized Roux-en-Y gastric bypass.The duodenal switch procedure has a track record greater than 15 years. The anticipated complications associated with other malabsorptive procedures (i.e., distal gastric bypass, jejunoileal bypass) has not been encountered with the duodenal switch. The duodenal switch has significant advantages in the super morbidly obese, especially when there is hepatosteatosis or a shortened mesentery making high Roux-en-Y gastrojej untenable. Furthermore, there is sufficient data to show that duodenal switch has a far more superior long-term outcome when compared to the gastric bypass. Therefore, the duodenal switch procedure is medically indicated for treatment of the patients super morbid obesity. However, although medically the patient meets criteria for consideration of the duodenal switch procedure, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss 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 depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the duodenal switch procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the duodenal switch procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old woman who experienced significant weight loss following gastric bypass surgery.  The patient is status post excision of excess skin on her abdomen, thighs, and arms. She has redundant skin folds at the medial and posterior aspect of the knees. A request has been made for surgical excision of the excess knee skin. The Health Plan has denied authorization for the requested procedure due to lack of documentation of medical necessity.The patient has undergone removal of redundant skin of her abdomen, arms, and thighs. The submitted photographs reveal a modest amount of excess skin about the knees. The submitted records and photographic evidence do not demonstrate that removal of the wrinkled skin in and about the patients knees is medically necessary. There is no evidence of intertrigo or other skin conditions that would warrant surgical excision of the excess skin. Sufficient evidence of a functional impairment has not been provided. 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 43-year-old female with a body mass index (BMI) of 41. The patient has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery. She wishes to undergo gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 41, gastric bypass surgery is medically indicated and necessary for this patient as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. 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 longest and best long-term outcome for the obese.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.