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

The patient is a four-year ten-month old male born the product of a term delivery who appeared to be developing normally until he was started in daycare/preschool. At that time it was noted that his language was not age appropriate. The patient was referred to a pediatric neurologist who documented expressive language delays and mildly reduced tone. The patient has also been seen by a speech therapist who diagnosed him with speech apraxia. An initial evaluation has been submitted along with daily progress notes. No follow-up formalized testing has been performed and none of the provided documentation reports a diagnosis of speech apraxia.At issue is whether speech therapy is medically necessary for treatment of the patients condition.Upon review of the relevant literature, there is no new evidence regarding the cause of developmental apraxia of speech. To date, the etiology remains unclear. Therefore, this condition is considered a developmental abnormality and does not represent a condition associated with a specific illness or injury. Thus, speech therapy in this setting is educational in nature and is not medically necessary. Accordingly, 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 54-year-old male with a history of loud snoring and significant daytime somnolence by clinical history. Polysomnography demonstrated an apnea index of 4 per hour, associated with snoring and oxygen desaturation to the 80s. Symptoms were worse when supine. A CPAP device was not prescribed. The patient has requested authorization and coverage for the medication Provigil. The Health Plan indicates the patient does not meet the medical necessity criteria for authorization of Provigil, as he has not demonstrated persistent somnolence despite the use of CPAP. In cases such as this, CPAP therapy is more physiologically correct and is more likely to address the broader issue of the patients sleep disturbance as opposed to masking the symptoms with a pharmacologic alternative such as Provigil. Furthermore, CPAP therapy is safer than Provigil. Accepted practice guidelines generally indicate an apnea index of 15 or greater justifies CPAP therapy. However, an apnea index of less than 15 should not prevent CPAP therapy in patients who are clearly symptomatic with daytime somnolence, nocturnal desaturation and/or endorgan effects of sleep apnea-hypertension. Despite an apnea index of 4, the patient is clearly symptomatic with severe desaturations to the 80s during sleep. The clinical findings endorse a trial of CPAP therapy. If CPAP fails to correct the daytime somnolence, the patients request for Provigil should be reconsidered.Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 55-year-old male who has progressive myleopathy of uncertain cause. MRI imaging has not shown relevant abnormalities and CSF was normal. The patient has had prior spinal surgery and findings consistent with this were seen on MRI. A brain MRI showed small vessel ischemic disease without evidence of multiple sclerosis plaque. Currently, the patient carries a diagnosis of myelopathy. Etiology has been uncertain, and magnetic resonance spectroscopy (MRS) has been requested. No diagnosis of tumor or cancer is reported in the submitted records.At issue is whether the requested MRS is medically necessary for treatment of the patients medical condition.The patient has myelopathy. No diagnosis of cancer or tumor is evident. MRS has not been shown to differentiate multiple sclerosis plaque from other lesions except for neoplasm (e.g., transverse myelitis). Sensitivity and specificity of MRS in multiple sclerosis has not been established in the literature. MRS is not clinically likely to be relevant in guiding decision making in this clinical setting and therefore is not medically warranted in this context. Therefore, I have determined the requested MRS is 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 57-year-old male with severe xiphoid pain. Despite an extensive workup, the etiology of his pain remains unclear. The patient has requested an MRI of the chest and xiphoid process and CT guided trigger point injections. The Health Plan denied these requests based on a determination that the procedures are not medically necessary.An MRI is not likely to provide clarification as to the source of the patients pain. Additionally, CT guidance is not indicated or necessary for trigger point injections.  CT guidance is not the standard of care in performing trigger point injections. Since the requested procedures have little clinical usefulness in this setting, they are not medically justified. Therefore, 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: Upheld Decision of Health Plan

This patient is an 11-month-old male with a diagnosis of brachycephaly and plagiocephaly. With brachycephaly, the predominant condition measurements demonstrate a cephalic index greater than 2 standard deviations above the norm and an asymmetry of the cranial vault of 4.5 mm. At issue is whether a cranial remodeling orthosis is medically necessary for treatment of the patients brachycephaly and plagiocephaly.Review of the medical evidence demonstrates that a cranial orthotic does not improve brachycephaly. Plagiocephaly of 4.5 mm without evidence of brachycephaly often corrects with time and positioning. The only study looking at both plagiocephaly and brachycephaly (Teichgraker) documents little effect on brachycephaly. For these reasons, the requested device is not likely to be of clinical value in this setting and is not medically warranted. Based upon the information set forth above, I have determined the requested device 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 17-year-old male who has been diagnosed with oppositional defiant disorder, cannabis abuse and alcohol abuse. He was experiencing severe family conflicts and was arrested for attempting to board an airplane with a concealed weapon. The patient was admitted to residential treatment in October 2005. A request has been made for coverage for the residential treatment service the patient received in October 2005 as well as for continued residential treatment services.The Health Plans denial should be upheld. The submitted records do not support medical necessity for 24-hour supervised skilled care. There is no evidence the patient has been suicidal, homicidal or psychotic. Furthermore, the patient has been prescribed no medications while in residential treatment. All told, the patient could have been appropriately treated at a less intense level of care. 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: Upheld Decision of Health Plan

This case involves a 51-year-old male who has been treated with chiropractic care for a diagnosis of upper extremity neuropathy and lumbar degeneration. The record over a span of months reveals very little variation in symptom intensity and no resolution of the symptom complex with stability. The patient feels the chiropractic care is helpful and requests additional services. The Health Plan has denied his request based on a determination that the services are not medically necessary.Neither the patient nor the record provided for review conveys which symptoms have improved over the course of the chiropractic treatment.  The clinical evidence does not demonstrate resolution of the initial diagnosis and there are no periods of notable improvement indicated. From an objective prospective, the benefit derived from chiropractic services at this time is not apparent. In the future, should an alternative service be less effective and the patients condition regress, then chiropractic services should be reconsidered.Based upon the information set forth above, I have determined the requested services 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 22-year-old female with myotonic muscular dystrophy and frequent respiratory infections. She has recurrent pneumonia secondary to her muscular dystrophy. According to her pulmonologist, the patient was hospitalized for 14 days in 2005 for pneumonia. She had been tried on various secretion clearance methods including chest physiotherapy, Flutter device and postural drainage. The pulmonologist ordered the Vest System for the patient in September 2005. Her condition improved and she was able to return to her baseline health status. The patients father indicates he has observed improvement in the patients health since she began using the Vest System and she has been able to return to her disabled adult work experience program.The Health Plan denied authorization and coverage for the Vest System concluding that there was not sufficient evidence to support the use of the Vest System in patients with muscular dystrophy. The purpose of this review is to determine if the Vest System is medically necessary for treatment of the patients medical condition.The material provided for review included articles supporting the use of external high-frequency oscillation (HFO) in patients with various neuromuscular diseases. Giaraffa et al. found improvement in all health outcomes, peak flows and FVC in patients using HFO. Piloplys et al. found less pneumonia and fewer hospitalizations in cerebral palsy patients using the Vest System.Secretion clearance is extremely important in preventing respiratory infections. Factors which influence clearance are mucus viscosity, an intact mucociliary system and an effective cough. The patient has a severe neuromuscular illness, which results in an ineffective cough. She had been on various secretion clearance methods including the Flutter device, postural drainage and an IPV machine. Since all the previous methods were ineffective, it was appropriate for the patient to undergo a trial of the Vest System. The patient has had significant improvement and improved quality of life since using the Vest System. As such, the patients continued use of the Vest System is medically reasonable and appropriate and indicated for secretion clearance.Based upon the information set forth above, I have determined the requested device 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 23-year-old male with a long history of polysubstance abuse, including prescription medications, since the age of 12. He was admitted to a residential treatment program in November 2005 and later discharged after testing positive for opiates. His prior residential treatment admission and intensive outpatient (IOP) attempts at treatment resulted in non-compliance. Based on the information provided, he was not suicidal, homicidal or psychotic. A request has been made for reimbursement for residential treatment services provided from November 2005 through January 2006. The Health Plan has denied this request on the basis that the services at issue were not medically necessary.The Health Plans denial should be upheld. Records indicate the patient was non-compliant with treatment and did not benefit from the program. Furthermore, the services offered by the Health Plan were medically reasonable and appropriate. The patient could have been appropriately treated in a day treatment chemical dependency program along with the medication Effexor and weekly individual psychotherapy. Based upon the evidence provided, the level of care the patient received was not medically warranted. Accordingly, I have determined 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 67-year-old male with back and knee pain. He indicates that several radiofrequency (RF) neurotomy treatments have been effective in the past as well as two prior series of Synvisc injections. He has now requested authorization for RF neurotomy treatments for his back and a third series of Synvisc injections for his knee. The Health Plan has denied his requests based upon a determination that the procedures are not medically necessary.RF neurotomy cannot be recommended for the patients spinal complaints. He has undergone spinal fusion, has had epidural injections, and is followed by a pain management specialist.  He indicated he has had RF neurotomy treatments in the past.  There is no indication that additional procedures will provide any further relief of his back pain. The medical literature does not support the efficacy of multiple RF neurotomy procedures for long-term pain relief.  In regard to the knee pain, he has already undergone two series of Synvisc injections according to his statement.  There is no clinical evidence to indicate that a third series is likely to be effective for relief of his knee pain. 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: Upheld Decision of Health Plan

The patient is a seven-month-old male who during his two-month well-baby exam was noted to have mild torticollis and some flattening of the right occiput.  Conservative treatment was discussed.  At three-months of age, the baby had increased flatness at the back of his head, primarily on the right, and an anterior shift of the right ear.  He was diagnosed with positional plagiocephaly and a cranial orthotic was advised.  The baby was fitted for the device and his parents are now requesting reimbursement for the cost.  The Health Plan has denied their request based upon a determination that the orthotic device was not medically necessary.Treatment of positional plagiocephaly with the helmet device is controversial.  With babies now sleeping exclusively on their backs, we are seeing positional plagiocephaly commonly.  Conservative practical treatment is effective in almost all cases, as it predictably will be for this child as well.  We are reserving helmet treatment to those infants with severe problems, defined as one ear one or more centimeters more anteriorly positioned than the other ear.  Since this child was making progress without the helmet, as indicated in January 2005 during casting for the helmet, there is no evidence demonstrating the need for its use.  Based upon the information set forth above, I have determined the device 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 56-year-old female with a very longstanding history of depression, stemming back to childhood. She is currently being treated for recurrent major depression with Cymbalta 120 mg, Lithium 900 mg, Lexapro 40 mg, Geodon 100 mg, Ritalin 100 mg and Trazodone 300 mg, all with poor response. Medications tried in the past include Topomax, Strattera, Dexedrine, Neurotin, Effexor, Zoloft, Paxil, Remeron, Risperdal, Lamictal, Wellbutrin, Seroquel, Zyprexa, Nardil, and Buspar; all discontinued due to either lack of response or intolerable side effects. She did initially respond to ECT in 2002 but found the memory difficulties to be intolerable, hence declining this treatment again. Instead, her psychiatrist has recommended VNS. There is no accompanying documentation as to the exact nature of the patients illness except it began in childhood and she has felt suicidal, off and on.  The patients request for authorization of VNS therapy was denied based upon the Health Plans determination that it was not necessary to treat her depression.Several factors argue against recommending VNS in this instance. First of all, the literature is not compelling as to efficacy; particularly when so many other standard treatments have not been effective. Secondly, if ECT was effective for at least some time, this could be considered a preferred treatment. The memory deficits attributed to ECT can be minimized with varying lead placements. Therefore, the patients subjective memory and concentration impairments after the ECT she received in 2002 are not sufficient reasons not to recommend ECT again. Finally, in an instance where depression begins in childhood and has essentially never let up, one has to consider underlying characterological factors. The catalog of psychotropic medications is enormous and the individual dosages are beyond what is typically prescribed. But questions arise as to whether the patient has been treated with concerted psychotherapy in addition to medications. Clearly, there appears to be more going on here than simple medication-refractory illness. Given all of these considerations and so little documentation about the true history of the depression, VNS cannot not be considered 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 56-year-old woman with a reported history of varied neurological and pain symptoms since 2000.  She has been evaluated by multiple physicians and a variety of diagnoses have been rendered at different times including systemic lupus erythematous (SLE), multiple sclerosis (MS) and transverse myelitis, among others. According to a review of the records her diagnosis remains unsure; spine and brain imaging were negative for significant pathology, VER and BAER were negative, a sedimentation rate (ESR) was normal and a cerebral angiogram was normal. The patients cerebral spinal fluid (CSF) protein was minimally elevated in 2000, but she has had prior spinal surgery.  The record indicates the patient had a more recent CSF exam in December 2005, but no results are noted. The possible diagnosis of transverse myelitis lead to a trial of plasmapheresis in April 2005.  The patient reports the procedure was beneficial, but there is no clear documentation of medical benefit (change in neurological function) evident from the record.  The most recent reports from her neurologist do not reveal a request for repeat plasmapheresis, nor is there a definite clinical diagnosis. A rheumatology consultation noted a concern about depressive symptoms.  The patients request for additional plasmapheresis was denied based upon the Health Plans determination that it was not medically necessary to treat her medical condition.A review of the record provided demonstrates that numerous diagnoses have been entertained, but no neurological diagnosis for which plasmapheresis is indicated has been clearly made.  Although plasmapheresis is appropriate for certain neurological diagnoses including acute transverse myelitis, it also carries certain risks such as sepsis and should only be used when the potential for benefit warrants the risk.  This patient does not have a clear diagnosis of such a condition. If indeed, she has transverse myelitis, it is not well documented and would not appear to be an acute condition.  The record also indicates the patient has been reevaluated for a second opinion and the report is pending at this time.  That information may lead to a more definitive diagnosis. 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 17-year-old female with depression and migraine headaches. She reported an increase in the frequency of migraines on her current antidepressant regimen. The patient was evaluated by a neurologist and Botox injections were initiated as a preventative measure. Her neurologist noted a decrease in the frequency of her migraines one month after the first treatment. There is no information in the record regarding the impact of the headaches or the degree of improvement post Botox. The patients father has requested reimbursement for the cost of the Botox therapy provided and continued authorization and coverage for future treatment. The Health Plan denied his requests based on a determination that the therapy is not medically necessary for the treatment of the patients migraine headaches.The patient has migraines and comorbid depression. She has been using Imitrex at a high frequency and preventive therapy is warranted. She may also be having more headaches as a result of her antidepressants. There is no evidence that any preventive regimen was tried before the Botox injections were initiated. In general there is limited evidence establishing that antidepressants have migraine preventive effects, except for the tricyclic antidepressants such as amitriptyline. Multiple preventive medications exist that could be tried, starting at low doses and increasing to a therapeutic level. Preventive medications often take one to two months before they begin to show a benefit. The patient should consider a trial of a tricyclic antidepressant, topiramate, or a beta-blocker.Based upon the information provided, the patient has not exhausted standard medications for the treatment of her migraines. Therefore, I have determined the therapy at issue is not medically necessary for treatment of the patients medical condition. The Health Plans denial of the therapy should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is 38-year-old male that is quite allergic due to defined sensitivities confirmed by skin testing and an elevated IgE. On the other hand, his spirometry studies indicate minimal obstruction. The patient began Xolair injections in February 2004 and has since discontinued his Advair, Singular. Mescalor and albuterol inhaler.  The records also indicate that the patients requirement for prednisone began only after he discontinued Advair.  There is no information in the record suggesting that strict environmental control and/or a HEPA filter has been employed.  This patient has not met the prerequisites for Xolair administration.  He had no significant requirement for steroids when Xolair was initially prescribed in January 2004.  The record does not reflect an effort to eliminate allergens or that a HEPA filter has been employed.  Based on further review, it does not appear that other non-allergic etiologies, i.e., sinusitis or reflux, have been sufficiently explored. The patient is slightly overweight; therefore reflux should be ruled out.  In summary, the use of Xolair is not appropriate based on the spirometric studies and absence of adequate anti-asthmatic medications, i.e. Advair.  Furthermore, his physician has not advised environmental control nor pursued other etiologies.  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.