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

The patient is a 45-year-old male who is on maintenance hemodialysis for end-stage renal disease due to focal segmental glomerulosclerosis and a failed first transplant. He is on a cadaveric transplant waiting list, but has reduced chances of obtaining such a transplant because of a high plasma renin activity (PSA). The patient received two doses of IVIG, which reduced the sensitization parameters insignificantly. A request has been made for authorization and coverage for participation in the Transplant Immunotherapy Program at Cedars-Sinai. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the patients condition.Recent literature in relatively small series of patients supports the use of IVIG, plasmapheresis and rituximab to desensitize patients such as this patient and facilitate transplantation. Renal transplant is superior to dialysis as a treatment modality in end-stage renal disease. All attempts should be made to facilitate difficult transplants. Though successful transplantation is not guaranteed, the patient is best served by full doses of IVIG, plasmapheresis and rituximab. The treatment protocol proposed by Cedar-Sinai is medically appropriate and indicated for this patient. 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: Upheld Decision of Health Plan

The patient is a 37-year-old female who is seeking coverage for a dermolipectomy. The patient states she has lost 100 pounds and now has hanging skin that bothers her. She is status post bilateral breast reduction. The Health Plan has denied coverage for the requested procedure on the basis it is cosmetic in nature and not medically necessary.The submitted records indicate the patients height is 63 and her weight has been steadily recorded as increasing from 172 pounds in April 2004 to 187 pounds in November 2004. Her body mass index (BMI) is 34.2, which rose from her earlier stated weight of 163 pounds (BMI of 29) and places her in an obese category. There is no documentation of medical necessity for the proposed procedure and there is question as to whether the requested procedure would benefit the patient prior to achieving the weight loss goal. 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 46-year-old male who has had a painful fungus infection of his toenails for many years. He received many forms of treatment, including Sporanox from July 2004 to September 2004, without improvement. The Health Plan has denied coverage for Lamisil on the basis that it is not medically necessary. The Health Plan indicates Sporanox stays in the nail plate for nine months.The question is whether Sporanox treatment, which demonstrated no improvement in the patients condition during a six-month period, can result in cure or significant improvement in nine months. If there has not been improvement within six months, it is medically reasonable and appropriate to conclude that the Sporanox treatment was ineffective. Lamisil treatment is medically indicated for treatment of the patients painful fungus toenail infection. Therefore, 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 46-year-old female with long-standing opioid dependence, sedative-hypnotic abuse, and alcohol dependence in remission, generalized anxiety disorder, and depression NOS vs. major depression. She was admitted to an intensive outpatient program through her Health Plan on 4/5/04. She continued in this program until approximately 5/26/04, having become largely abstinent of substance abuse during this time. She was later admitted to inpatient care for detoxification on 6/7/04, after having taken 36 Morphine pills on 6/3/04, noting a prior overdose six weeks prior wherein she was hospitalized for five days. She was subsequently detoxified with Suboxone, tolerating the downward taper as well, last dose administered on 6/21/04. After this time, she was transitioned to seeing a psychiatrist, who she saw from 6/22/04 to 12/3/04. She has now requested authorization for individual therapy or residential treatment. She does not have coverage for residential treatment, although the Health Plan provided her recommendations on how to find such through the County. Throughout this time period the patient was treated with a number of psychotropics, ranging from Serzone, Prozac, Paxil, Risperdal, Seroquel, Depakote, Lithium, naltrexone, and eventually Celexa. January 2005 notes from the patients psychiatrist indicate the patient was struggling with depression and anxiety, interspersed with substance relapse, either in the vein of benzodiazepines, muscle relaxants, or opiates.The Health Plan reported the psychiatrist as not recommending individual therapy until the patient was consistently clean and sober, and had referred her to dual diagnosis groups, given the severity of her co-occurring psychiatric diagnoses. Cognitive behavioral therapy has also been offered via group psychoeducational classes as well as evening CBT groups. However, the patient declined returning to the chemical dependency recovery program.There appears to be nothing in the documentation provided to show the patient has not and was not provided appropriate standard of care for her various disorders. Accordingly, it is within the purview of her psychiatrist to recommend a prioritization of what would or would not benefit her. Asking that she be consistently abstinent from drugs and alcohol prior to beginning individual therapy, for example, is very much within the standard of care. Moreover, the Health Plan has offered the patient a number of treatment options for her various illnesses that are known to be appropriate and effective for treatment of the patients diagnoses. Based upon the information set forth above, I have determined 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: Upheld Decision of Health Plan

The patient is a 54-year-old non-obese male who has obstructive sleep apnea/hypopnea syndrome diagnosed based on excessive daytime sleepiness associated with choking. Apnea hypopnea index (AHI) is less than six. In addition, the patient has a history of gastroesophageal reflux disease (GERD). The patient reports he has taken Provigil with therapeutic benefit. The information provided does not include definite defined sleep latency, history of aftercare following the polysomnography or history of endoscopic evaluation of GERD.The patient has requested coverage for continued use of Provigil. The Health Plan has denied the request on the basis Provigil is not medically necessary for treatment of the patients condition.The patients diagnosis is not well defined. The polysomnography study does not reach the threshold sufficient for a diagnosis of obstructive sleep apnea requiring treatment. Daytime sleepiness is not well established. There is no evidence of a sleep latency test, nor is the clinical history sufficient to determine if the patient is clearly excessively sleepy. The presentation with choking, plus the patients history of known GERD, challenges this diagnosis. The alternative diagnosis may be severe GERD.Notwithstanding the information set forth above, Provigil has proven clinically effective for the patient in terms of reduction of daytime sleepiness. This, in fact, is of clinical importance. If evidence is obtained that shows the patient does not have an alternative diagnosis and treatment (e.g., effective management of GERD) or if there is evidence of failed CPAP after clear use of alternative sleep hygiene interventions, then use of Provigil would be medically appropriate and the patients request should be reconsidered. However, at this time I have determined the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 61-year-old male with a long history of knee and lower back problems who was found to have a slightly elevated PSA in November 2004 (6.09) and again in December 2004 (6.13). Prostate biopsy on 1/11/05 was negative for metastatic disease. Assuming the prostate felt benign on digital rectal examination, the stage of this cancer would be T1c and based on Partin's Tables the cancer would have a 75% chance of being organ confined. Thus, it represents a cancer potentially curable by surgical removal. The patient has requested coverage for a robotic-assisted laparoscopic radical retropubic prostatectomy. The open surgical approach is a well-established treatment with good long-term results with regard to both survival and complications. Robotic-assisted laparoscopic prostatectomy is relatively new, and while short-term results are comparable, long-term data, especially with regard to survival, is not yet available. While there is no medical objection to the robotic-assisted laparoscopic approach, to date there is insufficient data to demonstrate its superiority to other procedures. The alternatives offered by the Health Plan are medically reasonable and appropriate treatment options for this patient. There is no medical justification for a robotic-assisted laparoscopic radical prostatectomy 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a three-year-old male who was diagnosed with asthma and prescribed Xopenex in November 2004. The patient had been treated with Xopenex in the past, which was stated to be effective. When the patients parents attempted to fill the prescription for Xopenex provided by the treating physician, they were provided with albuterol as an alternative. The parents have stated that albuterol has not been as effective as Xopenex for treatment of the patients symptoms. The Health Plan indicates that the effectiveness of albuterol and Xopenex is comparable, and that Xopenex is not approved for children under age six.The clinical records document the patient suffers from reactive airway disease, as he wheezes and coughs with infections, requiring the use of nebulized medication. The patient had been previously treated with Xopenex with beneficial results. Although the physician records do not indicate a failed trial with albuterol, the patients parents state they attempted treatment with albuterol with poor results. Although Xopenex has not been formally approved for use in children under six years of age, its use in very young children is rapidly becoming the community standard of care, as there have been recent studies which demonstrate the superiority of its efficacy over albuterol for these patients. Further advantages of Xopenex over Albuterol include: 1. Xopenex is a pure isomer with no pro-inflammatory property; 2. Xopenex is easier to utilize requiring no mixing with solution; 3. Xopenex is longer lasting than albuterol (6-8 hrs. vs. 3-4 hrs.). The records confirm that the patient required repeated treatments with albuterol vs. a longer lasting effect with Xopenex; and 4. Xopenex has been shown to prevent frequent emergency room visits and hospitalizations.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 49-year-old man with multiple medical problems. He has requested coverage for growth hormone (GH) for presumed adult GH deficiency (AGHD) based on nonspecific symptom, IGF-1 concentrations, and a sub-optimal response to an unknown GH stimulation test. The patient has type 2 diabetes, depression, obesity, abnormal liver function tests, hypothyroidism, hypogonadism, and is on a variety of medications, which could affect GH and GH stimulation tests. The Health Plan has denied coverage for GH therapy on the basis it is not medically necessary.The diagnosis of AGHD is generally based on the clinical context, signs and symptoms and the results of biochemical testing. The patients signs and symptoms are sufficiently nonspecific 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.The submitted records provide no evidence for 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. Other causes for the patients symptoms could be his depression, poorly controlled diabetes, hypothyroidism or obesity. These must be considered before undertaking a course of testing for AGHD. With the exception of his hypogonadotrophic hypogonadism, the rest of the tested pituitary hormones appear normal. The patients MRI results show no structural lesion in the pituitary. His low GH levels and inadequate response to the GH stimulation tests in this context could be caused by any of his other conditions. As such, there is insufficient evidence that GH is medically indicated for this patient.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old woman with chronic hepatitis C. She was treated with Peg-Intron and ribavirin for 48 weeks. It appears she did not respond to the therapy. Another course of therapy with Peg-Intron and ribavirin has been recommended by the patients provider. The patient has stated that she is seeking treatment with Infergen and ribavirin. The Health Plan has denied authorization and coverage for Peg-Intron and ribavirin on the basis it is not medically necessary for treatment of the patients condition.It is not standard of care to treat patients who have failed an initial course of Peg-Intron and ribavirin with a repeat course of the therapy. The submitted records indicate the patient failed to achieve viral clearance after 48 weeks of therapy. There is no prospective, peer-reviewed study showing benefit in retreating patients such as this patient. Thus, a repeat course of Peg-Intron and ribavirin is not likely to benefit the patient and is not medically indicated. However, use of Infergen in this situation would be medically reasonable and appropriate as Infergen has been approved by the Food and Drug Administration for patients who have not responded to prior therapy. Based upon the information set forth above, I have determined that treatment with Peg-Intron and ribavirin is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. However, if the patient and her provider request treatment with Infergen and ribavirin, such therapy would be medically indicated and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is an 18-year-old female who has a large right breast with significant ptosis and relative hyperplasia. The left breast, by photographic appearance, is small relative to the right breast, but it does not appear this is a case involving minimal development. The patients provider has recommended mastopexy of the right breast and augmentation of the left breast to achieve breast symmetry. The Health Plan indicates the requested surgery is not medically necessary. The Health Plan has recommended either augmentation of the left breast or reduction of the right breast for treatment of the patients breast asymmetry.The patient is requesting bilateral breast surgery to address the asymmetry in development. Neither of the patients breasts viewed alone could be described as congenitally abnormal. The issue is the asymmetry between the two breasts. Unilateral breast surgery in this patient is acceptable to achieve symmetry to the extent possible (either reduction of the right breast or augmentation of the left breast). Therefore, I have determined that the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 58-year-old man who has prostate cancer with a PSA of 18 and Gleason score of 6 (3+3). Based upon the information provided, it appears the patient is stage T1c because no disease was palpated. A biopsy of the prostate performed on 10/12/04 revealed no cancer in the left apex; Gleason 6 (3+3) in 30% of specimen of the left mid with 2 of the 4 cores positive; Gleason 6 (3+3) in 11% of specimen of the left base with 1 of the 2 cores positive; Gleason 6 (3+3) in 25% of specimen of the right apex with 1 of 2 cores positive; no cancer in the right mid; and no cancer in the right base. The patients radiation oncologist has recommended the patient undergo intensity modulated radiation therapy (IMRT) because the patients MRI shows a suspicious nodule on the left, and because of the patients obesity, chronic asthma, large volume of cancer, and enlarged prostate. The Health Plan has denied coverage for IMRT and recommends neoadjuvant hormone therapy and 3-D conformal radiation therapy. The patient has stage T1c cancer of the prostate with Gleason 6 (3+3) and a PSA of 18. Based on Partins Tables, there is a 62% chance of cancer being limited to the prostate; a 33% chance of capsular invasion, a 5% chance of seminal vesicle involvement, and a 3% chance of pelvic lymph node involvement. IMRT will deliver 8100 cGy to the prostate. 3-D conformal radiation therapy can deliver 7400-7600 cGy to the prostate. Neoadjuvant hormonal therapy can shrink the cancer and reduce the PSA in 75-80% of prostate cancer, within 2-3 months. There is no evidence the patient will experience a superior clinical outcome with IMRT than with these other therapies. The alternatives offered by the Health Plan are as good if not better than IMRT alone. Thus, use of IMRT in this clinical setting is not medically warranted. Accordingly, 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 63-year-old female with osteoarthritis in both knees. She was previously treated with a series of Synvisc injections in June 2004 with reported benefit. The patients provider has recommended another series of injections. The Health Plan indicates the requested injections are not medically necessary. The patient has already had three Synvisc injections. Based upon the information provided, it does not appear she has received steroid injections. Steroid injections are the appropriate next step for treatment of this patient. Additional Synvisc injections are not medically indicated at this time. The Health Plans recommendation of corticosteroid injections is medically reasonable and appropriate. Therefore, I have determined the requested injections 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 45-year-old female with idiopathic hypersomnia diagnosed in April 2002. There is documentation of severe pathological sleepiness with mean sleep latency of 4.3 minutes, otherwise normal sleep efficiency and normal sleep architecture with minimal snoring. The patient has been treated for three years with Provigil, with relief of symptoms. There have been no reported side effects to therapy. Her previous medication history included Ritalin 20mg, which was ineffective at clinically decreasing her daytime sleepiness. The patient changed carriers in October 2004, and her current Health Plan has denied authorization for Provigil on the basis that it is not medically necessary for treatment of the patients excessive sleepiness.The ICSD system lists four major categories of sleep disorders including dyssomnias. Dyssomnias are sleep disorders characterized by insomnia, excessive sleepiness or abnormal sleep-wake timing. Specific medicinal therapies are addressed for narcolepsy and obstructive sleep apnea. Idiopathic hypersomnia features excessive sleepiness without the other features sufficient to characterize narcolepsy. There is good documentation the patient has excessive sleepiness secondary to idiopathic hypersomnia (known as non-REM narcolepsy) based on a mean sleep latency test performed on 4/16/02.Provigil is effective in reducing excessive sleepiness. This has been characterized in many different conditions including obstructive sleep apnea nonresponsive to CPAP therapy, multiple sclerosis, and Parkinsons disease. Though Provigil is not FDA approved for idiopathic hypersomnia, there are multiple sleep conditions that feature excessive sleepiness that may be mitigated with Provigil. In fact, Provigil has been effective in controlling the patients excessive sleepiness for three years. Furthermore, it does not appear there is other alternative medicinal therapy available for this patient. Thus, continued use of Provigil is medically appropriate and indicated for this patient.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 60-year-old male who has requested Celebrex. The Health Plan has denied this request on the basis that Celebrex is not medically necessary for treatment of the patients arthritis. The patient has a history of multi-joint osteoarthritis, status post bilateral meniscopathies of the knees and status post ORIF of the ankle. The records provided document the patient is intolerant of aspirin, Aleve, and Naprosyn. In addition, he developed gastritis on ibuprofen. He has tolerated Celebrex at 200 mg twice a day for a number of months. He has no history of GI bleed or ulcer and is not currently on anticoagulant therapy or chronic oral corticosteroids. There is no documentation provided indicating he has tried and failed a course of NSAID formulary alternatives with low GI risk (e.g., salsalate, Trilisate, etodolac, Relafen).The Health Plans denial should be upheld. There is no advantage of Cox-2 inhibitors over traditional NSAIDs. There is some potential advantage for individuals with gastrointestinal intolerance of NSAIDs but this advantage is questionable and has not been established in the evidence-based literature. The patient should attempt a low risk NSAID prior to consideration of Celebrex. The Health Plan is offering the patient appropriate medications for treatment of the patients condition. There is no evidence that Celebrex is medically necessary at this time. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.