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

The patient is a 56-year-old male with multiple problems who is requesting Viagra to treat erectile dysfunction. The patients medical diagnoses include non-Hodgkins lymphoma (in remission), ulcerative colitis (in remission), primary sclerosing cholangitis with liver damage, multiple sclerosis, and depression.At the time of his hepatology consultation in May 2006 he was taking Vicodin as needed for kidney stone pain, Cipro for ascending cholangitis, and Protonix for GERD symptoms. It has also been recommended he be started on Provigil. The submitted notes indicate the patient has been having erectile dysfunction, with difficulty obtaining and maintaining penile erections.An MRI and MRCP imaging study performed in May 2006 demonstrated multiple areas of structuring and dilation of the intrahepatic duct, a small fibrosed cirrhotic liver, a small main portal vein, and findings suggestive of portal hypertension with numerous varices and spontaneous splenorenal shunt, with splenomegaly.Treatment with Viagra has been recommended. The Health Plan has denied coverage for Viagra on the basis that it is not medically necessary for treatment of the patients condition.This patient has multiple medical problems including a diagnosis of multiple sclerosis. His hepatologist prescribed Viagra to treat his erectile dysfunction. Regardless of the presumed source of the patients erectile dysfunction, Viagra is appropriate as a first-line therapy for patients diagnosed with erectile dysfunction. There are no contraindications to the medication based upon the information provided. 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 59-year-old male who presented with back pain of two to three month duration. He underwent workup including CT scan of the abdomen, which showed pancreatic metastases that extend to the aortocaval lymph node. In addition, there were two enhancing lesions in the liver. Further workup including PET scan showed multiple lung nodules. One of the patients providers has recommended that the patient undergo Cyberknife treatment to the pancreas followed by systemic chemotherapy. His medical oncologist recommended systemic chemotherapy rather than Cyberknife treatment.The patient has requested authorization for Cyberknife surgery and is seeking reimbursement for the PET scan that was performed in July 2006. The Health Plan has denied coverage for these services on the basis that they are not medically necessary.This patient has a presumed diagnosis of pancreatic cancer. Workup including CT and PET scans showed possible metastatic disease. Because of systemic disease in the liver and potentially the lung, Cyberknife treatment is not recommended. There is no evidence Cyberknife therapy is likely to be superior to other potential treatment modalities. As such, Cyberknife therapy is not medically warranted for this patient. With regard to the PET scan, this diagnostic modality is not generally utilized in the workup of presumed pancreatic cancer. PET scan is an emerging diagnostic modality without established efficacy in this setting. There is no medical indication or justification for PET scanning in the evaluation and treatment of this patient. Based upon the information set forth above, I have determined the services at issue are/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 an 18-year-old female with approximately a one-year history of binging and purging, increasing to twice a day in the month prior to referral to residential treatment. She also exercised excessively, running up to seven miles a day, though having discontinued this after four months. Two weeks prior to admission to residential treatment, she told her parents about her eating disorder, was briefly admitted to a behavioral center where she did not eat for about two days, and thereafter resumed eating. Subsequently, she was admitted to the residential treatment center.  During her stay, she was treated with a number of therapies and Prozac, the latter increased to a final dosage of 30mg. She was noted as consistently involved in the treatment program and rather soon compliant with meal expectations.  At issue is whether residential treatment services the patient received from beginning of September 2005 through mid September 2005 were medically necessary.All told, there appears to be nothing to indicate that the patient was not progressing as expected or that she was in such dire condition that inpatient treatment of any sort was indicated as of the beginning of September 2005. All the submitted notes from the end of August 2005 point to the patient as bright, cheerful, and fully involved in the various therapies. As such, she could have been transitioned to some form of outpatient treatment as of that point. Therefore, 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

This patient is a 47-year-old male with a history of methamphetamine abuse, depression and suicide attempts. He is hepatitis C, and HIV positive. The patient had a nine-month span of sobriety in 1999 and was again sober from June 2005 through February 2006. The patient was hospitalized for three weeks for detoxification and depression from May 2006 through June 2006. He had used intravenous (IV) methamphetamine three to four times per week before that admission. The patient was admitted to the residential care facility on the day following his hospital discharge. The record indicates he had refused sober living placement and outpatient treatment and had threatened to harm himself if not treated at a residential center. He was reportedly homeless at the time of his admission.The patient has requested reimbursement for the residential treatment services provided from June 2006 through July 2006.  The Health Plan denied the request based upon a determination that these services were not medically necessary.The documentation submitted does not demonstrate that the patient required residential treatment. Although he did have a long-standing history of methamphetamine abuse, he had been successfully detoxified prior to this admission and did not demonstrate physical symptoms of withdrawal. The patient had threatened to harm himself if he was not admitted to a residential treatment facility, however this type of manipulation does not indicate the patient was actively suicidal. There were no symptoms of homicidal ideation or active psychosis and he was medically stable at the time of admission. The patient did not require 24-hour residential care and could have continued his recovery through a partial hospitalization or intensive outpatient program. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The submitted documentation reveals the patient is a 14-year-old male who was admitted to a residential treatment center because of failing in school, shoplifting and oppositional defiant behaviors. He had a diagnosis of attention deficit hyperactivity disorder (ADHD) and a possible diagnosis of a bipolar disorder. The family conflict was documented as the mother being more supportive to the point of entitlement with the father being stricter with the patient. He was authorized for the residential level of care from his admission in April 2006 through May 2006. The patient was discharged from the facility in June 2006. A review of the progress notes reveals that the family told the patient that he was not going to return home after his treatment but was going to go to a long-term boarding school.  His mother and father were apparently going through a divorce at the time the patient was in the residential treatment facility. Progress notes in May 2006 reflect that the patient was angry concerning the lack of his input regarding whether he was to return home or go to another placement. He was reported to be cooperating with the program, was not a behavioral problem and was focused on his feelings of rejection and not having anything to say about his life and his future.At issue is whether the residential treatment services provided from the end of May 2006 through June 2006 were medically necessary for treatment of the patients condition.Review of the submitted records reveals the patient was ready to move to a lower level of care as of May 2006. His family had elected to continue his out of home placement and was attempting to find a long-term placement for him. Although the family was going through some significant transition issues, the patient was stable as of May 2006 and did not warrant continuation of a residential level of care. There is no evidence the patient was a threat to himself or others during the non-authorized dates; as such, he could have been appropriately treated at a less intense level of care. Therefore, 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: Overturned Decision of Health Plan

The patient is a 69-year-old male with a long standing disorder of sleep maintenance. He has had minimal response to Ambien 5mg and 10mg, and finds Lunesta 3mg significantly more effective than Lunesta 2mg. The patient reports improved sleep maintenance and subsequent improvement in daytime somnolence with the higher dosage of Lunesta. The patients request for authorization of Lunesta 3mg was denied by the Health Plan citing a lack of medical necessity.This patient has tried and failed various hypnotic agents. He had a long trial of Lunesta 3mg and found it to be the most helpful drug he has used. Neither the patient nor his provider have reported any adverse events with the higher dosage. The manufacturer may have made a general recommendation that the 2mg dosage be prescribed for patients over age 65, but that dosage has been found to be inadequate for this particular patient. Despite the package insert information, the treating physician may use a higher dosage at his/her discretion if he considers it medically indicated. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is an 18-year-old female with cerebral palsy with spastic quadriplegia.  She is dependent for all activities of daily living. She takes nothing by mouth and uses a gastrostomy tube for all nutrition. She receives bolus feeds and is tolerating all feedings.  Her weight is stable.  She has a history of constipation, but it is manageable with medications. The patient has had no recent medical issues requiring admission to the hospital. She receives oral medications for spasticity and GI issues, but no IV medications. At issue is whether continued in-home skilled nursing care is medically necessary.Upon review of the submitted clinical records and the needs associated with this patients medical care there are no services that cannot be provided by a trained attendant. There is no clinical indication for skilled nursing or skilled rehabilitation services in this particular setting. The patients needs are custodial in nature and therefore continued in-home skilled nursing services are not warranted. Accordingly, 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 52-year-old woman diagnosed with breast cancer. She has been found to have a 2.2cm moderately differentiated invasive cancer. Her cancer is estrogen receptor positive and node negative. In an effort to further define her risk of recurrence and her need for adjuvant chemotherapy, her tissue was submitted to Oncotype DX analysis. The results indicated a recurrence score of 24, placing her at intermediate risk for recurrence without chemotherapy. Accordingly, she elected to receive adjuvant chemotherapy. At issue is whether the Oncotype DX assay was medically necessary for evaluation of the patients condition.Oncotype DX assay is a 21-gene analysis of breast cancer cells, which produces a recurrence score that predicts quite accurately the risk of distant recurrence of the cancer by 10 years if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay has been shown to be valid only in node-negative, estrogen receptor positive tumors. The assay has become very important as it is particularly in this group of breast cancer patients that it is very difficult to make recommendations about adding adjuvant chemotherapy. Indeed, this assay has been rapidly adopted by many oncologists as part of their standard evaluation of such patients, and Medicare has approved it use.For the reasons set forth above, I have determined the diagnostic procedure at issue was medically necessary for evaluation 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 47-year-old female who had bilateral hip surgery in April 2005. Preoperatively she had a low normal hematocrit of 37.3%. In an effort to avoid transfusion, four doses of Procrit were prescribed. The Health Plan reportedly covered the first two injections but not the last two injections. The patients request for reimbursement for the cost of the last two Procrit injections was denied by the Health Plan based upon a determination that the therapy was not medically necessary.The patients provider likely recommended preoperative treatment with Procrit due to the greater blood loss anticipated with bilateral hip surgery. When this potential blood loss is considered in light of a hematocrit barely within the normal range and the prior authorization of the initial two injections, I believe that completion of the prescribed Procrit injections was medically appropriate. Therefore, I have determined the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 26-year-old female with medically uncontrolled epilepsy.  There is a question of whether the onset of her seizures is focal or generalized.  The patient has had three grand mal seizures over approximately seven months. She partially responds to Depakote, but has significant side effects, especially morbid obesity with secondary polycystic ovarian syndrome and glucose intolerance. The patient has failed all other new and old anticonvulsant medications and has requested authorization for VNS therapy.  The Health Plan denied the request citing a lack of medical necessity.The patient has pharmaco-resistant epilepsy. She has been followed by a specialist in the treatment of epilepsy and has tried and failed all epilepsy therapies except Depakote, VNS therapy and epilepsy surgery. The patient has had a partial response to Depakote, but at the expense of serious side effects. Her parents also report episodes of eye flutter and confused speech on a near daily basis which may represent partial seizures. Due to the serious adverse effects of Depakote, the presence of persistent grand mal seizures, and the failure of multiple single and combination anti-epileptics, I find that VNS therapy is a reasonable and appropriate treatment modality. Therefore, I have determined 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 46-year-old male with an extended history of eye irritation and redness.  He was initially evaluated by his optometrist, and then referred to an ophthalmologist within his Health Plan.  A diagnosis of episcleritis was made in 2004. The patient indicates that his condition did not resolve after two years of treatment, and he self-referred for homeopathic treatment. The patients request for reimbursement and continued authorization for homeopathic care and medication was denied by the Health Plan citing a lack of medical necessity.Chronic irritation and itchy eyes are very common conditions. In this case, the evidence of episcleritis is not overwhelming. It appears there is an inflammatory condition that is recurrent and often subsides with or without treatment. The clinical description of the patients condition is of a chronic condition that ebbs and flows. If treated during a period of remission, the treatment seems very effective. If treated during a period of exacerbation, the treatment does not give the impression of efficacy. There are no miraculous cures, and effective treatment generally involves on-going symptom management. I would question the use of steroids. With regard to the homeopathic medications, there is no scientific database to provide objective support of their efficacy. The homeopathic practitioner indicated in his notes that the eye drops were for allergy eyes. These drops would likely serve the purpose of washing out the offending agents and soothing the irritation, similar to the treatment the enrollee received within the Health Plan.Based upon the information set forth above, I have determined the services at issue were/are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 45-year-old female with a history of depression, ADHD and seizure disorder. She has had various medication trials and is effectively managed with Effexor, Tegretol and Provigil at present. Her psychiatrist indicates that amphetamines are contraindicated for this patient due to the increased risk of seizures. The patients provider submitted a request for authorization of Provigil. The request was denied by the Health Plan based upon a determination that the medication is not medically necessary.Augmentation of antidepressant therapy with stimulant medications for the treatment of depressive symptoms has been common practice in the psychiatric community for over 25 years. Provigil is a newer drug that is a non-amphetamine, non-addicting stimulant. It is currently FDA approved for the treatment of narcolepsy and excessive daytime sleepiness associated with sleep apnea. The patient is benefiting from her current medication regimen and there is sufficient evidence in the medical literature to support the use of Provigil as in this clinical setting. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 47-year-old female with a history of chronic plantar fasciitis. Conservative therapy consisted of non-steroidal anti-inflammatory drugs, icing and stretching, steroid injections and orthotics. Additionally, the patient underwent plantar fasciotomy surgery in June of 2005. None of these interventions have successfully relieved her right foot pain. The patient is now requesting authorization for extracorporeal shock wave therapy (ESWT).  The Health Plan had denied her request citing a lack of medical necessity.A review of literature related to ESWT reveals that optimal treatment parameters have not been established, patient selection criteria has not been adequately defined and there is limited information regarding the durability of the treatment effect or the long-term adverse effects. A recent randomized, placebo-controlled, double-blinded, clinical trial yielded results that contradict previous positive findings; raising further doubts as to the efficacy of the therapy. There is no data available that would suggest that ESWT would be effective after fasciotomy, and it is unlikely that this patient would benefit from the therapy.Based upon the information set forth above, 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 53-year-old male with a history of neck and back pain progressively worsening over the past ten years. He has been evaluated for surgery on the cervical spine by both an orthopedic spinal surgeon and a neurosurgeon, and both have discussed the treatment alternatives with him. The patient has requested that his surgery be performed by the consulting neurosurgeon. The Health Plan denied his request based upon a determination that it is not medically necessary that a neurosurgeon perform the surgery. I would normally consider an orthopedic spine specialist and a neurosurgeon fairly equivalent when it comes to operating on the spine. In this case the surgery proposed by the orthopedic surgeon is very extensive with three-level anterior cervical discectomy and fusion and partial propectomies. I would recommend that the Health Plan ensure the orthopedic spinal surgeon has the requisite qualifications. Subject to such assurance, I have determined the requested service is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.