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

The patient is a 17-year-old male with a history of bronchiectasis secondary to common variable immune deficiency and restrictive lung disease. The patients provider indicates the patient has not been prescribed a Flutter device because he would not be able to perform the technique due to coughing episodes that occur with increased shortness of breath. In July 2003, it was noted the patients clinical condition was worsening. It was suspected that the patient might have bronchiolitis obliterans with organizing pneumonia. The patients condition was observed clinically with serial CT scans. The patients provider has recommended use of the Vest Airway Clearance System (the Vest) in order to improve secretion clearance. The Health Plan has denied authorization and coverage for the Vest on the basis that it is not medically indicated.There are many studies, which demonstrate that enhancing mucus clearance in patients with pulmonary disease results in a benefit in disease control and symptoms. Methods to enhance mucous clearance include the use of chest physiotherapy, postural drainage, and mucolytics. Though the Flutter device has not been prescribed for the patient because of potential coughing, coughing is the bodys primary method of secretion clearance. The patient can also perform postural drainage without assistance, which may be more effective after using the Flutter device or receiving a bronchodilator treatment. Given the availability of other modalities, the Vest is not medically indicated for the patient. Based upon the information set forth above, I have determined that the requested equipment 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 17-year-old male with previously diagnosed bipolar disorder and conduct disorder, with background history of polysubstance abuse. The patient was admitted to a residential treatment center in May 2003 where he has continued in treatment until this time. A request has been made for continued residential treatment services. The Health Plan authorized treatment until 2/18/04, with intention to shift the patients treatment to an outpatient basis. Chart notes from 2/6/04, indicate the patient though struggling with his anger was stable for the most part with no major ups and downs. He was often noted to attend group therapy but to appear somewhat bored, maintaining a distanced but not outwardly contentious stance. His formal psychiatric evaluation of 2/12/04, notes the patient as doing well with stable mood and no behavioral issues presented. It was also noted the patient refused Depakote. At this point in treatment, Prozac had been discontinued for a month without problems and it was thought that the patient might not actually have had bipolar disorder. As such, Depakote was formally discontinued and the patient was scheduled to be seen in another four weeks or so as needed. The patients next formal psychiatric evaluation of 3/18/04, also noted the patients mood was stable with no symptoms, he was sleeping well with good focus/concentration, and he appeared pleasant/euthymic on exam. Throughout, the patient was not suicidal or nearly as contentious as he had initially presented.The Health Plans denial should be upheld. As set forth above, the submitted records do not demonstrate that continued residential treatment is medically necessary. Many of the serious components of the patients initial clinical presentation, such as fighting, drug use, stalking, and anger, had abated significantly by 2/18/04. In fact, based upon the provided chart notes, they actually extinguished by this point. While there is never a guarantee against relapse, the patient had sufficiently improved to the point that residential treatment was no longer medically indicated as of 2/18/04. By this date there had been sufficient time to transition the patient home and to outpatient treatment. Thus, it was medically reasonable and appropriate to discontinue residential treatment at that point in time. 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. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a four-year-old male who has been diagnosed with autism, sensory processing problems, delays in self-care/feeding problems, and delays in fine motor/adaptive skills. The patient has been receiving occupational therapy since March 2003. A request has been made for continuing occupational therapy including sensory integration therapy one time per week for six months. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary.Autism is a complex, difficult disease. Responses are at times in small increments. There are many treatment modalities, but few are universally accepted. Occupational treatment including a sensory integration component is a reasonable treatment approach 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. The patient should receive occupational therapy including sensory integration therapy once a week for a three-month period with transition to a home program at the end of the three-month period.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 38-year-old woman who has requested continuation of long-term intravenous immunoglobulin (IVIG) therapy for hypogammaglobulinemia and an unnamed autoimmune disorder. The records from the patients previous physician document the ongoing use of IVIG, as well as prednisone in unclear doses, but without any clear indication stated. The Health Plan has denied the patients request indicating that the submitted documentation does not demonstrate that the requested therapy is medically necessary.The data provided does not establish the patients diagnoses or provide any clear indication for treatment with IVIG. Hypogammaglobulinemia is not described nor documented in the provided records and there is no explanation for the initial use of IVIG in this patient five years earlier. There is no evidence given of recurrent or significant infection. The patients current treating physician has not recommended that IVIG be continued. In addition, the patients IgG levels were variable, with only one reading below normal. Furthermore, although the records suggest that the patient is being treated with prednisone for a connective tissue disorder of unclear origin this is neither described nor supported. It does not appear the patient has been examined by a rheumatologist to address this issue. She is reported to have diabetes mellitus as well, but any relationship between this diagnosis and her prednisone treatment is unstated.Thus, the submitted documentation provides no clear evidence of hypogammaglobulinemia or an autoimmune disorder, which would necessitate the continuation of IVIG therapy. The alternative approach of continuing management by the patients current hematologist/oncologist is medically appropriate. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old man with a 28-year history of type 1 diabetes mellitus now under good glycemic control on an insulin pump. The patient indicates he tests his blood glucose by home monitoring (SMBG) 10 to 14 times a day. His A1c on 3/5/04 was 5.6%. The patient has requested authorization for 10 to 12 test strips per day to sustain the level and intensity of monitoring required by his active work and lifestyle. The Health Plan indicates more than seven test strips per day are not medically necessary for management and control of the patients diabetes.The patients endocrinologist indicates that the patients frequent self-monitoring has allowed the patient to maintain his good control. It is extremely rare for patients to require more than seven SMGB values a day. Although testing before meals, at bedtime, and occasionally at 3:00 to 4:00 a.m. is standard practice for intensive regimen testing, it is also suggested to test before physical activity and other activities such as driving and using machinery. Additionally, the role of postprandial blood sugar testing in diabetes control is being increasingly recognized.Because of this patients continuously changing and challenging lifestyle, he requires more frequent monitoring in order to maintain near normal blood glucoses on his intensive insulin regimens. Therefore, I have determined that 10 diabetic test strips per day are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patients resultant blood glucose values and the actions taken to modify his insulin or activity should be documented to his endocrinologists satisfaction in order to maintain this level of testing.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 79-year-old man with a history of depression and bipolar affective disorder. The patient was admitted to an acute inpatient psychiatric hospital in May 2003 after experiencing increasing depression. At the time of admission, it was noted the patient was unable to care for himself and exhibited feelings of hopelessness and helplessness, severe anhedonia, decreased interest, and impaired judgment. The patient began treatment with antidepressants, psychostimulants, and a mood stabilizer. The patient continued to receive acute inpatient psychiatric treatment until 7/31/03. The Health Plan indicates that this level of care was not required after 7/9/03.The submitted records clearly indicate the patient was depressed during the period in question. The patients first euthymic day was not until 7/29/03. Given the patients initial presentation and ongoing depression without significant improvement, continued hospitalization was required. The documented evidence demonstrates that the patients entire stay was medically indicated. Therefore, I have determined that the services at issue were medically necessary. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 63-year-old man with Bells palsy since December 2002. The submitted records indicate the patient began receiving physical therapy in January 2003. The patient indicates he is still experiencing numbness on the right side of his face and sometimes has trouble controlling his right eye. The patient has requested authorization for continued physical therapy. The Health Plan has denied the patients request indicating that continued physical therapy is not medically indicated.The Health Plans denial should be upheld. The patient has had one year of treatment for his Bells palsy. Based upon the natural history of this disease, significant improvement is not expected after 9-12 months. Given this, additional improvement with continued physical therapy is not expected. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 47-year-old woman who has been diagnosed as having large vestibular aqueduct syndrome with bilateral hearing loss and vertigo. The submitted information indicates the patient has had difficulty with vertigo and hearing loss since she was a young child. In June 2003, the vertigo worsened. The patient was initially diagnosed as having Menieres syndrome and was prescribed meclizine and Diazide, as well as Amoxicillin, Flonase, and Sudafed. She did not improve and was referred to a neurologist for further evaluation. Through this evaluation a CT of the temporal bones revealed the presence of enlarged vestibular aqueducts bilaterally. Valium was prescribed for control of vertigo. Audiometric evaluation reveals bilateral severe to profound hearing loss, somewhat worse for the left ear. However, speech discrimination for the right ear was found to be 95% while that for the left scored 35%. The patient has requested authorization for cochlear implantation to help with her problem of vertigo. The Health Plan has denied authorization for cochlear implantation on the basis that it is not medically indicted based upon the patients hearing/discrimination level.Current standards for adult cochlear implantation dictate that this procedure is medically necessary and useful to patients with bilateral profound loss of hearing and poor aided speech discrimination. In September 2003, the patients provider indicated that the request for implantation of the patients left ear was made for the purpose of improving aided communication. Although this patient may become a candidate for cochlear implantation with progression of her disease, the procedure is not currently indicated given the patients discrimination scores of 95% and 35% for the right and left ears respectively. Furthermore, cochlear implantation is not medically indicated for the purpose of treating/curing vertigo. 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 52-year-old woman who experiences chronic muscle tension headaches. She has undergone multiple diagnostic procedures. The results of these procedures have been normal, thus confirming the diagnosis of muscle tension headaches (the most common form of chronic headaches). She has been followed by a pain management specialist who has treated her with a large number of medications, which the patient reports have not provided relief. The patient has requested authorization for a referral to an out-of-network headache specialist. The Health Plan indicates the requested referral is not medically necessary.The patient does not require the care of a headache specialist. Although the patient continues to experience tension headaches, there is no evidence that ongoing care from a headache specialist will result in an improved clinical outcome. The patient can be appropriately treated by a pain management specialist with strict compliance to a long-term program. 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: Overturned Decision of Health Plan

The patient is a 53-year-old woman with more than a 20-year history of diabetes mellitus type 1. The submitted documents indicate the patient utilized a MiniMed 507c insulin pump for over four years. In May 2003, the patient requested a new pump because of concern over accuracy of her current pump. In April 2003, the patients A1c was 8.9% suggesting that the patient was not in good glycemic control. In November 2003, the patients provider indicated that the patient was going to stop the pump and switch to multiple dose injections (MDI). Self-monitored blood glucose values from October 2003 to November 2003 while the patient was still on pump therapy compared to November 2003 to December 2003 values while the patient was on MDI showed no changes in her blood glucose control; an A1c in December 2003 was still 8.9%. The patients provider has recommended a Medtronic Paradigm insulin pump. The Health Plan has denied authorization for the requested equipment on the basis that it is not medically necessary.The patient has poorly controlled type 1 diabetes mellitus. While on MDI the patients A1c was greater than 7% and she had wide fluctuations in her blood glucose levels. Use of an insulin pump is the appropriate standard of care for patients such as this patient and is consistent with current medical literature as well as the guidelines set forth by the American Diabetes Association. However, there is no evidence that a Medtronic Paradigm insulin pump is medically indicated. The patient should receive a standard replacement pump similar to one that was previously authorized. In addition, the patient should take advantage of recommendations of the Health Plan for managing all aspects of her diabetes.Based upon the information set forth above, I have determined that a Medtronic Paradigm insulin pump is not medically necessary for treatment of the patients medical condition; however, a standard insulin pump is medically necessary. Therefore, the Health Plans denial should be partially overturned. A standard insulin pump should be authorized for the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 25-year-old woman who has requested reimbursement for a bunionectomy that was performed in April 2003. The Health Plan has denied this request indicating that the procedure at issue was not medically necessary. The submitted information does not document conservative treatment prior to surgery. The Health Plans denial should be upheld. Review of the submitted records does not demonstrate that there was an adequate course of conservative therapy prior to bunion surgery. Additionally, there was no pre-operative x-ray of the bunion deformity to support the procedure. Furthermore, the operative report reflects a bunion with soft tissue release while the billing information indicates an osteotomy was performed. Thus, the submitted records do not demonstrate that the procedure at issue was medically indicated.Based upon the information set forth above, I have determined that the procedure at issue was 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 44-year-old woman with a body mass index (BMI) of 48.7. The patient has multiple comorbidities including gastroesophageal reflux disease, high cholesterol, and arthritis. The Health Plan has denied authorization for gastric bypass with duodenal switch indicating that the safety and efficacy of the duodenal switch procedure has not been established in peer-reviewed literature. With a BMI of 48.7 and comorbid conditions, the patient is an appropriate candidate for consideration of weight loss surgery. In general, duodenal switch has been indicated for patients with a BMI of greater than 60. A recent study supports duodenal switch in a broader range of patients. However, there is no compelling evidence that duodenal switch is necessary for this patient. The patient can be safely and effectively treated through Roux-en-Y gastric bypass. Although the patient takes NSAIDs for treatment of arthritis, she will still be able to use NSAIDs following Roux-en-Y gastric bypass as the amount of acid in the pouch is significantly reduced. Furthermore, her analgesic needs should be significantly reduced by weight loss following Roux-en-Y gastric bypass. Based upon the information set forth above, I have determined that the requested duodenal switch procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. However, if the patient requests authorization and coverage for Roux-en-Y gastric bypass the Health Plan should authorize the procedure.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 41-year-old female with the diagnoses of severe persistent asthma, gastroesophageal reflux disease, severe eczema, multiple allergies confirmed by skin tests, and osteoporosis. The patient is seeking authorization for the medication Xolair.According to the records provided, the patient has had four emergency room/urgent care visits for asthma exacerbations over the last six months. The patient has been on multiple medications to help control her asthma including Foradil, Azmacort, Accolate, Singulair, albuterol MDI, albuterol nebulizer, and oral corticosteroids. Despite these medications, the patient has required multiple emergency room/urgent care as well as frequent office visits.According to the patients pulmonologist, the patient does not tolerate inhaled corticosteroids because of dysphonia. A spirometry performed in October 2003 demonstrated FEV1 114% of predicted normal FVL. This was attributed to the fact that the patient was on oral corticosteroids. Notes from the patients allergist confirm the patient has severe eczema and multiple allergies. The patient also has a history of anaphylaxis. In addition, the patients rheumatologist confirms the patient has glucocorticoid-induced osteoporosis stemming from her asthma treatment.The purpose of this review is to determine whether Xolair is medically necessary for treatment of the patients asthma.It appears the Health Plan has denied authorization for Xolair on the basis that the patient was not consistent with her use of leukotriene and that her FEV1 was greater than 80%. Based upon the information provided, the patient was on Accolate and Singulair with no significant benefit. The patient has had to be on chronic oral prednisone in order to control her asthma. The fact that the patient had a normal spirometry does not exclude asthma.According to the National Asthma Education and Prevention Center guidelines, based upon the patients frequent utilization of the emergency room and need for oral prednisone, the patient has poorly controlled asthma. The patient already suffers from steroid-induced osteoporosis and should discontinue use of oral steroids as soon as possible. In addition, because the patient has GERD the use of theophylline is relatively contraindicated. Furthermore, her atopy and severe asthma make her a good candidate for Xolair.Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old female with Barretts esophagus. Her last EGD was performed in May 2001 with biopsies demonstrating evidence of Barretts esophagus with no dysplasia. The patient has a first-degree relative who was diagnosed with esophageal cancer. The patient is requesting a capsule endoscopy for further evaluation.The Food and Drug Administrations approval criteria for wireless capsule endoscopy is quite clear and it is not approved for Barretts esophagus. Furthermore, there are no published, prospective, double blind studies in any peer reviewed journal showing the benefits of wireless capsule endoscopy in detecting and/or following Barretts esophagus. Wireless capsule endoscopy for this patient is not considered standard of care and is not the standard in the community.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.