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

This patient is a 43-year-old female with chronic active hepatitis C, genotype 1a who was treated with PEG Intron and ribavirin in 2004, and relapsed after the completion of therapy. She has no history of suicide or depression. The patients last liver panel revealed normal bilirubin, AST, ALT, total protein, albumin, total bilirubin, PT and INR. The HCV-PCR in December 2005 was 21,099,000 Iu/ml. Her liver ultrasound revealed mild hepatic steatosis without focal lesions.  When last evaluated by her hepatologist, the patient was doing well and showed no signs or symptoms of decompensated liver disease. She had no symptoms of mental confusion or forgetfulness. The patient has requested authorization for retreatment with Infergen and ribavirin therapy.  The Health Plan denied her request based upon a determination that the therapy is not medically necessary.Therapeutic options for hepatitis C treatment failures include retreatment with pegylated interferon, Infergen plus ribavirin, maintenance interferon therapy, and watch and wait for the development of new agents.  Infergen induction therapy together with subsequent ribavirin combination therapy showed promising results in two clinical trials conducted by Kaiser et. al. Two more recent trials have corroborated the Kaiser findings and there is significant interest in the use of Infergen for the treatment of nonresponders and relapsers.  Currently there is a large multicenter trial underway, and if response rates are confirmed we will be in a far better position to treat these patients. Although the proposed therapy is not yet FDA approved, it is being used extensively by hepatologists nationally and internationally to treat relapsers and nonresponders to previous combination therapy. The patient responded to 48 weeks of combination therapy with pegylated interferon and ribavirin in 2004, and later relapsed. She is genotype 1a and has a high viral load.  Based upon the studies citied above, the patient is an appropriate candidate for Infergen and ribavirin combination therapy.  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 nine-year-old female with a diagnosis of dento-facial dysfunction and developmental articulation delay for which she has received speech therapy. No specific medical report addresses the extent of the developmental delays. The therapist reports a Photo Articulation Test resulted in a standard score of 95 and an age equivalency of 8 years 3 months. In addition, a lingual neutral position accuracy of 90% was noted. At issue is whether speech therapy was medically necessary for this patient.Review of the scientific literature regarding myofunctional therapy does not reveal sufficient evidence of its efficacy. Although the program is sanctioned by the American Speech-Language Hearing Association, they acknowledge that the research evaluating its efficacy is limited, of a small scale, and uncontrolled. Most of the studies document some benefit in treating tongue thrust, but do not show significant evidence of improvement in articulation.In reviewing the medical reports as well as the daily progress notes there is no objective standardized or non-standardized data showing improvement in the patients condition or that the patient has a clinically significant delay in speech articulation or expressive/receptive language disorder. Furthermore, no medical illness or injury is documented in the records provided. As such, there is insufficient evidence speech therapy was medically warranted in this case.For the reasons set forth above, I have determined the therapy 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 45-year-old female with chronic neck pain due to disc disease. Her orthopedist prescribed a neuromuscular stimulator to help manage her pain. Previous treatment with cortisone injections, medications and chiropractic therapy has not resolved her symptoms. The patient reports the neuromuscular stimulator has provided significant pain relief and improved her range of motion. She has requested reimbursement and continued authorization and coverage for the device. The Health Plan denied her request based upon a determination that the neuromuscular stimulator was/is not medically necessary.The patient has chronic neck pain that is not muscular in origin, but more likely due to degenerative disc disease. The efficacy of a neuromuscular stimulator for the treatment of discogenic pain remains unproven at this time. No prospective study has been conducted to warrant its general use. The risks, benefits and long-term results of such therapy remain unknown. Therefore, I have determined the device at issue was/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 female with a history of arthritis, congestive heart failure, renal failure, diabetes, and peripheral neuropathy. She is seeking authorization for a power-operated vehicle (POV). The Health Plan indicates the patient does not meet authorization criteria for a POV and has denied authorization for the requested equipment. Information from March 2006 indicates the patients gait was unstable with a walker but could probably improve with physical therapy. Information from April 2006 indicates the patient could functionally ambulate in the home with a front-wheeled walker. It was also indicated a POV would not fit in the patients home. Therefore, a manual wheelchair was recommended. Based upon this information, the patient does not meet accepted criteria for authorization of a POV. Therefore, I have determined the requested equipment is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 59-year-old male who underwent knee arthroscopy and microfracture surgery in June 2006. The patients treating surgeon recommended the patient utilize a continuous passive motion (CPM) device for eight weeks post-operatively. The reason for recommending the CPM device was to assist the patient in achieving maximum benefit from the surgery and optimal results. The Health Plan has denied authorization for the CPM device.The patient underwent surgery to regenerate cartilage to a portion of his knee that had lost articular cartilage. Post-operative CPM is utilized to maximize the benefits of the procedure. It is standard within the California orthopedic community to recommend CPM for patients such as this patient. CPM is not considered experimental for this patients condition and is medically indicated for this patients condition. Therefore, I have determined the requested equipment is medically necessary. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 56-year-old male who had acute myocardial infarction with cardiac arrest and subsequent anoxic encephalopathy 18 months ago. The patient was treated with angioplasty and stent of the diagonal branch and placement of AICD. Cardiac echo and nuclear scan showed infarction of the anterior and lateral walls with EF of 20 to 25 percent. The patient is on eight medications to control hypertension and protect him from congestive heart failure. The patient has care provided mainly by his wife as he appears to function at the level of a six to eight-year-old as a result of his anoxic encephalopathy. The patients cardiologist recommends evaluation for cardiac transplant due to ischemic cardiac myopathy. The transplant cardiologist states that the patient is symptomatic enough to warrant evaluation for orthotopic heart transplant, but he had concerns regarding the patients neurologic status and peripheral vascular status (although the patient is asymptomatic for claudication).The Health Plan denied the request for the heart transplant evaluation based upon concerns over the patients ability to follow a structured medical regimen post transplant. The transplant cardiologist sates that he has concerns about the patients neurologic status but the transplant cardiologist did not state that the patient was not a candidate for a transplant. The evidence submitted demonstrates that clinically the patient is an appropriate candidate for a transplant evaluation. The patient has been on medical management for his ischemic cardiac myopathy of eight medications successfully and with the patients wifes assistance should be able to have a cardiac transplant evaluation. Based upon the results of this evaluation, it would be the transplant team to decide if the patient is a candidate for transplant. There is no evidence of any psychological or social contraindication such that the patient with the wifes assistance would be unable to follow a medical regimen post transplant.Based upon the information set forth above, I have determined the requested evaluation is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 25-year-old female who has a history of recurrent depression. She failed a trial of Lexapro and a stimulant but responded well to a six-week trial of Cymbalta. Her prescribing physician then gave her samples for another six weeks. The progress notes document that the patient responded to Cymbalta and is stable on this medication.  The patients request for authorization of Cymbalta was denied by the Health Plan based upon a determination that the medication is not medically necessary.Authorization of Cymbalta by the Health Plan requires a trial and failure of Effexor XR.  The patient has not tried Effexor XR, but has tried other medications that were not successful in treating her depression. Although Cymbalta and Effexor XR are similar in pharmacology, when individual patient variability is considered there is no guarantee the patient would have the same positive clinical response to Effexor XR.  At this point in time, it would not be medically appropriate to discontinue a medication that is successfully treating the patients depression.  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 six-year-old female with a history of expressive and receptive language deficits and a severe articulation disorder. Other diagnoses as stated include apraxia, auditory processing dysfunction, speech disorder and lack of coordination.  The patient has been receiving speech therapy for the above dysfunctions since July 2002. Her parents have requested retrospective coverage and reimbursement for speech therapy provided twice per week as well as on-going authorization at the same frequency.  The Health Plan denied the request based on a determination that the therapy at issue was/is not medically necessary.I have reviewed the literature regarding speech therapy in auditory processing disorders and apraxia of speech. The most apparent finding is that there is little consensus regarding the diagnoses of apraxia of speech or auditory processing disorder.  A study by Lewis, et al suggests that apraxia is associated with other learning disabilities (reading and writing deficits) and although the articulation disorder may improve somewhat, the functional deficits do not necessarily improve.  Likewise, the technical report produced by the American Speech-Language-Hearing Association (ASHA) indicates central auditory processing disorders (CAPD) are often associated with difficulties in learning, speech, language (including written language involving reading and writing), social, and related functions. Additionally, the report suggests that because both CAPD and learning disabilities are expressed in countless different ways, it is difficult to distinguish medically based treatment from an educational goal.  In this case, it appears that the most recent goals from the speech therapy progress report dated February 2006 are educational in nature, and not medically based.  Additionally, a review of the literature indicates there is no evidence to support the theory that intensive, or more frequent speech therapy is superior to the therapy provided in the educational setting.  I find no studies that even address the frequency of speech therapy intervention for these types of dysfunction.  Based upon the information set forth above, I have determined the therapy at issue was/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 33-year-old female that has undergone a series of surgeries to treat congenital absence of her breast. As she aged, her breasts became asymmetric. In May 2005, her surgeon performed open capsulotomy, left breast implant exchange, right breast augmentation and left nipple augmentation. These procedures were intended primarily to improve the appearance of the patients breasts rather than to treat a functional problem.  The patient was unhappy with the aesthetic appearance of her reconstructed breast. The patients breast asymmetry is the expected outcome of aging because a reconstructed breast ages differently from a normal breast.  Although the patient now has improved symmetry due to her recent breast surgery, her breasts will progressively become asymmetric again as she ages.  The Health Plan provided coverage for the original breast reconstruction. Revisions to treat the patients dissatisfaction with her breast appearance are not medically necessary. The records do not document that any of the procedures at issue were necessary to treat a functional problem or to maintain or improve health.  Therefore, I have determined the procedures 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 14-year-old female with an 18q chromosomal deletion and associated nystagmus, head tilt, tremors, and mild developmental delay.  She has been receiving speech and language therapy since 2002. An IEP is provided which documents she is receiving 60 minutes of speech therapy per session through school.  No speech therapy reports or testing from the school are provided to document gains, but the IEP team meeting report recommends continued speech therapy. The patient has also been receiving private speech and language therapy and her provider recommends continued treatment, but the frequency and duration are not specified.  The parents request for on-going speech therapy was denied by the Health Plan citing a lack of medical necessity. In evaluating the need for continuing speech therapy, a demonstration of functional gain is essential to a determination of medical necessity.  A review of the progress reports from the private speech therapy shows limited and inconsistent documentation of goals.  The long-term goals outlined in the January 2006 progress report are not reflected in the goals outlined in the May 2006 report. Thus, it is impossible to determine functional gains from these reports. Although the standardized testing indicates improved scores, the therapy reports do not demonstrate goals and/or functional gains that coordinate with the testing results.  Additionally, the patient is receiving appropriate speech therapy through the school system that is part of an overall educational plan. The added private therapy is a duplication of services. The patients condition is long-standing and involves developmental delay; a fully integrated plan is required to maximize academic success.  In most cases medically based therapy is provided due to an illness, injury of congenital abnormality and is meant to be restorative and of limited duration. In this case, the speech and language goals are long-term and better managed by the educational system.  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 67-year-old female who developed a wound infection following urgent colon surgery in April 2006.  Her wound healed by secondary intention, and photographs show a red, raised scar consistent with a recently healed wound. The patient is displeased with the scar and has requested authorization for scar revision surgery, which has been denied by the Health Plan.Review of the submitted clinical evidence demonstrates the proposed scar revision is not medically necessary. The patients general surgeon indicated in June 2006 that the patient was not having any functional problems with her scar. As recently as May 2006, the patient did not express any dissatisfaction or concerns regarding her scar. In the absence of a functional problem, scar revision is not medically necessary. Furthermore, the patients scar is only three months old. Most plastic surgeons recommend that a scar be allowed to mature for at least six months before proceeding with scar revision.  It is very likely that the quality and aesthetics of the scar will improve over time.For the reasons 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: Overturned Decision of Health Plan

 The patient is a 35-year-old woman who has had lymphedema of the left leg for several years. The pain and swelling secondary to the lymphedema interferes with daily activities including sleep and ambulation. The patient has tried conservative therapies including elevation and compression stockings since January 2006 or earlier without adequate relief. Her provider requests authorization for a course of manual lymph drainage therapy and wrapping; custom lymphedema compression garments will then be prescribed when the limb diameter is sufficiently reduced. The Health Plan has denied authorization for the requested therapy on the basis that it is not medically necessary.Generally accepted first-line treatments for lymphedema that interferes with activities of daily living include elevation and static compression (gradient compression stockings).  A Reid Sleeve, which has been suggested by the Health Plan, is substantially equivalent to a gradient compression stocking. Accepted second-line therapies after failure of elevation and compression include manual lymph drainage therapy.  Often, a course of manual lymph drainage therapy can achieve enough reduction of limb size to allow application of a custom compression garment, which maintains the reduced size of the limb. Third-line therapies include pneumatic compression devices.  The provider has adequately documented that this patients symptoms interfere with her activities of daily living. The documentation also shows that the patient has used compression stockings for over four months. This is generally accepted as an adequate trial of compression therapy.  Therefore, a course of manual lymph drainage therapy is appropriate and medically indicated.Based upon the information set forth above, 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: Overturned Decision of Health Plan

This patient is a 36-year-old man with metastatic malignant insulinoma with symptomatic hypoglycemia. He has requested authorization and coverage for Sandosatin LAR, a long-acting analog of the hormone somatostatin.His endocrinologist began him on a course of the short-acting Sandosatin when his cancer recurred postoperatively with good results. Both the short and long-term analogs have been shown over the past few years to be effective in a variety of pancreatic neuroendocrine tumors including metastatic insulinomas.The use of the somatotropin analogs such as Sandosatin and the longer acting Sandosatin LAR for the treatment of symptomatic gastroenteropancreatic neuroendocrine cancer is well established. These drugs can reduce symptoms of hypoglycemia and may even cause tumor shrinkage in otherwise incurable metastatic insulinomas. A comprehensive literature review published in January 2005 found more than 200 manuscripts published over the preceding one and half years on the use of somatotropin analogs in metastatic gut tumors, including insulinomas. The patient was shown to respond to the short-acting analog, Sandosatin. Both the article by Vinik and another series support the use of Sandosatin LAR in the treatment of gastroenteropancreatic neuroendocrine tumors. This preparation has been used for years in the community both for primary treatment of the severe hypoglycemia suffered by these patients as well as postoperatively if the tumor recurs as it has in this patient. The short-acting preparation has already proven to be effective in this particular patient. Sandosatin LAR is considered standard of care by endocrinologists in this clinical setting and should be authorized.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: Overturned Decision of Health Plan

The patient is a 45-year-old man who has psoriasis of the trunk and extremities, which his dermatologist describes as severely disabling. The ineffective therapeutic attempts include topical corticosteroids, phototherapy, sunlight and over the counter medications. Clinically, excellent improvement was achieved with Excimer laser treatment two to three times a week. At issue is whether the laser treatments were medically necessary.The submitted clinical information includes notes from the patients treating dermatologist documenting the effectiveness of Excimer laser therapy for this patient. The references provided document the efficacy and safety of the treatment, as well as its mechanism. Excimer laser is approved by the FDA for the treatment of psoriasis and is considered an appropriate choice for treatment of the condition. The laser therapy the patient received was medically indicated and clinically effective. Accordingly, I have determined the therapy at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.