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

The patient is a 28-year-old female with fibromyalgia, depression and degenerative joint disease (DJD). She has been treated with Provigil for years and reports a positive response. She has no documented history of obstructive sleep apnea, narcolepsy or shift work sleep disorder. She is presently treated with Effexor and Wellbutrin for her depression.  The patients request for Provigil was denied by the Health Plan based upon a determination that the medication is not medically necessary.Provigil was initially prescribed by the patients psychiatrist to serve as a stimulant in conjunction with her anti-depressant therapy. Such use does not fall within the FDA-approved indications for the drug (obstructive sleep apnea, narcolepsy or shift work sleep disorder). Furthermore, there are no peer-reviewed studies advocating the use of Provigil for the treatment of fibromyalgia. Although a few small studies showed a short-term positive effect, no long-term outcome data is available. The use of Provigil in the treatment of fibromyalgia is purely for the stimulant effect. The patient is presently receiving standard therapies such as pain relievers, muscle relaxants, and antidepressants to treat her condition. Provigil is not a standard therapy and should only be considered when commonly prescribed treatments have failed and there is a progression of symptoms. Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old female with Bipolar Disorder, Type II, who is currently treated with Wellbutrin, Xanax, and Ambien CR.  The Ambien was prescribed due to difficulty with sleep continuity and the patient found this medication more useful than the previously prescribed Rozerem.  A review of the patients medication log for the past two years shows her to have received other antidepressants such as Cymbalta and Lexapro, either alone or in combination with Wellbutrin. Topamax was also prescribed, presumably as a mood stabilizer.  The patients sleep reportedly did not improve with medications such as Seroquel due to unspecified side effects. In January 2006 the patients provider documented that the patient was sleeping better with Ambien CR, 25mg, but that she still has some ups and downs. The patient is now requesting authorization for Ambien CR at a dosage of 25mg nightly.  The Health Plan issued a denial based upon a determination that the requested medication dosage is not medically necessary.The approach taken in treating the patients Bipolar Disorder, Type II, is unique in that conventional mood stabilizers have only been prescribed on a limited basis and the patient is apparently maintained on concurrently prescribed antidepressants. A sleep continuity disturbance could certainly be understood in that context.  Treatment with Ambien or other soporific agents is not the typical treatment approach for discontinuity of sleep as a component of a Bipolar Disorder. Therefore, I have determined the requested medication dosage 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 32-year-old female who has the typical symptoms of macromastia and no known comorbidities.  She has been evaluated by her primary care physician (PCP), and his office notes document symptoms since October 2005, though the patient describes progressively worsening symptoms for two years. Strengthening and weight loss have not improved her condition. Her bra size is reported as 36G, and photographs show deep bra strap grooving.  The patient has requested authorization and coverage for a plastic surgery consultation for consideration of bilateral reduction mammoplasty. The Health Plan has denied her request citing a lack of medical necessity.Evaluation for a breast reduction is medically necessary for this patient. Her complaints of shoulder, neck and back pain and bra strap grooving are typical for this diagnosis.  Photographs confirm deep bra strap grooves. Her symptoms have not improved with exercise and weight loss, which is not surprising, as symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. As the authors of the Collins and Kerrigan paper conclude, non-operative treatments are unlikely to improve her pain, and surgery provides the only bona fide chance for symptomatic relief. This patient requires evaluation for a breast reduction. Her PCP has examined her, ordered appropriate x-rays and ruled out any comorbid conditions.  Plastic surgeons are the specialists with the most knowledge and experience in treating macromastia.  A trial of conservative therapy is not warranted based on the medical literature, which contains no studies that show that conservative therapy is of any value for this condition. Therefore, I have determined the requested consultation is 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 34-year-old female with an estimated delivery date of August 2006. She received genetic counseling and an amniocentesis was performed due to the patients concerns regarding the risk of fetal Downs Syndrome secondary to maternal and paternal age (the husband is 36 years old). By report, the patient carries the trait for alpha-thalessemia and she also has concerns secondary to limited teratogen exposure during this pregnancy and sporadic miscarriages in her family. The patient is requesting reimbursement for genetic counseling and amniocentesis. The Health Plan does not consider these services medically necessary and has denied coverage.This case involves the medical necessity of amniocentesis and genetic counseling in a patient less than 35 years old. A review of the Health Plans authorization policies for amniocentesis reveals that they are clearly written and in accord with the current standard of care.  Although the patient indicates there are other mitigating factors, these factors are not germane to the issue of amniocentesis and the procedure was not medically necessary. However, genetic counseling is an appropriate intervention to address the patients concerns and should be covered by the Health Plan.  Therefore, I have determined that one of the services at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 59-year-old female who weighs 201 pounds and has a BMI of 39.3. The comorbid conditions reported included hyperlipidemia, hypertension and depression. The patient indicates that she has tried supervised and unsupervised weight loss programs and medications but has not achieved a sustained weight loss.  The patient has requested authorization for a laparoscopic Roux-en-Y gastric bypass. The Health Plan denied her request based upon a determination that the procedure is not medically necessary.With a BMI of 39.3 and comorbid conditions such as hypertension, hyperlipidemia, and depression, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese.  The psychological evaluation indicates the patient is an appropriate candidate for the surgery.Based upon the information set forth above, I have determined the requested procedure 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 nine-year-old male with a complex presentation that includes an above average IQ and the diagnoses of bipolar disorder and ADHD.  He could not be managed in his public school and was hospitalized in the acute setting prior to the admission to the Partial Hospitalization Program (PHP).  His parents are involved in a custody dispute and interactions with the father may have been curtailed.  The Health Plan terminated care at the PHP level in Arpil 2006. The patients mother has requested reimbursement and continuing authorization and coverage for the PHP services.  Her request was denied by the Health Plan based upon a determination that the services at issue were/are not medically necessary.The diagnosis of ADHD along with a bipolar disorder in a nine-year-old child is unusual and the record provided for review clearly documents the need for the PHP level of care. That criteria includes: The need to closely monitor and regulate medications on a daily basis; the need to establish coordination of care and to find the appropriate level of care in the community; the need to coordinate services with the local school district and to transfer funding via the IEP for either the continuation of PHP or the transfer to a program nearer the residence of the patient. Additionally, the situation between the mother and the father places this patient in the middle of the conflict. It is in the best interest of the patient to receive a clear message concerning his ability to communicate with his father. If the court has determined that the communication with his father is prohibited, this communication must stop. If the mother does not have the supportive documentation to prohibit communication, the father must be involved with the treatment and therapy.Due to the complexity of medication management and the need for well-coordinated care, PHP should be continued through April 2006.  This should meet the needs of the patient and allow the program to address the coordination of care issues, find an appropriate step-down placement and stabilize the pharmacological management.  Therefore, I have determined the services at issue were/are 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 68-year-old female who is in need of a screening colonoscopy. Because of her previous bad experience during a flexible sigmoidoscopy, she is requesting authorization for MAC anesthesia during the colonoscopy.  The Health Plan denied her request based upon a determination that the requested services are not medically necessary.There is no objective medical indication for MAC anesthesia documented in the record provided for review. It does not appear that the patient has ever had a colonoscopy or had a bad experience with a colonoscopy where conscious sedation was used. The use of anesthesia during a colonoscopy is not the standard of care.  Therefore, 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: Upheld Decision of Health Plan

The patient is a 68-year-old male who had a cerebral vascular accident (CVA) in 1995.  He currently weighs 450 pounds and has problems with sleep apnea, osteoarthritis and poor balance. The patient has been using a standard hospital bed and claims that the bed requires frequent mechanical repairs and does not provide adequate support. The patients request for authorization and coverage of a bariatric hospital bed was denied by the Health Plan based upon a determination that the equipment is not medically necessary.There is no information in the medical record provided indicating the medical need for a hospital bed. There is no documented evidence that the patient requires special positioning or frequent repositioning which necessitate the features of a bariatric hospital bed.  It appears that this bed has been requested for the patients convenience.  Therefore, I have determined the requested equipment is not medically necessary for 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 22-year-old obese female with gallstones and generalized abdominal pain in the upper and lower abdomen. There is no clear documentation of her pain characteristics or of the pain in relation to eating. The patient is a candidate for bariatric surgery and is on a waiting list for the procedure. Based on the evidence provided, there has been no further workup of her pain except for one general surgical consultation, which indicated possible irritable bowel syndrome. A second opinion consultation was scheduled, but the appointment was not kept. The submitted records do not show elevation of her alkaline phosphatase or bilirubin levels. There is no evidence of a HIDA scan and no documentation to indicate acute cholecystitis.The patient has requested authorization and coverage for a cholecystectomy. The Health Plan has denied this request on the basis that the procedure is not medically necessary at this time.Based on the findings above, there is insufficient evidence that the patient has symptomatic gallstones warranting surgical intervention at this time. Furthermore, since the patient is planning to undergo weight loss surgery, it would be preferable to wait until the bariatric procedure to undergo removal of the gallbladder in order to avoid an additional operation and the adhesions that could complicate the primary bariatric procedure. Given the limited information available regarding the patients symptomatology, she should undergo a second opinion consultation including a HIDA scan. There is insufficient evidence demonstrating that a cholecystectomy is medically warranted at this 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 61-year-old male with hepatitis C.  He was treated with Pegasys and ribavirin for one year and has since relapsed. The patients provider has requested authorization for retreatment with Infergen and ribavirin. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.Infergen has been approved by the FDA and is specifically indicated for the treatment of patients who have not responded to pegylated interferon therapy. This patient was compliant with the prescribed pegylated formulation treatment and has now relapsed as demonstrated by a viral load of 4,649,000 IU/ml. At this point, it is reasonable to proceed with Infergen 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: Overturned Decision of Health Plan

The patient is a 46-year-old female with a long history of migraine headaches with some cervicalgia. She has tried and failed with multiple abortive and prophylactic medications as well as alternative therapies. She has responded well to Botox therapy and wishes to continue.  The patient has requested reimbursement and authorization for future Botox therapy.  The Health Plan denied her request based upon a determination that the therapy was/is not medically necessary.Treatment with Botox injections is an accepted therapy for patients that have tried and failed conventional medical management. The therapy is no longer experimental or investigational and there is a significant body of evidence to support its use. This patient had a good response to the therapy as documented by the decrease in her use of triptan medications.  It is appropriate for the patient to continue with the Botox injections at a frequency of every three to four months for as long as the therapy is efficacious.Based upon the information set forth above, I have determined the therapy at issue was/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 56-year-old male with mixed hyperlipidemia, glucose intolerance and obesity.  Meridia was prescribed for weight loss in January 2006. At that time, the patient was 511 tall and weighed 240 pounds with a calculated body mass index (BMI) of 33.5. The patient paid out of pocket for Meridia, and lost 11 pounds after taking the medication for approximately six weeks. His request for reimbursement and continuing authorization of Meridia was denied by the Health Plan based upon a determination that the medication is not medically necessary.The medical records provided do not demonstrate that the patient has a BMI greater than 35 as indicated in the criteria for the usage of Meridia. His associated comorbidities are conditions that will affect his general health and well-being, but do not necessitate the use of Meridia. Therefore, I have determined the medication 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: Overturned Decision of Health Plan

The patient is a 56-year-old male with diabetes mellitus type 2.  He is presently well controlled on metformin, glyburide, pioglitazone (Actos), and exenatide (Byetta). According to the records, the patients hemoglobin A1c was 9.0% on metformin, a sulfonylurea, a thiazolidinedione and insulin.  He discontinued the sulfonylurea and the insulin and began taking Byetta.  As a result, his hemoglobin A1c dropped to 6.4%.  The patients request for authorization of Byetta was denied by the Health Plan based upon a determination that it was not medically necessary for treatment of his type 2 diabetes.Patients who are not well controlled on oral agents generally progress to insulin therapy.  Byetta is at least as effective as insulin in improving blood glucose control. Byetta is indicated as adjunctive therapy to improve glycemic control in patients who are taking metformin, a sulfonylurea, or both, but have not achieved adequate blood glucose control. As an added benefit, treatment with Byetta is associated with weight loss as opposed to insulin, where treatment frequently causes further weight gain.This patient was not well controlled on multiple medications as demonstrated by a hemoglobin A1c of 9%.  When Byetta was added to these agents, the patients blood glucose values dramatically improved and his hemoglobin A1c decreased to 6.4%.  The improvement in the patients blood glucose control demonstrates the medical necessity of Byetta in this case. 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 43-year-old male who was initially admitted for detoxification in January 2006 and was transferred to the residential treatment program in January 2006.  Notes from his admission assessment indicate he was in good health, was able to work with the problem (alcoholism), and had no physical disabilities. It was also noted that his family was supportive and he was motivated.  He had not developed a tolerance for alcohol and stated he was able to manage the problems of day-to-day life.  The patient had only one prior treatment for alcohol dependence dating back to 1994.  The patient is requesting reimbursement for residential treatment services provided in January 2006.  The Health Plan has denied his request based on a determination that those services were not medically necessary.Based on the ASAM criteria, services in either an Intensive Outpatient Program (IOP) or Partial Hospitalization Program (PHP) would have been most appropriate for this patient.  He had no significant symptoms of withdrawal, was motivated to receive treatment and had good family support.  The literature does not support the use of this level of care in preference to an IOP or PHP.  Further, the use of the IOP or PHP format would potentially have allowed the individual a longer episode of care and better facilitated his integration into a program of daily sobriety.  There were no indications that alternative approaches for the treatment of his alcoholism were tried, including the use of medications to treat the craving for alcohol that he described.  Based upon the information set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old female status post gastric bypass in November 2004 for morbid obesity. Her weight decreased from 306 pounds to 177 pounds. She has numerous complaints referencing problems of skin irritation, rashes, yeast or bacterial infections, hygiene, back pain, neck pain, shoulder pain, lifting over ten pounds, and standing for prolonged periods. The skin issues are reportedly caused by trapped moisture in the patients skin folds present from the massive weight loss she accomplished following her gastric bypass surgery. The patients request for authorization of abdominoplasty was denied by the Health Plan based upon a determination that the procedure is not medically necessary.A letter from one of the patients providers dated January 2006 notes chafing and discomfort in the abdominal area and recommends reconstructive surgery for the abdomen and legs. There are no corresponding clinical notes from any of her providers that fully document this condition. Chafing, irritation and discomfort are not indications for panniculectomy or abdominoplasty without further notes and documentation of the severity of symptoms, chronicity of treatment, and attempts and failures of treatment. There is insufficient medical information documenting the patients complaints to support the need for an abdominoplasty in this case. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 71-year-old female who sustained a spinal cord injury approximately four years ago and now has central pain syndrome. Standard pain medications have either failed to provide relief or caused intolerable side effects. Her pain is currently managed with transdermal fentanyl and Actiq for breakthrough pain. Her request for authorization of the Actiq was denied by the Health Plan based upon a determination that the medication is not medically necessary.Actiq is currently approved by the FDA for the management of cancer-related breakthrough pain. The medication has not been approved for the management of central pain syndrome.  The use of Actiq in this context is not medically indicated and is not consistent with the community standard of care. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.