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

This patient is a 41-year-old female who has idiopathic thrombocytopenia purpura (ITP). She typically has a platelet count of 50,000 to 65,000 and is appropriately not chronically on therapy. The patient is scheduled for an oophorectomy and her surgeon believes she needs a higher platelet count for the surgery. The patients provider has submitted a request for preoperative treatment with IVIG. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.The patient needs treatment for her ITP prior to surgery to increase her platelet count. In all likelihood, she would not be medically cleared for the operation with a platelet count in the range that is typical for her. IVIG generally works well for the treatment of ITP and would be expected to increase the patients platelet count to a safer level. The Health Plans requirement of a platelet count below 50,000 before IVIG is authorized does not take into account a preoperative situation such as this one. The administration of IVIG to increase the platelet count of a surgical patient with ITP is common practice and consistent with the standard of care. 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: Upheld Decision of Health Plan

The patient is a 16-year-old female who has a history of oppositional/defiant behaviors manifested by truancy from school, verbal altercations with her mother and aunt and running away from home for a period of three weeks. She started outpatient psychotherapy and was prescribed Zoloft but had reportedly refused to take the medication and stopped seeing the psychiatrist. The patient also had a history of smoking marijuana and drinking alcohol. There was a report of some self-mutilation, but no evidence of psychotic behavior or suicidal ideation prior to admission to the residential treatment facility that utilized a 12-step program. Her admission diagnoses included major depressive disorder with polysubstance abuse and oppositional/defiant disorder (ODD).  The patients mother has requested reimbursement for residential treatment services provided from August 2006 through September 2006. The Health Plan denied her request based upon a determination that admission to residential treatment was not medically necessary.A review of the clinical record for dates of service August 2006 through September 2006 reveals no manifestation of self-destructive behaviors such as self-mutilation or suicidal ideation nor did the patient manifest behaviors suggestive of a thought disorder. The patient was diagnosed with a major depressive disorder and there was a psychiatric consultation suggesting a possible bipolar disorder with borderline features. There was no documentation of weekly, face-to-face psychiatric sessions. The therapy sessions and discharge summary were conducted by a Masters prepared therapist. The primary modalities of treatment were generic and utilized the 12-step group model. The patient did receive individual therapy sessions which provided an opportunity for personal disclosure of sexual identity issues and anger and resistance about a proposed family move and having to leave friends behind. The patients mother missed many of the parenting classes but did come to several family therapy sessions.  The documentation provided indicates the patient did not meet standard criteria for admission to a residential treatment program with a primary focus on substance abuse rehabilitation. The primary issues with the patient were related to her sexual identity, her depression and her relationship with her mother. Additional concerns regarding the possible diagnosis of a bipolar disorder were raised, but not adequately addressed during her inpatient stay. The patient did not require 24-hour nursing supervision and an intensive outpatient program with a focus on the interaction of the patient and her mother would have been more appropriate.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 43-year-old female with a five-year history of Type II Diabetes Mellitus who is noted to also have hypertension and obesity. Her blood glucose levels have been well controlled on metformin and Amaryl. The patients hemoglobin A1c was 6.1% prior to beginning Byetta in August 2006. The Byetta was apparently added to her diabetic regimen to help her to lose weight. Over the course of a month the patient lost seven pounds and regained three pounds with a dosage of 5mcg per day of Byetta. The patients endocrinologist would now like to increase the dosage to 10mcg daily. The patients request for authorization of Byetta was denied by the Health Plan based upon a determination that the medication is not medically necessary.This patients blood glucose levels are well controlled on a combination of metformin and Amaryl. Byetta was apparently begun to help the patient to lose weight. Byetta is not medically indicated for blood glucose management for this patient with a hemoglobin A1c of 6.1% and is not generally prescribed solely to assist with weight loss. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 28-year-old female with an apparent diagnosis of bipolar disorder. Her current medications include Risperdal, Effexor, Trileptal, Lamictal and Ambien. She has requested coverage for Provigil for daytime sedation. She reports that she has had good results with the use of Provigil to date. The Health Plan has denied coverage for Provigil citing a lack of medical necessity.The patient reports experiencing daytime fatigue, some of which may be attributable to her current medications, which can produce sedation. Of note, is her use of Ambien for treatment of insomnia. This drug can contribute to daytime fatigue when used on a regular basis. The use of Provigil to counteract the side effects of other medications is not within the standard of care. 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: Upheld Decision of Health Plan

The patient is a 45 year-old male who is status post anterior cruciate ligament (ACL) reconstruction in April 2006 for a torn ligament and medial meniscus. The record indicates he progressed well with physical therapy, but a knee brace was recommended for more demanding physical activities such as sports, yard work and occasional job requirements. The enrollee submitted a request for authorization of a custom knee brace. The Health Plan denied his request based upon a determination that the equipment is not medically necessary.According to the records provided for review, the patient had a non-complicated ACL reconstruction with no evidence of postoperative instability. The physical therapy note of June 2006 did not document symptoms such as his knee giving way or weakness with jogging, high knee stepping, quick reversals or side shuffle. Additionally, it would appear the brace was prescribed primarily for sports activities. There is no evidence in the peer-reviewed clinical literature that prophylactic bracing prevents re-injury in an otherwise stable postoperative knee.Based upon the information set forth above, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old woman who reports a six-year history of gastrointestinal problems. She states that she became ill in December 2000 after eating watercress and drinking water from a stream. She reports multiple problems including irritable bowel syndrome, constipation, gas and abdominal bloating. The patient also experiences extreme fatigue, concentration problems, and short-term memory loss. She wishes to undergo further workup with an Intestinal Permeability and Comprehensive Digestive Stool Analysis. The Health Plan indicates the proposed testing is not medically necessary for evaluation of the patients condition.The Health Plans denial is correct. The patient has vague and generalized symptoms. It appears she has undergone a thorough workup with evaluations by multiple specialists. The use of the proposed intestinal permeability test in this patient is not within the community standard of care. The requested testing is not likely to add clinically useful information for the care and management of this patient. Therefore, I have determined the requested testing is not medically necessary for evaluation 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 who underwent left unicompartmental knee replacement in June 2005 due to medial compartment degenerative joint disease. She began using the continuous passive motion (CPM) machine in the immediate postoperative period, as prescribed by her orthopedic surgeon, to assist with her rehabilitation. She is now requesting reimbursement for the rental cost of the device. The Health Plan denied her request based upon their determination that the CPM machine was not medically necessary following the patients partial knee replacement surgery. A CPM device is the standard of care for postoperative rehabilitation following knee replacement. Patient compliance is high and many surgeons find that patients regain their range of motion faster and have better pain control with the device. Regardless of whether the patient underwent total or unicompartmental knee replacement, immediate mobilization of the joint is imperative. Therefore, I have determined the device 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

The patient is a 41-year-old man who saw his physician for painful, swollen toes secondary to thickened, crumbling toenails. The physicians diagnosis was onychomycosis. The Health Plan denied coverage for Lamisil. A fungus culture grew out coagulase-negative staph and no fungus. Liver function tests were normal. The condition worsened to the extent that the patients mobility was impaired. The patient then took Lamisil tablets for 180 days. During the course of the treatment, the nails improved, the pain and swelling disappeared, and the patients mobility was no longer impaired.The submitted clinical information is sufficient to support the diagnosis of onychomycosis. A toenail condition such as this patients with irregular crumbling and thickening and resultant painful swelling of the toe does not improve on its own. The condition worsened until the patient underwent treatment with Lamisil, at which time his symptoms improved dramatically. A negative fungus culture does not rule out a fungus infection, especially in light of the compelling clinical information presented in this case. The presence of staph in a fungus culture can mask the presence of fungus. Given the evidence provided, Lamisil was the only medication that was likely to be effective for this patient and as such, was medically warranted.For the reasons set forth above, I have determined the medication 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

The patient is a 28-year-old male who had a cerebral hemorrhage due to a ruptured AVM at the age eight years, which left him with a left hemiplegia. He has been receiving Botox injections since 1995 for left upper extremity spasticity, with a positive outcome. The patient continues to have left arm and hand spasticity and has requested authorization for continued Botox therapy. The Health Plan denied his request based upon a determination that the therapy is not medically necessary.The patient has a 10-year record of improvement in his splasticity with the application of Botox injections. With established efficacy, Botox therapy is the standard of care for the treatment of upper extremity splasticity and is a covered Medicare benefit. The Health Plan recognizes that Botox may be medically indicated for the treatment of spastic hemiplegia due to hereditary, degenerative or demylinating diseases of the central nervous system and the plan specifically covers Botox injections for the treatment of  spastic hemiparesis that occurs with cerebral palsy. Spastic hemiparesis related to intracranial hemorrhage in a child is not substantially different from those conditions for which the medical necessity of Botox injections is acknowledged by the Health Plan.  The treatment has clearly provided a benefit and continued treatment is consistent with the standard of care within the neurological community. As such, 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 67-year-old female with asthma and sinusitis with elevated IgE. She has been stable without prednisone burst or hospitalization. She is on three medications for asthma (fluticasone, salmeterol and montelukast). The submitted records indicate that in December 2005 the patient had normal flow volume loop and mild obstructive disease despite lack of compliance with Advair. As of July 2006 the patients spirometry continues to be stable. It does not appear she has had recent skin testing or RAST demonstrating that she is still allergic/atopic. Since the patient has had immumotherapy since her previous skin test, she may no longer have those sensitivities. The patients provider has recommended that the patient begin treatment with Xolair. The Health Plan has denied authorization for the requested medication on the basis that is not medically necessary in this setting.The submitted clinical information does not demonstrate that Xolair is medically necessary for this patient. She is a moderate asthmatic. Spirometry findings were normal to mild obstructive disease. Based on these findings and the submitted office notes, the patient has been well controlled with a high IgE level. Her IgE level is higher than the Food and Drug Administrations recommended level for Xolair treatment. As such, 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 an 18-year-old female with the reported onset of eating disorder behaviors at the age of 14. She was diagnosed with bulimia nervosa and described as having a bad body image with binging and purging behaviors once per day during her most acute period. The record indicates she had not been binging or purging with any regularity since her discharge from the intensive inpatient program in October 2004. The patient did admit to urges to restrict her intake approximately three times per week, however she denied over-exercising, using laxatives or diuretics or water loading. Her admission weight was 139.8 pounds in February 2005; her estimated ideal body weight being between 134 and 142 pounds.  The patients treatment course was generally unremarkable, and she received Prozac 40mg per day in addition to a variety of therapies. The patients discharge weight was 139.2 pounds. The patients parent has requested reimbursement for residential treatment services provided from March 2005 through April 2006. The Health Plan denied the request based upon a determination that the services were not medically necessary.The progress notes indicate the patient was compliant with her treatment program despite some irritability and a somewhat challenging attitude. She was not actively binging and purging either before or during her residential treatment stay, and her weight was entirely stable.  There is nothing in the clinical record to indicate that her condition warranted a level of care with 24-hour supervision beyond March 2005. 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

This patient is a 44-year-old woman, gravida 3, para 2, with secondary infertility. Her last pregnancy resulted in a spontaneous loss in the spring of 2004, and she and her partner have apparently had unprotected intercourse since that time without conceiving. The patient has regular menstrual cycles, which is consistent with normal ovulation, and there is nothing in her history to suggest ovulatory dysfunction per se. Her evaluation to date includes a battery of hormonal studies obtained in May 2006, presumably on day two or three of her menstrual cycle. All of these studies were normal, including relatively reassuring FSH (7.3) and estradiol values (29.2). In addition, a hysterosalpingogram was normal in May 2006. The patient also underwent formal genetic counseling in March 2006, at which point the impact of her age on fetal chromosomal abnormalities was reviewed along with other topics. Based upon the record, it does not appear that semen analysis has been obtained.The patients request for treatment to address her infertility was denied by the Health Plan based upon a determination that the therapy is not medically necessary.I would consider the patients infertility to be unexplained aside from her age, assuming her partners semen analysis is relatively normal. Injectable fertility drugs combined with intrauterine inseminations (IUI) can be used successfully to treat women with unexplained infertility, increasing the chances of pregnancy each month by a factor of two or three. In this situation about half the benefit derives from the drugs and about half from the IUI. The patients baseline chances of conceiving a viable pregnancy any one month are almost certainly less than 1%, because of her age. Thus the expected benefit for her from such treatment would be very low. For example, her chances of conceiving a viable pregnancy might rise from 0.3 or 0.5% to 1% or 1.5%. In contrast, her chances of a live birth following donor oocyte invitro fertilization (IVF) treatment, as recommended by the Plan providers, would probably be 50% or higher. I have assumed the patient does not have coverage for this alternative.The portion of the Evidence of Coverage submitted by the Health Plan includes a description of covered infertility services. There is no explicit age cutoff given for the female partner. As such, if her partner has a reasonably normal semen analysis, then I believe there is no basis for the denial, despite the very low chances for success. With normal day two/three FSH and estradiol levels, a total of three combined gonadotropin/IUI treatment cycles would be reasonable. Such treatment would be medically necessary from the standpoint of increasing her chances of pregnancy above what they would be without treatment. Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition pending the partners sperm analysis. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old male who underwent surgical resection of a recurrent acoustic neuroma in 2001. Subsequent postoperative MRI scans showed residual tumor within the right cerebellopontine angle. The most recent MRI from September 2004 showed a stable appearance of the residual right acoustic neuroma. The patients current request for a surveillance scan was denied by the Health Plan based upon a determination that the MRI is not medically necessary.Close medical monitoring with serial MRI studies of a patient with recurrent acoustic neuroma and two previous surgeries is medically reasonable. The Milliman criteria for follow up of an acoustic neuroma cited by the Health Plan applies to patients who have either undergone radiosurgery or have not had surgery at all. This patient does not fall into either of these categories. While there is no fixed interval for surveillance MRI for patients such as this one, Dr. Timothy Hain advocates for three to six MRI scans over a period of five years. As 2006 marks five years following the patients last surgery, it is medically appropriate to perform an MRI scan at this time. Therefore, I have determined the requested diagnostic procedure 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 42-year-old female with papular acne and rosacea. She had been treated previously with Plexion cleanser and Metrolotion. When Retin-A Micro 0.04% was added to her treatment program, the rosacea is reported to have improved considerably. The patients request for authorization of Retin-A Micro 0.04% was denied by the Health Plan based upon a determination that the medication is not medically necessary.Retin-A Micro is widely prescribed by dermatologists for the treatment of acne rosacea. Several studies have been conducted and the efficacy of treatment for patients such as this one is well documented. In fact, many standard textbooks of dermatology recommend this treatment. There is no question that Retin-A Micro has been beneficial for the patient and its continued use is medically appropriate. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.