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

The patient is a 72-year-old male with a 40-year history of bipolar disorder, type I, referred to partial hospitalization in January 2004 due to persistent depression over a two month period, with decreased energy, increased anxiety, poor sleep with early morning awakening, ruminating, and fleeting suicidal ideation without intent.  The patient had been previously treated with Depakote and Lamictal, with little benefit, hence this regimen was eventually eliminated and Lithium begun. Despite a high-therapeutic level of 1.1 he remained depressed, hence Lexapro was begun and titrated up to 10 mg daily. The patient also suffered from coronary vascular disease and was told by his physician to no longer lift items.  He found this to be yet another significant stress. In an effort to better help the patient structure his time, he was referred to volunteer work, which he initially approached reluctantly.Given the severity of the patients illness, bipolar disorder, type I, his age, and the stressors with which he is coping, and the persistence of his depression, partial hospitalization was indicated for this patient. Though he did respond somewhat to the Lithium and secondary to Lexapro, his robust was not especially robust. Even the note of January 2005 points to his depression as fairly pronounced. Given the potentially more complicated course of treatment for elderly patients with bipolar disorder, more, not less, extensive services are often indicated. In this instance the records demonstrate it was appropriate and necessary for the patient to continue to receive partial hospitalization until January 2005. Therefore, I have determined the services at issue were 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 17-year-old female who has been reported to have severe skeletal class III malocclusion with impacted maxillary canines. She has been evaluated by an oral and maxillofacial surgeon and orthognathic surgery has been recommended. The Health Plan has denied coverage for the requested procedure as not medically necessary.The Health Plans denial should be upheld. The letter submitted by the patients orthodontist and the panorex x-ray do not demonstrate the patient meets medically necessity criteria for the requested procedure. Furthermore, the submitted records do not document a functional deficit. Moreover, the degree of skeletal deformity and the secondary dental malocclusion are not documented by lateral skull x-rays, cephalometric analysis, models, and/or photographs. Based upon the information provided, medical necessity for the requested procedure has not been established. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 50-year-old female with a history of hypertension, gastroesophageal reflux disease (GERD), allergic rhinitis and chronic sinusitis. She has been maintained on Atacand HCT and Toprol XL for blood pressure control since 2002. There is no documentation indicating treatment with any ACE inhibitor prior to therapy with Atacand HCT. The Health Plan has denied coverage for Atacand HCT.The Health Plans denial should be upheld. There is no medical necessity for treatment with Atacand HCT at this time. The patient has not been tried on an ACE inhibitor and has no known contraindications to ACE inhibitors. Nationally accepted guidelines demonstrate ACE inhibitor therapy is appropriate therapy for the patients hypertension. In addition, records do not demonstrate the patient requires treatment with an angiotensin receptor blocker at this time. Furthermore, the Health Plan indicates if the patient is unable to tolerate treatment with an ACE inhibitor or treatment is ineffective, there are angiotensin receptor blockers other than Atacand HCT available to treat the patients condition. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 27-year-old female who is scheduled for bilateral calcaneal osteotomies with bunion correction. Her provider has requested authorization for a 24-hour inpatient admission. The Health Plan has denied this request on the basis of medical necessity.The request for an overnight hospital stay is medically appropriate. The proposed procedures are known to be associated with significant pain. The patients postoperative pain will not be adequately controlled with oral medication  she will need intravenous administration of intramuscular pain medications for the first 24 hours. Furthermore, the patient must be non-weight bearing following the procedure. Moreover, an overnight stay following such a procedure is within standard of care. For these reasons, I have determined the requested services are 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 46-year-old female with documented low immunoglobulin levels who has received intravenous immunoglobulin (IVIG) since 1999. The Health Plan has denied reimbursement for the IVIG therapy the patient received from June 2003 to October 2004. The primary issue in this matter is whether the observed low immunoglobulin levels in this patient represent a primary abnormality of immunoglobulins or a secondary change resulting from steroid therapy the patient received for treatment of asthma. The Health Plan is correct that steroid therapy depresses IgG levels. This patients immunoglobulin levels were obtained at times when the patient was receiving large doses of steroids.Based upon the information set forth above, I have determined the therapy 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 15-year-old male with an apparent diagnosis of attention deficit hyperactivity disorder (ADHD). He had been treated with Strattera, recently at 40mg per day, with improvement noted by his parents. The Health Plan formulary approves methylphenidate and amphetamine as first-line therapy. However, the patients parent prefers Strattera due to side effects of formulary-approved medications. At issue is whether Strattera is medically necessary for treatment of the patients condition.Based on the records provided, Strattera is not medically necessary as a first-line therapy for this patient. Trials of formulary drugs should be tried. If the formulary alternatives are found unacceptable for medical reasons, thenother medications such as Strattera should be considered. Absent a trial of the formulary alternatives, use of Strattera is not medically warranted. Therefore, I have determined that 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 50-year-old male who has quadriplegia. He has requested coverage for a shower/commode wheelchair. The Health Plan has denied this request indicating the requested equipment is not medically necessary.Review of the information provided does not demonstrate the requested equipment is medically necessary. Though the patient indicates he needs a commode chair for digital stimulation it is not clear how the commode chair facilitates this. The Health Plan indicates the patient has been offered a standard commode chair that is non-mobile. Based upon the information provided, there is insufficient evidence a mobile shower/commode wheelchair is medically necessary for the patient. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 48-year-old male who is seeking authorization for the medication Celebrex. The Health Plan has denied this request and recommended the patient proceed with trials of formulary alternatives.The Health Plans denial should be overturned. A review of the information submitted demonstrates the patient is a 48-year-old male with a history of arthritis involving his knees and lower back. He is status post left rotator cuff repair, status post lumbar fusion at L5-S1, and status post meniscectomy of the right knee. He has been taking Celebrex since 2002 and reports relief of his arthritis related pain. Prior to treatment with Celebrex he tried and failed therapy with Motrin, Naprosyn, Feldene, and Vioxx. He utilized PPI therapy with his previous trials of NSAID therapy. The information submitted documents the patient has significant degenerative joint disease as well as a chronic pain condition related to his spinal fusion. He has tried traditional NSAID therapy and reported no significant pain relief. He has obtained significant pain relief with Celebrex since 2002. There is no medical indication for him to attempt trials of NSAID therapy. Given his arthritis history and previous surgical interventions, he should be maintained on a medical therapy that has provided documented improvement in his condition. 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 14-year-old female who was diagnosed with an unresectable mixed brain tumor (ependymoma, grade II and low-grade glioma) in December 2004. The patient underwent surgical exploration at that time, and complete resection was not possible due to the vascularity of the tumor with bleeding issues. In addition, the patient was found to have metastatic disease with several spinal cord lesions. The patient subsequently began therapy with antineoplaston. Follow-up CT in March 2005 demonstrated stable or slightly increased tumor size with a large suprasellar mass and right parasellar tumor. The patient underwent vetriculoperitoneal shunts on both sides for treatment of hydrocephalus. An MRI in April 2005 demonstrated marked progression of the tumor.The patient has been re-evaluated by an in-plan pediatric neurosurgeon and has obtained a second opinion at USC. Both physicians felt that surgical resection would not be beneficial given the metastatic disease and would subject the patient to significant neurologic risks. The patient was seen at UCLA where a pediatric neurosurgeon recommended surgical resection under MRI guidance, and the pediatric oncologist recommended postoperative radiation and chemotherapy, likely using carboplatin.At issue is whether tumor resection performed at UCLA is medically necessary for treatment of the patients medical condition.The patient is a 14-year-old female with metastatic mixed brain tumor. UCLA physicians have recommended surgical resection under MRI guidance followed by radiation therapy (cranial and spinal) along with chemotherapy of carboplatin. A recent MRI demonstrated significant progression of the tumor, which was initially unresectable in December 2004.Review of the submitted clinical evidence reveals the tumor is clearly unresectable based on the MRI of April 2005, and there remains evidence of spinal metastases. The tumor was very vascular during the initial operation in which a total resection was abandoned due to bleeding issues. Therefore, it is unclear what benefit intraoperative MRI would offer since the tumor is unresectable and anatomic boundaries were not the limitation to complete resection in December 2004. Furthermore, given the progression of disease and the local extent of the tumor, it is unclear what benefit debulking therapy will offer the patient. It is not known whether the goal of this procedure is palliation of the current neurologic symptoms or to provide some benefit to the subsequent chemotherapy and radiation therapy. In any event, the surgical treatment recommended by the UCLA physician is not significantly superior to the services offered by the in-plan provider, nor does there seem to be any direct benefit provided to the patient, though significant risks will be incurred.Accordingly, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 14-year-old female diagnosed with a metastatic mixed ependymoma. The patients pediatric oncologist recommended radiation therapy and chemotherapy. The patients family declined radiation and chemotherapy and the patient began receiving antineoplaston therapy with Dr. Burzynski. A recent MRI showed marked progression of the patients tumor. The Health Plan has denied coverage for treatment with Dr. Burzynski on the basis the therapy is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Conventional therapy for this situation would involve radiation therapy with chemotherapy agents that have shown some response (i.e., carboplatin, etoposide). Antineoplaston therapy is experimental with no evidence of better success compared to conventional therapy. Furthermore, the results of a recent MRI show antineoplaston therapy has not been effective for this patient. Accordingly, 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 55-year-old female with a partial bilateral mastectomy and failed non-autologous breast reconstruction. She is seeking authorization for a superior gluteal artery perforator (S-GAP) bilateral breast reconstruction. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary. The Health Plan has recommended other reconstructive procedures for the patient.Elective, optimal breast reconstruction surgery is medically necessary for treatment of patients post mastectomy. However, based upon the information provided, it has not been objectively established that breast reconstruction using the S-GAP procedure is medically necessary for this patient. While the S-GAP procedure may be more appropriate than other reconstructive procedures in light of the patients weight of approximately 135 pounds, the clinical information provided is not sufficient to determine whether the requested procedure is medically warranted. Therefore, the patient should be re-evaluated by an in-network microvascular reconstructive surgeon; if the surgeon determines an S-GAP reconstructive procedure is medically necessary, the procedure should be authorized.Accordingly, I have determined the requested procedure is not medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 61-year-old obese female who underwent bilateral mastectomies in 2004 for breast cancer. She was further treated with chemotherapy. She is now seeking bilateral breast reconstruction. She has been seen by a board certified plastic surgeon in the past prior to her mastectomy and in follow-up in December 2004. At that time it was proposed that the patient be seen in July or August 2005 to plan the reconstructive procedures. It was appropriately suggested that the patient lose 60 pounds if she were to be considered a candidate for a TRAM flap. There is no record of the patient being seen by the plastic surgeon since December 2004. In the interim, the patient transitioned to a new medical group in January 2005. Her reconstructive surgeon is not affiliated with the patients new medical group. She has requested authorization and coverage to continue care with her reconstructive surgeon.Review of the submitted information reveals no medical necessity for the requested services. Recent medical records have not been provided and there is no evidence indicating whether the patient is/is not a candidate for breast reconstruction. The Health Plan has appropriately offered the patient the option of seeing an in-network plastic surgeon for a breast reconstruction evaluation. Based upon the information provided, there is no evidence the patient requires the services of her reconstructive surgeon. Therefore, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 62-year-old female with a long history of back pain. She has attempted physical therapy and medications without sustained relief. The medications caused her to have side effects. In November 2004, the patient received an epidural injection.  The Health Plan has denied coverage for the procedures at issue on the basis they are considered experimental.Though the patients chronic pain warranted the epidural injection she received, the other procedures performed were not indicated or warranted. The procedure codes are considered experimental and were not required or indicated. Accordingly, I have determined that the procedures at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 62-year-old female with chronic low back pain. The patient failed conservative treatment options and continued to have severe low back pain. In November 2004, the patient received an epidural injection. At issue is whether these procedures were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I agree with the Health Plans decision to deny coverage for the procedures at issue. The specific interventions at issue were not likely to be more beneficial than standard treatment options. Adhesion lysis is generally considered investigational. None of the procedure codes at issue were within the standard of care or medically warranted. Therefore, I have determined that the procedures at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 62-year-old female with chronic low back pain who underwent an epidural injection in November 2004. At issue is whether the procedure codes at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. There is no evidence the procedures at issue were medically warranted for treatment of the patients chronic pain. While an epidural was appropriate, the procedures at issue are either unproven or are not indicated for patients such as this patient. Therefore, I have determined that the procedures at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 50-year-old female with poor sleep, fatigue, and weight gain. Her representatives believe she has adult growth hormone deficiency (AGHD) based on a minimally normal increase in growth hormone response to arginine, a low IGF-1 on a single test, and the above listed clinical symptoms. All other general and metabolic blood tests as well as a bone density study are normal. The patient has requested authorization for growth hormone therapy. The Health Plan has denied this request. There is no evidence this patient has AGHD. The patients symptoms are non-specific. The results of her arginine stimulation test by themselves are not adequate to make a diagnosis of AGHD. In addition, a single low IGF-1 is not adequate to make a diagnosis of AGHD  particularly when all other pituitary parameters are normal. Therefore, there is no evidence to support a diagnosis of AGHD in this patient.Based upon the information set forth above, I have determined 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 47-year-old man who has a thickened right first toenail, which cracks, disintegrates, and falls off with resultant pain. This limits the patients ability to exercise. Pathology examination in December 2004 of a nail segment revealed hyphae, i.e., fungus. The patient and his provider have requested authorization for Lamisil. The Health Plan has denied coverage for Lamisil on the basis it is not medically necessary for the patients condition.Analysis and Findings:The patient meets all medical necessity criteria for oral Lamisil treatment. He has had a consistent physical exam, laboratory confirmation, and a history of functional impairment, namely, pain with exercise. Lamisil is a medically appropriate and indicated treatment for patients such as this patient and therefore, should be authorized. Accordingly, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old female who underwent laparoscopic cholecystectomy in September 2004. Thereafter, the patient began experiencing abdominal pain and noticed an increasing bulge in the lower abdomen near the umbilicus. In April 2005, the patient underwent ventral hernia repair. Notes from May 2005 indicate the patients wounds were well healed. A postoperative seroma was aspirated and sent for gram and stain culture. The gram stain showed no white cells and the results of the culture were not provided. The patient is now requesting a full body scan.There is no justification for a full body scan in this case. An abdominal and pelvic CT scan may be indicated but only after further evaluation by the patients surgeon. The results of the seroma culture and physical findings will determine whether a CT scan is necessary. There is no evidence to support the need for a full body scan; if necessary the patient can be appropriately evaluated by CT scanning. Therefore, I have determined the requested full body scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.