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

The patient is a 36-year-old male who has requested authorization and coverage for the medication Regranex for treatment of a chronic foot ulcer. The Health Plan has denied this request indicating Regranex is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Regranex is indicated for diabetic patients with ulcers that meet several specific criteria. Review of the documentation provided does not demonstrate these criteria have been met. Thus, there is insufficient evidence to conclude Regranex is more effective than traditional accepted modalities for treatment of the patients ulcer. 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

This patient is a 40-year-old female who is 59 weighing 205 pounds. The patient has a hanging pannus, which is stated to have developed post gastric bypass though one physicians notes indicate a gastric stapling procedure was performed. There is evidence she has been seen and evaluated by an orthopedic surgeon for probable obesity related knee problems. The patient wishes to undergo an abdominoplasty. The Health Plan has denied the request on the basis that the requested procedure is not medically necessary.There is no evidence the patient has undergone an appropriate evaluation by a plastic surgeon or other surgeon experienced in post massive weight loss excess tissue removal procedures. While there may be valid reasons to consider removal of the pannus, they are not documented in the records presented. As such, there is insufficient documentation the proposed procedure is medically indicated. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plan s denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 61-year-old male diagnosed with prostate cancer by his urologist (stage T2a, PSA of 10.2, and a Gleason score of 3+4=7). The patient was referred to a radiation oncologist for discussion of radiation options and was seen on 9/22/04. According to the consult note, examination of the prostate identified a small nodule in the right side of the gland, which was highly suspicious for capsular involvement. Clinical evidence of capsular invasion, therefore, resulted in a stage of T3a. Options were discussed including initial hormone therapy (LHRH agonist) followed by either external beam irradiation (with a dose of 7000 cGy given to the prostate) or combined external beam and permanent iodine seed implant (brachytherapy). The patient has requested authorization for treatment with proton beam therapy as he believes it is the most appropriate treatment for his condition. Review of the submitted medical records reveals there is a variation in the patients clinical stage as determined by his two physicians. Following National Comprehensive Cancer Network (NCCN) Prostate Guidelines, PSA, clinical stage, and Gleason score are used to determine a patients risk profile. This profile, in turn, is used to determine initial treatment recommendations. A PSA greater than 10 is an intermediate risk, Gleason score of 7 is an intermediate risk, and clinical stage T2a is a low risk. By upstaging to a clinical stage T3a, this would raise the risk to high. With two intermediate risk factors, which this patient exhibits, it is appropriate to bump up to the next category for treatment recommendations. Therefore, in the high-risk category the recommendations for initial therapy include radical prostatectomy, which according to the attached notes was ruled out, or 3D conformal irradiation with hormone therapy. The specific NCCN guidelines for irradiation specify that for intermediate or high-risk patients, either 3D conformal irradiation or IMRT photon beam is preferred over conventional photon beam irradiation. Furthermore, doses in excess of 7500 cGy are better than lower doses (7000 cGy), which are used for low-risk patients. Finally, for doses in excess of 7500 cGy, either ultrasound or implanted fiducials should be used so as to localize the prostate prior to each fraction of photon beam radiation, reducing excess dose to bladder and rectum. At this time, proton beam therapy is not a standard treatment option for patients such as this patient. Therefore, based upon the patients clinical state and NCCN guidelines, 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 52-year-old female with recurrent major depression and borderline personality disorder who was seen in weekly dialectic behavioral therapy for the past year through December 2004. During this time, the patient was on Zoloft with dosage varying between 150mg and 175mg per day. She has requested authorization for continued weekly psychotherapy; the Health Plan recommends every other week therapy in addition to monthly visits with her psychiatrist.A review of her therapists notes indicates that on 7/6/04 the therapist noted the patient continues to state that she has always wanted to kill herself and that feeling will never change. Client was cooperative, pleasant - outside of her commitment to being suicidal and actually stated that she feels happy that she has been granted SSDI benefits. She insists that she be treated as fragile. It is important that this writer remember that the patient is not fragile-she will not melt down if she is pushed to use her skills. Notes from 10/9/04, 10/22/04, 10/29/04 and 11/12/04 discuss the patients application for admission to UCLA and her related anxiety surrounding the application process. On 12/10/04, it was noted the patient and her therapist worked together on a chain analysis on the patients discomfort with her study partner. Notes from 12/21/04 indicate the patient was seen on that day because she was going to be away for the next two sessions and was experiencing intense depression. The patients therapist reported the patient did not want to connect the intensity of this depression to the holiday or the uncertainty about whether she passed her courses.Based upon the information provided, it does not appear the patients antidepressant course changed during this time.Upon review of the therapists notes the patient does not appear to be grossly distressed and, in fact, was even noted by the therapist on 7/6/04 as not fragile. Furthermore, a good bit of what appears to have gone on for months pertains to helping the patient with her application to UCLA, which though important in the entire scheme of all things therapeutic for the patient, was not needed on a weekly basis. The patients reported chronic thoughts of dying are consistent with her diagnosis of borderline personality disorder. The submitted records indicate the patient was cooperative and pleasant and her energies were directed toward entering UCLA. Based upon the submitted therapy notes and the patients history, every other week therapy as offered by the Health Plan is medically reasonable and appropriate. Accordingly, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old male with chronic constipation and/or irritable bowel syndrome (IBS) with constipation. He has failed to respond to traditional therapies. The patient has had documented response to use of Zelnorm. The Health Plan indicates Zelnorm is not medically indicated for the patient.Review of the submitted clinical information clearly demonstrates the patient responded well to Zelnorm after suboptimal response to other constipation therapies. FDA indications do not cover the use of many medications that are indeed standard and indicated therapies for a disease or symptom. FDA indications alone are never the basis for determining standard of care or appropriate use of an agent, but are only part of the information used in making this individual determination. Furthermore, Zelnorm has in fact received an FDA indication and labeling for chronic constipation regardless of gender. Thus, the patient meets the clinical indication for Zelnorm as well as the FDA labeling indication for use of this compound. Accordingly, I have determined the requested medication is medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old female who has lost over 100 pounds following gastric bypass surgery. She has since developed excess abdominal skin. The patient has requested authorization and coverage for an abdominoplasty. The Health Plan has denied this request indicating the requested procedure is cosmetic in nature.The patient is requesting authorization for abdominoplasty to relieve back pain and intertriginous dermatitis. The lack of significant rash on her examinations indicates that whatever dermatitis may be occurring can be controlled with conservative medical therapy. Furthermore, based upon the submitted photographs, it does not appear the excess abdominal skin pictured would be a significant factor in the patients lower back pain. Thus, the proposed abdominoplasty is not likely to have greater therapeutic effect than conservative medical therapy in this situation. Accordingly, 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

This patient is a 45-year-old male who has long-standing widespread psoriasis and now psoriatic arthritis. The patient has tried many medications over the years as well as UVB therapy to treat his condition. He was enrolled in a study with Enbrel and had a great response. The patients medical history is significant for hypertension and hypercholesterolemia, for which he takes medication. The patients dermatologist feels Enbrel is the best treatment at this time for the patients psoriasis. The Health Plan has determined Enbrel is not medically necessary for the patients condition.  Upon review of the submitted clinical evidence and relevant medical literature, Enbrel is medically appropriate for this patient. The Health Plan has proposed the patient be tried on cyclosporine. Cyclosporine can further increase blood pressure in this patient who already is on blood pressure medications. Additionally, cyclosporine will not help the patients arthritis, and can cause elevation of his triglycerides or cholesterol. The other medicine the Health Plan has recommended is Soriatane; however, Soriatane can be difficult to use in patients such as this patient who already have elevated lipid profiles. Furthermore, it can cause liver disease and this patient has had liver enzyme elevations with his methotrexate. Moreover, Soriatane will not help the patients arthritis.The submitted clinical information documents that the patient has been tried on systemic medications in the past including methotrexate and Amevive. Thus, he has already failed two systemic medications and UVB. Enbrel is the most medically appropriate medication for this patient at this time. For this patient it carries less risk of complication, and helps two disease processes at the same time. Therefore, I have determined that 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 54-year-old female who has a history of obesity, hypertension, hypothyroidism, osteoarthritis, and chronic lymphedema. The patient indicates physical therapy has provided her with pain relief. In February 2005, the patients physician recommended the patient receive additional physical therapy sessions for her lymphedema. The Health Plan has determined additional physical therapy sessions are not medically necessary. A consultation visit with a lymphedema clinic has been authorized for the patient. Evaluation through a lymphedema clinic is more clinically appropriate than additional physical therapy at this time. It is likely the consultation with the lymphedema clinic will result in a more effective treatment program specific to the patients needs. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Review of the physical therapy notes document the patient was walking in standing frame initially following his stroke. He received a brace on 9/21/04, at which time he was able to walk with the brace and pickup walker with minimum assistance. On 9/28/04, it was noted the patient was walking with a brace and hemiwalker (assist not recorded). On 11/20/04, the patient was walking with a brace and quad cane up to 50 feet. On 12/7/04, the patient was walking up to 100 feet. It was noted that he was not safe with gait and his family was having problems putting on the brace at home. On the patients last visit, adjustments were made to the brace by his orthotist. A request has been made for continued physical therapy sessions. The Health Plan has denied the request on the basis that further therapy is not medically necessary for this patient.Review of the submitted clinical records indicates the patient was clearly making progress with gains documented. However, as of 12/7/04, the patient and his family were having significant difficulty with applying the brace at home. Furthermore, there was no chance to follow-up after the brace was adjusted because therapy was discontinued. Given that the patients condition is likely to continue to improve additional physical therapy is medically necessary and should be authorized. The Health Plans denial should be overturned. The patient should receive three months of physical therapy with re-evaluation at the end of the three-month period.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 58-year-old male with degenerative disc disease at C4-5 and C5-6. His provider is recommending a two-level artificial disc replacement. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, I have determined the requested procedure is 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 58-year-old male with a diagnosis of cervical disc disease. He has requested coverage for artificial disc replacement surgery. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.There is little data supporting the long-term efficacy of artificial disc replacement. No prospective, blinded, controlled studies have shown conclusive benefit with this procedure. Additionally, several studies have shown diminishment or loss of range of motion in patients with artificial cervical discs when followed for extended periods of time. Additionally, revision remains a potentially life threatening proposition. At present, the efficacy of disc replacement remains unproven. Therefore, I have determined that the requested procedure is 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 58-year-old male who was injured in a motor vehicle accident in August 2004. He has herniated discs at C4-5 and C5-6. The patient is requesting artificial disc replacement surgery. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding the artificial disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial artificial disc replacement remains experimental. Therefore, I have determined the requested procedure is 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 13-year-old male with a diagnosis of autism who has been receiving speech therapy three times a week for one-hour sessions since January 1999. He has made progress toward communication, but continues to have difficulties with pragmatics and social communication. Additionally, auditory comprehension and behavior continues to be an issue. The patients parent has requested coverage for continued speech therapy. The Health Plan has denied the request on the basis the requested therapy is not medically necessary for treatment of the patients condition.Review of the relevant medical literature reveals no support for individual therapy to treat the remaining areas of deficiencies in the patients speech. The patient has difficulty with pragmatics, social communication, and auditory processing, all of which are educationally based deficiencies rather than medical issues. As such, standard of care is to manage the patients condition through other means than individual speech therapy. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old male who was treated for hepatitis C in February 2004. In light of his history of cirrhosis the patient is now being continued on Pegasys for maintenance purposes to prevent transplantation. The Health Plan indicates since the patient did not respond to previous therapy, continued Pegasys therapy is not medically necessary. The Health Plans denial should be upheld. The use of Pegasys as maintenance therapy is of unproven efficacy. The HALT-C study is an ongoing study and its conclusions and results have not become the standard or the community care. Short of the HALT-C program, there is no prospective, double-blind study looking at the maintenance issue. As such, there is insufficient evidence at this time that the requested therapy is likely to be effective for patients such as this patient. Therefore, 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: Overturned Decision of Health Plan

The patient is a 34-year-old male with a long-standing history of polysubstance abuse, involving principally marijuana but also more recent abuse of cocaine, including intravenous use. He first began using marijuana at age seven, introduced to such by his father amidst an otherwise exceedingly dysfunctional background, including his parents divorce, drug smuggling for his father, mother being a heavy marijuana smoker, and, at one point, being seduced by his grandmother who drank heavily and brought pornography into the home. Subsequently, the patient become a chronic user of marijuana (exact daily quantity unclear) but has also used a multitude of other drugs. Most recently, he was drinking daily and shooting a lot of cocaine, noted by his wife to have become very bizarre in the process. The patient noted a number of consequences to his drug use over the years, including several arrests involving alcohol and drugs, two DUIs, one possession charge, one resisting arrest charge, conflict with his wife, and stealing syringes from a physician when the physician left the room. His wife was also noted to smoke marijuana; the frequency of such is unclear.The patient was admitted to residential treatment on 1/22/05. When he was evaluated by a physician on 1/28/05, the physician noted it was difficult to elicit a clear and concise history from the patient because of his tangentiality. The patient was diagnosed with polysubstance dependence and personality disorder  not otherwise specified (primarily narcissistic).A request has been made for reimbursement for the substance abuse treatment services at issue. The Health Plan indicates the patient could have been treated at a less intensive level of care.While the documentation provided by the residential facility is quite topical in terms of treatments afforded the patient and concurrent treatment by a physician, the patients history is very telling for fairly egregious drug use. To the extent that just prior to his admission the patient had been shooting cocaine, having overdosed the week prior, and was using marijuana daily, he was clearly worsening. His wife noted him to be acting very bizarre and when he was seen by a physician some six days after his admission, he was so tangential and circumstantial as to make it difficult to elicit a clear and concise history. It appears the patient was also suffering from a concurrent substance induced mood disorder, not simply polysubstance dependence. Therefore, the morbidity of this patient was quite substantial and in the face of his most dysfunctional background, alongside tension in his marriage and his wife also smoking marijuana, he did not appear to have nearly enough support for sobriety if left in his usual setting. Rather, the patient required a physically separate space and program where he would not have access to drugs or alcohol (i.e., a residential program). Accordingly, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.