Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 48-year-old female who has chronic fatigue syndrome. She is requesting authorization for Benicar to treat her condition. The Health Plan has denied the patients request indicating the requested medication is considered experimental for treatment of chronic fatigue syndrome. The Health Plans denial should be upheld. Benicar is an anti-hypertensive medication. There is no literature supporting its use in chronic fatigue syndrome. There is no evidence the patient will benefit from the requested medication. Therefore, I have determined that the requested medication 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 2: The patient is a 48-year-old female with chronic fatigue syndrome in a Marshall protocol and wants to use Benicar, an anti-hypertensive drug. Her blood pressure is 80/50/50-60. The Health Plan has denied authorization and coverage for Benicar on the basis the drugs efficacy has not been established for treatment of chronic fatigue syndrome.Benicar is an anti-hypertensive drug. The patient does not have hypertension. Off-label use in chronic fatigue syndrome is experimental and is not likely to be effective. There are other appropriate therapies available for treatment of the patients condition. Therefore, I have determined that the requested medication 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 48-year-old woman who has chronic fatigue syndrome. Her physician notes the patient has researched chronic fatigue syndrome and believes Benicar is an appropriate treatment for her condition. Current symptoms are not described. No laboratory data is presented. The Health Plan has denied authorization and coverage for Benicar on the basis it is considered experimental for the patients diagnosis.No data has been submitted that meets relevant criteria showing the patient actually has chronic fatigue syndrome or that chronic fatigue syndrome is responsive to Benicar.  Review of the relevant medical literature revealed no data on Benicar for treatment of chronic fatigue syndrome.  Furthermore, there is no data regarding use of Benicar in Th1 inflammatory disease. The only relevant article involves ACE enzyme as a marker for chronic fatigue immune dysfunction syndrome and comparison to ACE in sacoidosis. However, there was no information in that study to support treatment with one ACE/ARB over another. Based upon the information set forth above, I have determined that the requested medication 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: Overturned Decision of Health Plan

The patient is a 46-year-old male who has psoriasis and psoriatic arthritis. Methotrexate, cyclosporin, Soriatane, UVA, and UVB treatments did not result in improvement of the patients psoriasis. Enbrel 25 mg twice a week for 10 months resulted in significant improvement of the arthritis. Initially, the psoriasis improved. Recently, however, new psoriatic plaques have appeared. The dermatologist recommended increasing the patients Enbrel prescription to 50 mg twice a week. The patients rheumatologist has been treating the patient with methotrexate, which has reportedly been ineffectual for the patients psoriasis. The patients psoriasis is worsening. A long list of systemic treatments have not helped in the past. Response to treatment in psoriasis, as in many other medical conditions, may vary from patient to patient. In this patients case 25 mg of Enbrel twice a week is not presently sufficient. Therefore, it is medically indicated and appropriate to increase the Enbrel dosage to 50 mg twice as long as there is not an increased risk. This patient does not appear to be at risk if the dosage is increased. Furthermore, the proposed dosage of 50 mg twice a week is recommended by the manufacturer as well. Based upon the information set forth above, I have determined the requested dosage increase is 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 15-year-old male who has been diagnosed with septo-optic dysplasia resulting in pituitary growth hormone deficiency. He has been receiving growth hormone for more than 12 years. The patient has responded well to treatment. In September 2004, it was noted the patient was receiving Nutropin at 2.2 mg once a day and had a height of 177.2 cm. On 5/17/04, the patients IGF-1 level was 571 and IGFBP-3 was 4.4 (both high normal values). The patients parents indicate the patients mid-parental height was 69.5 inches, though there is some indication in the submitted documentation the mid-parental height may be 72 inches. At this time, the patient, by whatever criteria is used for attainment of mid-parental height, should have achieved this mark, albeit his epiphysis may not have completely closed as yet. Therefore, continued therapy for his growth is not necessary or indicated. However, the patient has been apparently documented to have a structural or developmental problem of his brain that will likely cause him to be growth hormone deficient for life. Thus, there should be consideration to providing the patient with smaller, adult maintenance amounts of rhGH hereafter to sustain his IGF-1 level within a normal adult range, for all of the other indicated reasons excluding that for his growth. Repeat stimulation testing for his growth hormone reserve would be problematic since he likely has high levels of GH antibodies that would interfere with routine laboratory measurements of the hormone in serum samples. In any event, continued growth hormone therapy is no longer medically necessary for the patients growth. Because growth hormone therapy has been requested for continued growth, I have determined that the requested therapy is not medically necessary. The Health Plans denial should be upheld. However, the Health Plan should consider providing adult maintenance doses of growth hormone because of the patients developmental brain problem.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 28-year-old male with failed back surgery and on-going chronic pain. Based upon the information provided, it appears the patient was scheduled for further back surgery in March 2005 and his provider requested authorization for Actiq for post-operative pain. The Health Plan has denied authorization for Actiq.The Health Plans denial is correct. No information has been submitted demonstrating Actiq is necessary. Although Actiq may be indicated for treatment of the patients condition in certain situations, there is no evidence suggesting this patient requires Actiq or that other indicated pain relief medications and therapies are ineffective or contraindicated for the patient. 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 53-year-old female who reportedly has had gastroesophageal reflux disease for many years. It has been reported the patient has been tried on Aciphex, Protonix, and Prilosec. The patient indicates Nexium has been an effective treatment for her condition.  The Health Plan has denied authorization and coverage for Nexium on the basis the submitted documentation does not demonstrate it is medically necessary.Review of the submitted information reveals detailed information regarding the patients clinical history is lacking. There are no progress notes or medical records to show in detail the medications the patient has reportedly tried and failed. Additionally, it is not known how long the patient was tried on these medications. Furthermore, the patients endoscopy results have not been submitted. As such, the submitted documentation does not demonstrate Nexium is 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 55-year-old male who has sclerosing cholangitis and cirrhosis. The patient has been followed by a transplant center since 1995. A new in-network primary care provider (PCP) was assigned to the patient as of 1/1/05. The patient wishes to continue to receive treatment from his previous PCP.Upon review of the submitted documentation no information has been presented that demonstrates it is medically necessary for the patient to continue with his out-of-network PCP. The evidence does not demonstrate the patient cannot be appropriately cared for by an in-network PCP. Furthermore, the Health Plan has approved continued care with the patients transplant provider until 12/31/05 to allow time for appropriate transition to another transplant provider. The Health Plan is offering the patient appropriate services for treatment of his medical condition. 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: Overturned Decision of Health Plan

The patient is a 54-year-old female who is 53 weighing 226 pounds with a body mass index (BMI) of 41. She has comorbid conditions of hypertension, gastroesophageal reflux disease, and degenerative joint disease. She has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. She is requesting authorization for a duodenal switch procedure. The Health Plan has denied this request and in the alternative authorized Roux-en-Y gastric bypass. Peer-reviewed literature demonstrates duodenal switch has superior long-term outcomes and quality of life compared to Roux-en-Y gastric bypass. In addition, the incidence of weight regain is much higher for patients who undergo Roux-en-Y gastric bypass than those who undergo duodenal switch. Furthermore, there is less likelihood of complications with duodenal switch than with Roux-en-Y gastric bypass. Therefore, 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 13-year-old male who has been having difficulty in school. As a result he underwent a battery of tests including expressive and receptive language, standard air, and central auditory testing (a SCAN-A test). The results of the SCAN-A test were abnormal indicating a central auditory processing disorder. The Health Plan has denied reimbursement for the SCAN-A test.Central auditory processing testing such as the SCAN-A test is a widely accepted tool for evaluating central auditory processing disorders or dysfunction. Based upon the information submitted, this patient was exhibiting signs and symptoms demonstrating a need for central auditory processing evaluation. Given the patients history the results of the SCAN-A test whether normal or abnormal would have had an impact on the patients treatment plan. Based upon the information set forth above, I have determined the SCAN-A test at issue was indicated and medically necessary for evaluation 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 50-year-old male with multiple medical problems who is requesting authorization for growth hormone therapy for presumed adult growth hormone deficiency (AGHD) based upon nonspecific symptoms and the response to an arginine/GHRH growth hormone stimulation test. He has hypertension and depression and is treated with large doses of Diovan and Effexor. He complains of fatigue, weakness, poor concentration, obesity and decreased libido.An evaluation by the patients endocrinologist revealed a normal MRO of the pituitary, normal pituitary function tests and an IGF-1 concentration. An arginine/GHRH stimulation test revealed a peak growth hormone of 5.6 ng/ml in the Esoterix RAI assay. The Health Plan has denied authorization for growth hormone therapy.There is no evidence this patient has AGHD. Such a diagnosis is usually made based upon the clinical context that is suggestive of some disorder of the hypothalamic/pituitary axis. Other potential causes for the patients symptoms include his depression or the medication utilized to treat his depression and his hypertension. The patients tested pituitary hormones and IGF-1 appear normal. His MRI shows no structural lesion in the pituitary. His growth hormone response is said to be subnormal based upon a cutoff using a immunoradiometric assay; however, different published assays do not completely agree on the cutoff between normal and subnormal responses.The diagnosis of AGHD is based upon the clinical context, signs and symptoms, as well as the results of biochemical testing. The patients signs and symptoms are sufficiently nonspecific and growth hormone tests are sufficiently inaccurate that there is good potential he has a false positive diagnosis. Regardless, there is insufficient information to demonstrate growth hormone therapy is medically necessary for this patient. Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old female with bilateral meniscus tears. She has pain during work and exercise and would like to attempt physical therapy. The Health Plan has determined physical therapy will not benefit the patients condition and that the patient should proceed with surgery.The patient has had a physical therapy evaluation. The results of this evaluation indicate the patients range of motion is full and that her strength is 5/5. Therefore, there are no physical therapy goals for the patient to achieve. Furthermore, there is little, if any, evidence demonstrating physical therapy would improve the patients underlying condition of meniscus tears. There is no likelihood that physical therapy would assist in this patient avoiding surgery. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The submitted information indicates the patient is 34-year-old woman who has keratoconus. The clinical notes indicate she is having problems tolerating a contact lens. She is status post penetrating keratoplasty in the other eye. The patients ophthalmologist has recommended the patient undergo a penetrating keratoplasty. The Health Plan indicates scientific evidence does not support the requested procedure as safe and effective for treatment of the patients condition.Keratoconus in one of the primary indications for penetrating keratoplasty, particularly when the patient is contact lens intolerant or has such a high degree of irregular astigmatism that a contact lens cannot adequately improve the vision. Penetrating keratoplasty is not an experimental procedure. It is well documented in the literature as effective and there have been excellent results in keratoconus patients. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 62-year-old female with a history of COPD, degenerative joint disease, hepatitis, and cholecystectomy. She was admitted to the hospital on 2/22/05 with a LLL infiltrate. A sputum culture taken on 2/25/05 demonstrated staphylococcus epidermis sensitive to cefazolin, gentamicin, and vancomycin. Zyvox was started on 2/28/05. Authorization and coverage for Zyvox was denied and vancoymcin was started. The patient was to receive 1 gm of vancoymcin intravenously every 12 hours until 3/14/05. The patient received this therapy until 3/9/05 when IV access was lost. Zyvox was subsequently ordered. The Health Plan has denied reimbursement for Zyvox indicating the medication was not medically necessary for treatment of the patients pneumonia.The Health Plans denial should be upheld. The provided documentation does not demonstrate medical necessity for Zyvox. There is no evidence of any culture positive for VRE, VISA or MRSA. The sputum cultures were positive for coag-negative staph, which in this case was unlikely to be pathogenic. Furthermore, the patient was not formally evaluated by an infectious disease specialist. For these reasons, I have determined the requested medication was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 48-year-old female who has a long history of back pain secondary to degenerative disc disease. A discography showed concordant axial back pain and annular degeneration at L3-4 and L4-5 disc levels. Conservative therapy has failed to provide pain relief. Therefore, the patients provider has recommended the patient undergo intradiscal electrothermal therapy (IDET). The Health Plan has denied authorization and coverage for IDET on the basis it is considered experimental.IDET remains a controversial treatment for degenerative disc disease. Several cadaveric studies demonstrate the IDET procedure does not heal the disc very well. Review of the medical literature reveals several studies showed little to no efficacy of the IDET procedure. IDET is not the standard of care and it is not in the mainstream of lumbar degenerative disc disease treatment, particularly when there is more than one disc involved. 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 2: The patient is a 48-year-old woman with chronic back pain secondary to degenerative disc disease. A request has been made for an IDET procedure. The Health Plan has denied the request.There is no information available to warrant and support the use of IDET. No long-term prospective study has shown significant long-term benefits, and the risks of the therapy are still unclear. In this community, when IDET has been used the results have been poor. As such, IDET cannot be recommended until the efficacy of the procedure has been established. 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 48-year-old woman with a history of degenerative disc disease. She has undergone conservative treatments with no long-term benefit. The patients provider has recommended the patient undergo an IDET procedure. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.IDET remains an unproven procedure without clearly defined efficacy. There is no substantial proof of its effectiveness for the treatment of chronic back pain. Multiple studies have demonstrated that it is not beneficial or has limited effect. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 35-year-old male who may have a history of fungus infection of his toenail and fingernails. A fungus culture reported in December 2004 grew out penicillium species. Coverage for a prescription for Lamisil tablets has been denied by the Health Plan. At issue is whether Lamisil is medically necessary for treatment of the patients condition.The records provided do not include a detailed history of a dermatology physical exam. As such, it is not known if the patient is experiencing a functional impairment. Furthermore, the presence of penicillium in a fungus culture may indicate either pathogen or non-pathogen containment. It appears further workup is needed in this case and the patient should be evaluated by a dermatologist. The submitted documentation does not demonstrate the requested medication is 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 53-year-old male with a history of high cholesterol and LDL. He also has a family history of coronary artery disease. The patient took Zetia and his cholesterol and LDL came down. The patient has declined the use of statins on the basis he is concerned about the side effects including liver function problems and rhabdomyolysis. It appears the patient has never been tried on statins. The patient wishes to continue to use Zetia. The Health Plan has denied authorization for the requested medication on the basis it is not medically necessary.The Health Plans denial should be upheld. Based upon the information provided, it appears the patient has not been tried on statins. The relevant medical literature recommends statins as first-line therapy because of endothelial stabilizing effects and anti-inflammatory effects. Furthermore, not all patients experience side effects from statins. Though the patient expresses concern over rhabdomyolysis, this side effect is very rare. The patient should be tried on statins prior to pursuing medication alternatives. 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: Overturned Decision of Health Plan

The patient is a 17-year-old female who underwent anterior cruciate ligament reconstruction in February 2004. The patient received a course of physical therapy post operatively. She is highly active in athletics and has returned to playing basketball. Given the patients level of activity, the patients provider has recommended the patient receive a custom knee brace. The Health Plan indicates a custom knee brace is not medically necessary for the patient.Based upon the information provided it appears the patient participates in a high level of strenuous activity. As such, such is prone to injury and requires protection of the knee and graft post repair. Prefabricated braces are not comparable in function and protection to custom braces for patients such as this patient who are highly active. Therefore, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.