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

The patient is a 34-year-old woman with a BMI of 40 without significant comorbid conditions. The patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan indicates the patient does not meet Health Plan criteria for authorization of gastric bypass surgery.With a BMI of 40 the patient meets nationally accepted criteria for consideration of weight loss surgery. Further, it is unlikely that the patient will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Furthermore, the patient has undergone an appropriate psychological evaluation and is considered an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 35-year-old man who has been prescribed Elidel to treat intertriginous dermatitis of the groin. The patients provider is concerned that treatment with steroids could cause atrophy and permanent damage. The Health Plan has denied authorization and coverage for Elidel on the basis that it is not medically necessary.Elidel is an effective treatment for many skin conditions including atopic dermatitis, eczema, intertriginous dermatitis, and allergic contact dermatitis. This topical medication does not have the side effects of topical corticosteroids, namely telangiectasis and possible permanent skin atrophy. The side effects of systemic corticosteroids have been reported with the use of topical corticosteroids due to percutaneous absorption. Elidel is more effective and safer than topical steroids particularly since intertriginous areas have the potential for a high degree of systemic absorption. 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 58-year-old male with moderate to poorly differentiated adenocarcinoma of the prostate, Gleason 4+3, and a PSA of 43. The results of a CT scan reveal two left iliac lymph nodes measuring 1.8c, and 1.9cm in size. The biopsy from the left side shows over 75% involvement. The patient is seeking authorization for intensity modulated radiation therapy (IMRT).Based upon Partins Tables, the patient has a 6% chance of the tumor being limited to the prostate and over a 40% chance of pelvic lymph node metastases. IMRT is a powerful tool in eradicating localized cancer; however, it is not the most appropriate tool for this patients advanced cancer. The patient should benefit most from a course of pelvic irradiation with boost of radiation to the prostate. IMRT is not medically indicated or necessary for treatment of this patients medical condition. Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 31-year-old woman with a BMI of 42.6 and a history of degenerative joint disease and asthma. The patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan indicates the patient does not meet Health Plan criteria for authorization of gastric bypass surgery.With a BMI of over 40 the patient meets nationally accepted criteria for consideration of weight loss surgery. Further, it is unlikely that the patient will be able to lose weight and maintain the weight loss through non-surgical means. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Furthermore, the patient has undergone an appropriate psychological evaluation and is considered an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure 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

A 40-year-old female enrollee has requested authorization and coverage for continued physical therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees degenerative disc disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 67-year-old male with Kugelberg Welander syndrome. He is a quadriplegic with a tracheostomy tube. The patient indicates that his current power-operated wheelchair is too loud, not fast enough, and damages the woodwork in his home. The patient has requested upgrades to the wheelchair that include replacement of the wheels and an upgraded motor. The Health Plan has denied the patients request indicating that the requested upgrades are not medically necessary.The patient has requested upgrades to his power-operated wheelchair that would allow him a quieter motor and different wheels, as well as faster speed. However, based on the documentation provided the patient is able to perform his activities of daily living with his current wheelchair. He is able to maneuver his wheelchair within his home and can use it for mobility within the community. Thus, the patients current wheelchair meets the patients medically necessary needs for his condition. There is no evidence that the requested upgrades are medically necessary.Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for the 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 50-year-old male who underwent successful ACL reconstruction in September 2003. The patients knee is now stable and the information presented does not explain symptoms or issues of concern regarding the patients rehabilitation. The patient is seeking authorization for a custom ACL knee brace.The Health Plans denial should be upheld. There is no Class I literature/evidence to support the need for the requested knee brace for this patient. Furthermore, the patient underwent successful surgery almost nine months ago and his knee is now stable. The patient wishes to have the brace so that he may continue playing soccer. There is no evidence establishing that a custom brace is necessary for the patient to return to athletic activities.Based upon the information set forth above, I have determined that the requested equipment is 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 14-year-old female who was admitted to a residential treatment center on 3/8/04, with the diagnosis of major depressive disorder, recurrent/moderate and oppositional defiant disorder. The patients outpatient psychiatrist also diagnosed the patient with bipolar disorder, which evaluation at the residential treatment center did not confirm. The patients outpatient therapist diagnosed the patient as having conduct disorder. Prior to admission, the patient was apparently abusing alcohol, leaving home, engaging in high-risk situations with sexual acting out, and had poor school performance and attendance. The patient apparently was the victim of a rape approximately ten months prior to admission.Three months prior to admission, it appears the patient superficially cut her arms, which did not require medical attention. The patient denied suicidal ideation at the time of admission and during her stay. She had been treated as an outpatient by two therapists and a psychiatrist but was never treated in a more structured setting such as intensive outpatient or a partial hospitalization program. During her admission, the patient was treated medically with Zoloft 150mg/day with apparent good response.A request has been made for continued residential psychiatric treatment services. The Health Plan has denied the request on the basis that the requested services are not medically necessary.The Health Plans denial should be upheld. The submitted records do not demonstrate that the patient experienced imminent suicidal risk or was a danger to others. In addition, it appears the patient participated appropriately in her treatment during her stay and evidenced no self-destructive behavior or high-risk taking behavior. Furthermore, there is no evidence that as of 3/22/04, the patient was unable to function in meaningful areas of her life. Thus, the submitted evidence does not demonstrate that the patient required the requested level of care after 3/22/04.Based upon the information set forth above, I have determined that the requested services are 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 14-year-old female with arteriovenous malformation in the left mandible. This was treated with embolization of the feeder vessels by an interventional radiologist followed by segmented resection of the mandible with immediate iliac crest and graft reconstruction. The segment of the mandible that was removed controlled teeth #18, #19, #20, #21, and #22. The graft reconstruction site is edentulous with the exception of impacted tooth #17. A request has been made intraosseous dental implants. The Health Plan indicates the requested procedure is not medically necessary.The first stage of mandibular reconstruction consisted of bone graft of the left mandibular continuity defect. Donor site was the anterior iliac crest. The second stage of mandibular reconstruction should consist of replacement of the missing dentition with intraosseous dental implants to replace teeth #22, #21, #20, #19, and #18. The requested procedure is medically necessary because there are no teeth that would serve as adequate abutments to support a partial denture. Furthermore, pressure from a partial denture would cause reposition of the grafted bone leading to failure of the entire reconstruction. 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: Upheld Decision of Health Plan

The patient is a 35-year-old male with a history of refractory major depressive disorder. The submitted information indicates the patient has been in treatment for several years.  The patients psychiatrist notes that the patient has failed to respond to multiple medications. The patients provider has prescribed Zoloft 500mg. The Health Plan has denied authorization and coverage for the requested dosage of Zoloft on the basis that it is not medically indicated. A dose of Zoloft this high could only have theoretical utility in the treatment of obsessive-compulsive disorder. Given that this patient has been diagnosed with major depressive disorder, augmentation strategies (the use of Zoloft with a second agent such as bupropion, protriptyline or mirtazapine) represent the appropriate psychopharmacologic intervention. Combining multiple antidepressants from different categories is the standard of care for patient such as this patient. The safety and efficacy of the requested dosage of Zoloft for treatment of major depressive disorder has not been established. As such, the requested prescription is not medically indicated for treatment of the patients disorder.Based upon the information set forth above, I have determined that the requested prescription is 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 46-year-old male who first presented in outpatient care in September 2003 with an approximate two-month history of anxiety and depression, attendant with insomnia, depressed mood, loss of energy, decreased attention and concentration, and sense of panic and agitation. He noted this as secondary to several stressors including long work hours, suffering a pay cut with no cost of living increase, job promotion but uncertainty as well, refinancing his house, and his two young children being very active. The patient has been diagnosed with generalized anxiety disorder as well as major depression. He was prescribed a combination of Paxil, Trazodone, Imipramine, Lorazepam, and Celexa, the latter being the most recently added medication, as well as Klonopin. He was also seen in couples therapy in October 2003. On a follow-up visit with his psychiatrist it was noted the patient had improved mood with Celexa 20mg though he reported feeling too tired during the day. Subsequently, Klonopin was phased out. Upon the patients follow-up visit on 10/23/03, it was noted that the patient was feeling sustained improvement in mood but had periodic problems with sleep. The patient expressed an interest in taking a lower dosage of Celexa and as a result, Celexa was decreased to 10mg. By his next follow-up appointment on 11/5/03, the patient reported feeling well with 5mg of Celexa but expressed interest in discontinuing medication entirely and so plans were made for him to entirely phase out Celexa. By 12/15/03, the patient was noted to have had some relapse in his depression though he expressed ambivalence about starting a new antidepressant. Since beginning treatment, the patient has been referred to some of the psychoeducational groups offered by the Health Plan. The patient has declined to participate expressing a preference for individual weekly psychotherapy. At issue is whether individual psychotherapy sessions are medically necessary for treatment of the patients medical condition.While individual therapy is the patients preference, the submitted clinical evidence does not demonstrate that it is medically necessary. The chart notes clearly document the patients improvement with Celexa. Medicinal treatment is at least as important as therapy in the treatment of both major depression and general anxiety disorder. Furthermore, the patient and his wife have been seen in couples therapy and the patient was referred to a number of psychoeducational groups. Thus, the patient was not deprived of psychotherapeutics as a whole. The submitted evidence demonstrates that the treatment offered by the Health Plan is medically reasonable and clinically appropriate. 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 71-year-old male with idiopathic pulmonary fibrosis (IPF). Based upon the submitted medical records, the patient has IPF, cor pulmonale, atrial fibrillation. The patient is being treated with Actimmune injections, azathioprine and prednisone for his pulmonary fibrosis. In February 2004, the patients provider indicated the patients decline in lung function might be due to the reduction of the dose of prednisone or a paradoxical response to Actimmune. In April 2004, the patients provider stated that the decline in lung function might be due to progression of disease rather than a paradoxical response to Actimmune. The patient was then referred to another provider who recommended continuation of Actimmune treatment. Pulmonary function tests performed on 1/7/04 showed TLC 49% and DLCO 28%. Pulmonary function tests performed on 4/9/04 showed TLC 50% and DLCO 28%. Clinically, the patient complained of worsening respiratory symptoms in that interval. CT scan of the chest performed on 4/12/04 showed stable pulmonary fibrosis when compared to the 8/28/03 study. The Health Plan has denied authorization and coverage for Actimmune on the basis that it is not medically necessary for treatment of the patients condition.A study by Ziesche and colleagues enrolled 18 patients and studied the effects of Actimmune in the treatment of IPF. The results showed statistically significant improvement in total lung capacity, forced vital capacity, and PaO2 in patients treated with thrice weekly Actimmune. The results were promising and led to a phase III trial using Actimmune versus placebo in the treatment of IPF. However, subsequent studies found Actimmune provided little or no benefit for patients with IPF. Kalra, et al. concluded that Actimmune did not benefit IPF patients. Davies, et al. found little evidence to support use of Actimmune. Honoreet, et al. found that Actimmune can cause respiratory failure in IPF patients. Furthermore, the most comprehensive and clinically relevant study of the role of Actimmune in the treatment of IPF (Raghu, et al.) found that treatment with Actimmune did not affect progression-free survival, pulmonary function or quality of life. Thus, use of Actimmune is not medically indicated for treatment of the patients IPF given the lack of proven benefit and some evidence for harm.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the 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 53-year-old female with a BMI of 39. She has hypertension and a history of diabetes mellitus. In addition, the patient is status post two bariatric procedures. Her most recent procedure was Roux-en-Y gastric bypass in 1999. Currently she has abdominal symptoms and an incisional hernia, which could be symptomatic. Her primary care provider referred her for consultation with a bariatric surgeon. The Health Plan has denied this request.Given the patients current condition and history the patient should be evaluated by a bariatric surgeon. The patient has an incisional abdominal hernia and other abdominal symptoms that require evaluation by a bariatric surgeon. The referral to a bariatric surgeon by the patients primary care provider is medically indicated and necessary. Therefore, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old woman who was diagnosed with ductal carcinoma in situ of her right breast approximately eight years ago. The patient was treated with surgery and radiation. Presumably unrelated to that, she was then diagnosed with metaplastic breast carcinoma of the left breast in 2001 and received conventional treatment for breast cancer. In early 2003, a solitary area of metastasis was discovered in the patients lung. This was felt to be recurrent metaplastic carcinoma. The patient was then treated with chemotherapy with good response. In October 2003, the patient underwent surgical excision of the metastasis, followed by two additional cycles of chemotherapy. Since that time, the patient has not had any evidence of any further metastasis or recurrence of this cancer. A recent PET scan was negative. In February 2004, the patient was placed on oral Celebrex and doxycycline as potential antiangiogenic agents to prevent further recurrence. The Health Plan has denied authorization and coverage for Celebrex on the basis that it is not medically necessary.Celebrex, which is marketed as an anti-inflammatory drug, inhibits the COX-2 enzyme, which is important in prostaglandin production. There is increasing interest in its use in cancer, as many cancers do over-express this enzyme. There is some evidence that Celebrex can reduce the number of colonic polyps developing in patients with familial adenomatous polyposis. However, there is no data as yet as to what impact this finding might have on the eventual development of cancer. There is also some evidence in mice that Celebrex might prevent the development of mammary tumors in HER2 positive mice. There are ongoing human trials looking at the incorporation of Celebrex with conventional cancer protocols. However, there is no data demonstrating the value of Celebrex in the treatment of human breast cancer. Though the patient has a rare type of breast cancer about which not much is known, conventional chemotherapy has had a good effect on the patients tumor suggesting that it responds in ways similar to more typical breast cancer. There is no evidence to support the use of Celebrex in this situation.Based upon the information set forth above, 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: Overturned Decision of Health Plan

The patient is a seven-year-old male who has been diagnosed with idiopathic short stature. The submitted records indicate the patients stature is well below the third percentile and is inappropriate for mid-parental height. The patients growth velocity over the most recent 15 months is less than 4cm/year (3.8). The patients evaluation was otherwise non-diagnostic. It appears that a genetics consultation has been requested to rule out syndromal etiology for the patients short stature/slow growth. A request has been made for Humatrope therapy. The Health Plan has denied the request on the basis that Humatrope is not medically necessary for treatment of the patients short stature.The patients history, physical examinations, and growth records support a diagnosis of idiopathic short stature. The patients abnormal growth velocity attests to the need for growth hormone therapy. Stimulation testing is not indicated or necessary prior to starting Humatrope as most children with idiopathic short stature test normal. Furthermore, abnormal stimulation tests are not required by the Food and Drug Administration in order to initiate therapy in patients with idiopathic short stature once diagnosis is established as long as other possible etiologies are ruled out and the patients stature and growth velocity support initiation of treatment.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.