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

The patient is a 16-year-old male who has cerebral palsy with spastic quadriplegia. The patient lost the ability to transfer as he gained weight. A ceiling track lift system has been recommended. A Hoyer lift has been authorized by the Health Plan. At issue is whether the requested equipment is medically necessary for the patient.Upon review of the submitted information it does not appear that an in-home evaluation has been performed. As such, it has not been demonstrated that the requested ceiling track lift system is medically necessary at this time. An in-home evaluation is needed to determine if the Hoyer lift authorized by the Health Plan is medically appropriate. Doorways in the patients home should be measured to determine if the Hoyer lift will fit through the bathroom and bedroom doors. Also, measurements of the bathroom and bedroom should be taken to determine if the Hoyer lift can be turned once inside the room. Furthermore, the style of the patients tub should be evaluated to determine if a Hoyer lift can be placed on the tub or to the side of the tub to support safe and appropriate transfers. If the results of the in-home evaluation determine that a Hoyer lift cannot be used, the patients request for a ceiling track lift system should be reconsidered. Based upon the information set forth above, I have determined that the requested equipment is not medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time. However, the patient should receive an in-home evaluation to determine if the Hoyer lift offered by the Health Plan will allow safe and appropriate transfer of the patient. If it is determined the Hoyer lift will not provide safe and appropriate transfer of the patient the request for a ceiling track lift system should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is an 18-year-old female who was evaluated by a plastic surgeon for symptomatic mammary hypertrophy. The patient reported back, neck, and shoulder pain related to heavy, pendulous breasts and had demonstrated bilateral shoulder grooving. The patients plastic surgeon has recommended bilateral breast reduction surgery. The Health Plan has denied authorization and coverage for breast reduction surgery on the basis that it is not medically necessary given the amount of tissue that is to be removed.Although the patient is somewhat young, there have been documented physical findings associated with mammary hypertrophy and symptoms of back and neck pain. The patient has not had the problem long enough to have developed the permanent skin changes associated with repeated/constant intertrigo but such changes are likely to occur. Symptomatically, the procedure is medically indicated. According to the American Society of Plastic Surgeons guidelines, the weight of the removed breast tissue does not determine whether the procedure is medically necessary. In this case, the submitted clinical information and photographs demonstrate that breast reduction surgery is medically indicated. Based upon the information set forth above, I have determined that the requested procedure 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 38-year-old woman who underwent a needle localization breast biopsy in May 2003 that resulted in a scar on her left breast. The patient consulted a plastic surgeon in December 2003 while the incision was very immature. The plastic surgeon recommended that the patient undergo scar revision. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is not medically necessary.The submitted records lack documentation of the medical necessity for the proposed scar revision. The documentation provided includes a surgical consultation regarding an immature scar of the left breast. The submitted photographic evidence demonstrates an immature scar. Based upon the information that has been provided, there is no indication of a physical need for scar revision at this time. Therefore, I have determined that 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: Upheld Decision of Health Plan

The patient is a 36-year-old male with hyperlipidemia who underwent an electron beam tomography (EBT) scan for evaluation of and screening for possible coronary disease. The patient has requested reimbursement for the procedure at issue. The Health Plan has denied the request on the basis that EBT scanning of the heart is not medically necessary in the screening or management of coronary artery disease. EBT for cardiac disease is not the standard of care and has not been generally accepted in the medical community as standard diagnostic testing. Review of the medical literature indicates that EBT is not a medically appropriate replacement for other conventional screening tests within the standard of care such as treadmill stress testing. Thus, there is no evidence that EBT was medically indicated for evaluation of this patient. Therefore, I have determined that the procedure at issue was not medically necessary for evaluation 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 35-year-old woman with an apparent history of several abdominal procedures including repair of right lower quadrant/inguinal hernia followed 10 days later by image guided drainage of right abdominal wall fluid collection. The patient continued to have abdominal pain and a November 2003 CT scan demonstrated a small peri-umbilical hernia. Her surgeon has recommended the patient undergo hernia repair, which has been approved by the Health Plan. The patient has also been evaluated by a plastic surgeon who found a moderate panniculus (5cm overhang). Authorization was then sought for a panniculectomy of the right lower quadrant of the abdomen. Photographs of the patients condition are not available due to religious reasons. The Health Plan has denied authorization for the panniculectomy on the basis that the requested procedure is not medically necessary.The Health Plans denial should be upheld. The hernia at the umbilicus is essentially asymptomatic. The panniculus described is most likely due to the Pfannenstiel incisional approach and delayed healing. A hernia repair is medically necessary and has been authorized by the Health Plan. However, the size of the pannus described without corroborating photographs does not appear to present a functional problem. Furthermore, given the patients body habitus (63, 166 pounds) it is not likely there is very much excess tissue. Thus, there is not sufficient evidence that the requested panniculectomy is medically indicated. Based upon the information set forth above, I have determined that 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: Upheld Decision of Health Plan

The patient is a 16-year-old male with left lower lobe and minimal right middle lobe bronchiectasis. The patient does not have cystic fibrosis. Review of the submitted records indicates daily chest physical therapy has not been used. A request has been made for the Vest Airway Clearance System (the Vest). The Health Plan has denied the request indicating that the Vest is not medically necessary based upon the information provided.The Vest is a high frequency chest wall device for chest physical therapy and has been available since 1988.  It has been studied most frequently in patients with cystic fibrosis where daily chest physical therapy is generally accepted treatment. There are no randomized, controlled, long-term clinically significant outcome clinical trials (where the end point is fewer hospitalizations for pulmonary infections or decrease in the progression of pulmonary disease) that document the safety and efficacy of the Vest in patients with bronchiectasis.  Furthermore, any patient with a recent pulmonary infection will have local bronchiectatic changes.  Chest physical therapy is the generally accepted treatment for clinically significant bronchiectasis and there is no documented superiority of the Vest over chest physical therapy except for convenience.    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 52-year-old woman with left breast cancer. The results of the patients mammogram in July 2002 were normal but in October 2002 a left breast mass was discovered, which was identified on a follow-up mammogram later that month. The mass was biopsied under ultrasound guidance and invasive ductal carcinoma was revealed. The patient had a lumpectomy and radiation and is on anti-estrogen adjuvant chemotherapy. The patients left breast is tender with no evidence of recurrent tumor. The patients provider has requested a routine follow-up mammogram and MRI of the patients breasts. The issue is whether the requested MRI is medically necessary.The indications for breast magnetic resonance have been increasing over the last several years as imaging techniques have been refined and more clinical studies have been published. However, the indication for routine follow-up MRI for recurrent cancer in breasts that have been previously treated with surgery and radiation has not yet been established. While several European studies have shown the possible efficacy of magnetic resonance in this clinical setting, overall improvement in patient care and outcomes has not been determined. Thus, MRI of the breast in this clinical setting has not been established and is not medically necessary. In light of the patients present tenderness and the difficulty in recognizing the initial breast cancer, follow-up mammography (with compression to the patients tolerance) and ultrasound would be appropriate.Based upon the information set forth above, I have determined that the requested MRI is not medically necessary for evaluation 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 woman who is two years status post bariatric surgery. The patient has reportedly experienced a 150-pound weight loss. The submitted photographs demonstrate multiple areas of trunk skin excess. The patient reports pain in the buttock area upon sitting. The patient wishes to undergo a surgical procedure to resect the redundant skin and residual adipose of her trunk. She was examined by two plastic surgeons who determined that the discomfort complained of was not explainable by the presence of the patients excess skin and that other studies should be carried out. The Health Plan has denied the patients request for a trunkplasty on the basis that it is not medically necessary. The submitted documentation confirms the examining physicians findings. Although the patient reports pain in the buttock area upon sitting, there is no demonstrated etiology for the patients pain. It is unlikely that the skin folds themselves would cause pain. Additionally, there is no evidence of intertrigo, which would cause burning pain. Thus, there is no evidence that the requested procedure would alleviate the patients pain. Furthermore, there is no other documented symptomatology that would warrant a trunkplasty. Therefore, I have determined that 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: Upheld Decision of Health Plan

The patient is a 43-year-old man who has muscular dystrophy with severe myopathy and is unable to ambulate. The submitted records indicate the patient currently has a power wheelchair, a seat lift mechanism, and a commode chair. The patient indicates that he is unable to access parts of his home due to the width of his chair. The patient has requested authorization and coverage for a standing wheelchair and power-assisted commode chair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the patients medical condition.The patient has requested a standing wheelchair due to problems with access. Review of the occupational therapy evaluation from 4/6/04, indicates the patient can maneuver his current power wheelchair into the bathroom off his bedroom and that his bedroom is accessible. Apparently, the patient cannot reach the kitchen in his current power wheelchair due to a cupboard blocking access. However, a standing wheelchair does not address the issue of access since only the width of the chair is at issue. Thus, a standing wheelchair is not medically necessary to resolve the patients problem of access. The problem with access could perhaps be resolved by use of a portable commode chair and placing a small refrigerator within reach or by use of a narrower chair. Furthermore, a standing wheelchair is not required for purposes of pressure relief as the patient currently has a power wheelchair with recline.The patient has also indicated that he has difficulty urinating on a toilet and requires a power-assisted commode chair. However, the in-home occupational therapy evaluation indicates the requested commode would not allow the patient to be independent with urination since he would still require assistance. Thus, a power-assisted commode chair does not resolve the patients problem with urination and is not medically indicated. Given that the patient would still require assistance with a power-assisted commode chair the alternatives of transfer training with family or a portable commode proposed by the occupational therapist are more clinically appropriate.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: Overturned Decision of Health Plan

The patient is a 49-year-old man who has erectile dysfunction. The patient received a temporary prescription of Viagra, which reportedly improved his condition. In addition, review of the submitted records indicates the patient has received multiple medications for treatment of depression including Lorazepam, Wellbutrin, Desipramine, Ativan and Adderall. The patient has requested authorization for a consultation with an urologist for treatment of his erectile dysfunction.Viagra is accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. Whatever treatment is successful and acceptable to the patient has his partner is appropriate therapy. The patient has depression and is being treated with anti-depressants. The fact that the patients anti-depressive medication has a known side effect of erectile dysfunction should not preclude appropriate treatment of his erectile dysfunction. The patient should have a urology consultation and the urologist and the patients psychiatrist should coordinate care so that appropriate adjustment to the patients medications can be made in order to treat both the patients depression and erectile dysfunction. These two conditions are potentially contributing to each other and both need to be addressed. Based upon the information set forth above, I have determined that the requested consultation 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 14-year-old male who was seen by a rheumatologist for bilateral patellofemoral syndrome, limb length discrepancy, and flexible painful pes planus. The patient has a history of knee arthralgia. The patient also experiences lower back pain and bilateral plantar calcaneal pain with activity. A request has been made for custom orthotics. The Health Plan has denied the request on the basis that the requested equipment is not medically necessary.Review of the submitted medical records does not demonstrate the need for custom-molded orthotics. The submitted documentation shows the patient has a limb length discrepancy but no modification reflecting that fact is noted on the orthotic prescription. The records indicate heel pain but it does not appear that x-rays were obtained to rule out any bone pathology. Although the patient has a pes plano valgus foot structure the submitted information does not demonstrate that standard orthotics have been tried. Furthermore, there is no record of any posting instructions to compensate for any subtalar valgus. 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 59-year-old man who is 510 weighing approximately 305 pounds. The patient has a history of degenerative joint disease of the left hip and wishes to undergo minimally invasive anterior hip replacement surgery. The Health Plan has denied authorization for the requested procedure but has indicated that standard hip arthroplasty can be performed subject to the patients ability to meet the surgical criteria such as acceptable weight loss.The requested procedure is not medically necessary for treatment of the patients degenerative joint disease. The patients weight makes any procedure difficult to perform, especially a minimally invasive procedure. The primary difference between standard hip arthroplasty and the requested procedure is that the latter requires a smaller incision. However, the incision must be of significant length to see clearly and heavier patients such as this patient require longer incisions. Furthermore, there is no evidence that an anterior approach is superior to a posterior approach. Thus, the requested procedure is not medically indicated for this patient. Based upon the information set forth above, I have determined that 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: Upheld Decision of Health Plan

The patient is a 26-year-old woman who has requested myofascial release therapy for the treatment of vulvodynia. The submitted records indicate the patient experiences vulvar and rectal burning, itching, vaginal pain with penetration, burning with urination, and vaginal discharge. The patient has been receiving myofascial release therapy from an out-of-network provider. The patients treatment regimen also consists of connective tissue manipulation, muscle energy techniques, and neuromuscular re-education. The patient has requested authorization for continued therapy. The Health Plan has denied her request indicating that there is insufficient evidence to support myofascial release technique for vulvodynia. Myofascial release therapy is not standard of care for treatment of vulvodynia. Review of the current medical literature does not reveal any peer-reviewed case controlled studies evaluating the effectiveness of myofascial release therapy for this indication. Thus, there is no evidence demonstrating that the requested therapy is medically indicated. The physical therapy services offered by the Health Plan are more 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: Overturned Decision of Health Plan

The patient is a 51-year-old female with a left breast mass. A mammogram performed in February 2004 showed a 3cm mass. Ultrasound-guided biopsy was performed with the mass being invasive ductal carcinoma. The patients surgeon ordered a positron emission tomography (PET) scan as part of the staging evaluation. The Health Plan has denied authorization for the requested PET scan.Over the last decade, there have been many studies showing the efficacy of PET for staging breast cancer. In October 2002, the Centers for Medicare and Medicaid Services approved PET scans for breast cancer staging/restaging of local/regional recurrence or distant metastases. PET scan has been shown to be more sensitive and specific than CT scan for detection of mediastinal and internal mammary lymph node metastases. Additionally, PET has been shown to be more sensitive, accurate and have better positive and negative predictive values than conventional imaging for detecting local recurrence or distant metastases.  PET has been shown to have a significant impact on the management of breast cancer patients, influencing both clinical stage and management. In the case of this patient, her provider has requested a PET scan to assess her disease status. A PET scan to assess breast cancer patients such as this patient is medically indicated.Based upon the information set forth above, I have determined that the requested PET scan is medically necessary for evaluation 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 57-year-old man with a history of hepatitis C. The patient was given Peg-Intron and Rebetol for at least five months. Review of the submitted records indicates the patient did not clear his virus and there was only a 1.4 log drop in his viral count. A repeat course of Peg-Intron and Rebetol therapy has been recommended by the patients provider. The Health Plan indicates that a second course of Peg-Intron and Rebetol therapy is not medically indicated given the patients insufficient response to the initial course of therapy.It is not the standard of care to retreat patients who have not responded to an initial course of Peg-Intron and Rebetol therapy.  The article by Fried, et al. cited above clearly shows that if a patient does not respond to Peg-Intron and Rebetol therapy within three months (i.e., experiences a 2 log drop in viral count or undetectable viral count), there is a 97% certainty that the patient will not respond to continued therapy. Although the patient indicates that he did not receive a full six-month course of Peg-Intron and Rebetol therapy, the patient did not experience a significant decrease in his viral load after three months of therapy. Thus, a repeat course of Peg-Intron and Rebetol therapy is not likely to benefit the patient and is not medically indicated.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.