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

The patient is a 50-year-old female with a history since October 2003 of visual distortion in the left eye. She has a past medical history of irregular vaginal bleeding with normocytic anemia (history of normal endometrial biopsy); hepatitis C; and back pain. The patient also reports a history of migraine headaches. The patients optometrist indicated the patient needed to see a retinal specialist after seeing a distortion on the membrane of the retina. The patient was seen by an ophthalmologist who noted the patient had 20/20 vision in both eyes. In November 2003, a Humphrey visual field test showed non-specific changes, and fundus exam/photos and fluorescein angiogram revealed a splinter heme in the left eye. It appears a follow-up appointment was scheduled but was subsequently canceled. The patient continues to experience distorted vision and headaches, and reports that she has difficulty driving and reading. She has requested authorization for a referral to a retinal specialist. The Health Plan has denied the patients request on the basis that a referral to a retinal specialist is not medically necessary.The submitted documentation does not demonstrate the requested referral is medically necessary. A general ophthalmologist is capable of evaluating the retina and rendering an opinion as to whether follow-up or referral is necessary. The submitted evidence shows the patients ophthalmologist has chosen to continue follow-up with the patient. A referral to a retinal specialist may be necessary in the future based on the results of the follow-up examination; however, at this point there is no medical indication for the requested referral. Therefore, I have determined that the requested referral is not medically necessary for the 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 an 18-year-old female with a several year history of varying degrees of bulimia nervosa consistent with the criteria outlined in the Diagnostic & Statistical Manual of Mental Disorders IV. The patient was admitted to residential treatment center level of care on 4/19/04 and her stay was authorized by the Health Plan until 5/25/04. In addition to her eating disorder, the patient also has major depressive disorder and is being treated with psychotherapy and Prozac 60mg per day. Although not described as actively suicidal, the patient continues to indulge in self-harm with scratching, picking and stabbing sharp objects into her skin. The patient has an apparent history of failed inpatient and intensive outpatient treatment. In addition, there are possible post-traumatic stress disorder symptoms related to apparent sexual abuse that has only recently been discussed in individual and family therapy. The patient has made progress in the residential treatment center program and seems independently motivated to remain in treatment. Her recent past history is subnormal body weight, bradycardia, and electrolyte imbalance as a result of her eating disorder. According to the clinical records provided the patient is reported to have reached her ideal body weight with normal electrolytes and heart rate.A request has been made for continued residential treatment services. The Health Plan states that the submitted documentation does not demonstrate that residential treatment services were medically necessary after 5/25/04.Based on the submitted medical records, it appears the patient has greatly benefited from her five-week authorized stay at residential treatment center level of care. However, the information provided demonstrates that by 5/25/04 the patients condition had stabilized and improved enough for the patient to be transitioned to partial hospitalization level of care for continuation of her treatment. The Health Plans recommendation that the patient be transferred to a less intensive level of treatment is consistent with national and local community standards of care. As of 5/25/04, the patient was reported to have reached her ideal body weight with normal electrolytes and heart rate, and was stable from a psychiatric standpoint. As such, there is no medical indication for continued residential treatment services.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. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 64-year-old man who is requesting authorization and coverage for Viagra. He has used Viagra in the past with reported success. The patient has been taking several drugs for arthritis, but none of these have a known negative effect on erectile function. The Health Plan has denied authorization for Viagra on the basis that it is not medically necessary for treatment of the patients condition.Viagra is an accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. Whatever treatment is successful and acceptable to the patient and his partner is appropriate therapy. It is estimated that 50% of males over the age of 60 have erectile dysfunction. This is thought to be due to early atherosclerotic changes that develop in the small arterioles before lesions are demonstrated in the larger vessels, which are easier to document. Those who are partially impaired are likely to have an excellent clinical response with Viagra or one of the other, newer 5-phosphodiesterase inhibitors. In fact, the submitted documentation indicates the patient has used Viagra in the past with benefit. 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 55-year-old female with multiple sclerosis who has developed a progressive gait disorder with scissoring. She has been able to ambulate 100-200 feet with a cane and 300 feet with crutches. The patient appears to be able to ambulate with assistive devices for household distances. She has requested authorization for a wheelchair for community mobility purposes. The Health Plan has determined a wheelchair is not medically necessary for the patients mobility.The patient does not meet nationally accepted medical necessity criteria for authorization of a wheelchair. The patient is not bed or chair confined. The submitted information indicates the patient is able to ambulate with assistive devices in her home. While it is probable based upon the patients diagnosis that she will eventually require a wheelchair for home mobility, such need has not been demonstrated at this time. Therefore, I have determined that the requested equipment is not medically necessary for the 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 37-year-old female with a history of irritable bowel syndrome (IBS) and constipation. Apparently Zelnorm at the recommended dose of 6mg twice a day was not effective for the patient. The patients provider has prescribed Zelnorm 12mg twice a day. The patient indicates the increased dosage of Zelnorm has been effective. The Health Plan has denied authorization for the requested prescription on the basis that it is not medically indicated for treatment of the patients IBS with constipation.The Food and Drug Administration (FDA) approval for Zelnorm was intended for females with constipation at a dose of 6mg twice daily for a period of four to six weeks with an additional four to six weeks of treatment if necessary. Clearly the proposed doubled dosage is outside the FDA approval and is not the standard of care. There have not been any double-blind prospective studies examining the requested dosage reported in the literature. As such, the safety and efficacy of the proposed dosage is not known and therefore, the requested prescription not medically indicated at this time.Based upon the information set forth above, I have determined that the requested prescription 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 72-year-old man with a history of back pain and sciatic pain. The patient has apparently been unable to tolerate physical therapy except for aquatic therapy, which he reports has been very effective. The patient has requested authorization and coverage for aquatic therapy. The Health Plan had denied the request on the basis that aquatic therapy is not medically necessary.Review of the relevant medical literature suggests that aquatic therapy is at least as efficacious as land-based therapy. A randomized, controlled study showed the efficacy of aquatic therapy for back pain subjects (McIlveen, et al.).  Furthermore, the patients previous experience with aquatic therapy has proven beneficial. The patient is unable to tolerate land-based therapy. As such, aquatic therapy is a medically appropriate and indicated alternative to land-based therapy. Therefore, I have determined that the requested therapy 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

This patient is a 28-year-old woman who has irritable bowel syndrome (IBS) with constipation dominance. The patient has been taking Zelnorm for several months. The submitted documentation indicates that since the patient has been taking Zelnorm she has had normal bowel habits and no abdominal pain. The Food and Drug Administration (FDA) approved dosage for Zelnorm is 6mg twice daily for four to six weeks, which could be extended another four to six weeks depending upon results. The patient wishes to continue treatment with Zelnorm. The Health Plan has denied authorization for Zelnorm on the basis that it is not medically indicated.Although the duration of the patients use of Zelnorm has exceeded FDA guidelines, IBS and constipation are lifelong conditions. The patients provider has indicated that the patient has not responded to any conventional medications. In addition, it has been noted that the patient has developed rectal prolapse due to her severe constipation. In this particular case, given the patients clinical condition and her past success with Zelnorm, continued use of Zelnorm may be medically indicated. However, this determination cannot be made because the information submitted does not contain the necessary recent history to determine whether the patient is experiencing any of the known complications from the medicine such as syncope, diarrhea, or symptoms of ischemic colitis. Absent a sufficiently detailed history, the prolonged use of Zelnorm is contraindicated. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if the patients provider submits documentation demonstrating the patient has no history consistent with known complications to Zelnorm, the Health Plans denial should be reconsidered because the patient has demonstrated a positive response to Zelnorm and no other medication previously tried was beneficial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 31-year-old with multiple somatic complaints but no definitive diagnosis. Her primary symptoms include chronic fatigue and hypersomnolence. The patient is on several psychotropic medications including Lexapro, Effexor, and Zoloft. All of these medications could be contributing to the patients fatigue and other symptoms.The case involves a 31-year-old female with a diagnosis of hypersomnolence without narcolepsy or obstructive sleep apnea, and her physician is requesting Provigil 200 mg. The clinical summary of January 2004 from the patients provider indicates the patient has a myriad of medical conditions leaving the patient feeling fatigued and tired with significant nausea, vomiting, abdominal discomfort and somnolence with hypersomnolence. Multiple treatments have been utilized previously; including pain medications and SSRIs. The SSRIs have associated fatigue and hypersomnolence. The medications have not demonstrated any benefit for the patient.The patients medical records do not indicate sleep studies such as polysomnogram and multi-sleep latency test were performed to support the diagnoses of hypersomnolence, narcolepsy, obstructive sleep apnea/hypopnea syndrome, shift work disorder or other sleep disorders. Furthermore, it does not appear the patient has been referred to a sleep study specialist to further investigate the symptoms being experienced. Without such information, Provigil cannot be considered necessary for this patient.Based upon the information set forth above, there is no clinical documentation indicating that the requested medication is medically necessary for treatment of the patients medical condition. 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 58-year-old male with a smoking history of approximately 60 pack/year. He has had episodes of acute bronchitis that were treated with antibiotics. He complains of cough, fatigue, chest tightness, and shortness of breath. A chest x-ray performed in December 2003 was normal. The patient is requesting a low-dose helical screening CT scan of the chest. The Health Plan has denied the request on the basis that the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plan recommends further evaluation by a pulmonologist.  Currently, there are several on-going clinical trials evaluating the efficacy of screening CT scans of the chest for lung cancer. This patient may qualify for one of these studies. However, earlier detection of lung cancer by screening CT scans of the chest (low-dose or otherwise) has not yet shown to decrease mortality from lung cancer and is currently not the standard of practice. The Health Plans recommendation that the patient be evaluated by a pulmonologist is medically reasonable and appropriate. Low-dose helical screening CT scans of the chest are of unknown efficacy at this time and therefore, not medically necessary. Based upon the information set forth above, I have determined that the requested CT scan is 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 59-year-old woman who experienced over a 100-pound weight loss following bariatric surgery. In 2003, the patients primary care physician noted the patients weight was 165 pounds. One year later the patient was seen by a plastic surgeon who noted the patients weight was 173 pounds and she had intertrigo of the abdominal panniculus. The patient wishes to undergo an abdominoplasty. The Health Plan has denied authorization for the requested procedure on the basis that it is cosmetic in nature and not medically necessary.The submitted photographs demonstrate a modest hanging pannus. The photograph of the pannus suspended does not show signs of intertrigo. The submitted records do not demonstrate that the patient has intertrigo that has been refractory to standard treatment. There is insufficient documentation of functional impairment to warrant an abdominoplasty 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 58-year-old female three years post gastric bypass with weight loss in excess of 160 pounds. She has experienced anatomic changes due to massive weight loss. The patient indicates she is troubled with the laxity of her upper arms. Accompanying photographic evidence documents hanging excess skin of the arms. A request has been made for surgical excision of the excess skin. The Health Plan has denied the request on the basis that the requested procedure is cosmetic in nature and not medically necessary.The submitted photographic evidence of the patients hanging skin of the upper arms does not demonstrate medical necessity for the requested procedure. Evidence of a functional impairment has not been provided. Thus, there is no indication that the requested procedure is medically warranted in order to treat clinical symptoms or functional complaints. Therefore, I have determined that the requested procedure is cosmetic in nature and 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 54-year-old man with end-stage liver disease secondary to hepatitis C, currently inactive on the liver transplant list because of morbid obesity. The patient was under the care of a hepatologist for several years. The patient is requesting that he continue to be treated by a hepatologist. The submitted records indicate the patients care is being managed by his internist and gastroenterologist. The patient has been advised that he needs to decrease his weight to 225 pounds or a body mass index of 35 before he can be re-listed on the liver transplant list.  In light of this, the Health Plan has indicated that the patient does not need to be followed by the transplant teams hepatologist at this time; the Health Plan states that a gastroenterologist is qualified to treat the patients liver condition, which is stable.The treatment proposed by the Health Plan is medically reasonable and appropriate. The patients liver condition is stable. No evidence has been provided that demonstrates that the patient cannot be appropriately treated by a gastroenterologist. Accepted community standards indicate a gastroenterologist is fully qualified to provide ongoing care of the patient at this time. Until such time as the patient loses weight and is re-listed on the liver transplant list, there is no medical indication for continued treatment by a hepatologist. Therefore, I have determined that the requested services are not medically necessary for the 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 35-year-old female who experienced approximately a 100-pound weight loss following gastric bypass surgery. The patient consulted a plastic surgeon regarding removal of excess hanging skin of the ptotic breasts, arms, and abdomen. The procedures requested were mastopexy, removal of excess skin from arms and trunk and a ventral hernia repair. Though a ventral hernia was previously documented by the patients physician no evidence of the hernia was found on a recent ultrasound of the abdomen. The Health Plan has denied authorization for the requested procedures citing lack of medical necessity.The submitted documentation, including photographs of the patient, does not establish medical necessity for the requested procedures. Evidence of a functional impairment has not been provided. There is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. Furthermore, with regard to the requested ventral hernia repair a recent ultrasound of the abdomen revealed no evidence of an abdominal or ventral hernia. Therefore, I have determined that the requested procedures are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 34-year-old man with a long history of tinea pedis and onychomycosis. He has requested authorization for Gris-Peg for treatment of his condition. The patient is not otherwise immunocompromised or with significant medical disease. The Health Plan has determined that Gris-Peg is not medically necessary for treatment of the patients medical condition.Antifungal agents for treatment of onychomycosis are not medically necessary unless there is evidence of a positive culture and documentation of severe impairment, dysfunction or comorbidity. In this case, evidence of a positive culture has not been provided. In the absence of documentation of a fungal infection the requested medication is not medically indicated. Therefore, I have determined that the requested medication is not medically necessary for the 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 male with pleuritic chest pain who was prescribed Vioxx by his cardiologist and primary physician. The patient has a past history of gastroesophageal reflux disease (GERD), hypertension, and hypercholesterolemia. The patient has a history of pericarditis in 1980. Electron beam CT scan of the chest and coronary arteries showed normal lung tissue and pleura as well as a normal coronary calcium score. The patients cardiologist determined the patients chest pain was pleuritic and prescribed Vioxx. The Health Plan has denied authorization for Vioxx indicating that there is no documentation that the patient had tried alternative low risk NSAIDs.At issue is whether Vioxx is medically necessary for treatment of the patients pleuritic chest pain. Standard treatment for pleurisy is non-steroidal anti-inflammatory drugs (NSAIDs). The patient was initially prescribed Vioxx, which is a COX-2-specific NSAID. The patient has not been shown to have any indication for initial therapy with a COX-2-specific NSAID such as Vioxx. COX-2 specific NSAIDs do not have better efficacy than non-specific NSAIDs in relieving pleuritic chest pain. The standard treatment is generally ibuprofen or indomethacin. There are also NSAIDs with low GI risk available, such as Relafen or Lodine. Based on the submitted evidence, there is no medical indication for use of Vioxx in this case. Therefore, I have determined that the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.