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

The patient is a 50-year-old woman with chronic back pain radiating to her right lower extremity. She states she has numbness. She has attempted use of medication, physical therapy, chiropractic, and exercises. An MRI was performed in 2003. The study was repeated in June 2005 at the request of the patients treating neurologist. At issue is whether the repeat MRI was medically necessary for evaluation of the patients medical condition.Review of the submitted clinical evidence indicates the MRI at issue was medically reasonable and appropriate. The patient has had chronic pain with failure of conservative treatment and radicular complaints. The study was performed to evaluate her for facet hypertrophy, neural impingement, stenosis, disc herniation, etc. and to see if surgery was an option. The MRI was reasonable, clinically indicated and the appropriate test at the time. Therefore, I have determined the MRI at issue was medically necessary for evaluation 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 37-year-old male who has a dsytrophic right first toenail due to onychomycosis verified by fungus culture. The patient has pain and discomfort of his right foot secondary to the onychomycosis. Liver function tests are normal. At issue is whether Lamisil is medically necessary for treatment of the patients medical condition.This patient meets all the medical necessity criteria for oral Lamisil treatment of onychomycosis. The submitted evidence documents consistent clinical features, a positive fungus culture, and symptoms resulting in functional impairment, namely pain and discomfort of the right foot. The absence of a coexisting medical condition should not preclude the use of Lamisil in this case because there is functional impairment, which is likely to worsen if systemic treatment is not instituted. Therefore, I have determined 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: Overturned Decision of Health Plan

This patient is a 25-year-old female with a history of persistent nausea and vomiting. Vomiting has occurred as much as 14 times a week. There is also evidence of dental erosion from the vomiting. The patient has tried Reglan, erythromycin, Protonix, Zantac and Pepcid. A gastric emptying study demonstrated delayed emptying at two and four hour intervals.  The Heath Plan denied the patients request for authorization of gastric electric stimulation therapy based on a determination that the therapy is not medically necessary.The gastric stimulation device was approved by the FDA in March 2002. It was studied in the Worldwide Anti-Vomiting Electrical Stimulation Study (WAVESS), which demonstrated a 50% improvement in symptoms and quality of life over a 12-month period. The therapy reduced the rate of hospitalizations by 30% in the first year after implantation of the device. The benefits of this form of therapy were also reported in the GEMS study group from 1997 to 1999 and several other studies as noted above.The manufacturers study inclusion criteria is outlined in the Summary of Safety and Probable Benefit of the Gastric Electrical Stimulator. The patient meets these criteria as she has had symptomatic gastroparesis for greater than one year, been refractory or intolerant to at least two anti-emetic and prokinetic drug classes, had vomiting at a frequency greater than seven times per week, and had delayed gastric emptying defined as greater than 60% retention at two hours and greater than 10% retention at four hours.  The patients symptoms have continued despite a wide range of conservative therapies and treatment with the gastric electric stimulator is medically appropriate at this juncture. Based upon the information set forth above, I have determined 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 50-year-old female with a history of Hepatitis C, genotype 3a.  She was treated with a six-month course of Pegasys and ribavirin. The patients last PCR level was 223 in November of 2005. She has requested authorization for an additional six months of Pegasys and ribavirin therapy.  The Health Plan determined the requested therapy is not medically necessary, and denied her request.The record provided is somewhat limited with respect to past medical history.  The value of the initial quantitative PCR is not clear from the reports submitted, however the norm is to discontinue therapy if there is not a 2-log drop within the first three months of treatment.  This patient completed six months of therapy. Although some investigators continue treatment up to 48 weeks in genotype 3, it is not the standard of care and is not FDA approved. Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 67-year-old female who is status post keratoplasty in the left eye with a refractive error of + 3.00  7.00 x 59 degrees with visual acuity of 20/100 in the left eye. The submitted notes from her ophthalmologist show no improvement in visual acuity with a pinhole. The patients ophthalmologist has recommended the patient undergo photorefractive keratectomy of the left eye. The Health Plan has denied authorization for this procedure on the basis that it is not medically necessary for treatment of the patients condition.The patient wishes to undergo photorefractive keratectomy in her left eye that has 8.5D of corneal astigmatism following penetrating keratoplasty. While this may be an appropriate treatment in an eye with better potential vision, the refraction in this patient demonstrates a best-corrected vision in the left eye of only 20/100. Thus, based on the limited degree of potential visual improvement in this patient, photorefractive keratectomy is not medically warranted.Accordingly, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 48-year-old female with a body mass index (BMI) of 41. She has multiple comorbidities. The patient has undergone a psychological evaluation and has been found to be an appropriate candidate for weight loss surgery. Her provider has recommended that she undergo a duodenal switch procedure. The Health Plan has denied coverage for the requested procedure citing a lack of medical necessity. The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Accordingly, I have determined that 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 44-year-old woman with intractable chronic daily headache requesting coverage for Actiq. The patient has been evaluated at multiple pain clinics and has failed usual acute and chronic therapies. She has been using Actiq for three years with improvement in her condition including reduction in emergency room visits and the ability to stay employed. She has requested authorization and coverage for Actiq, which has been denied by the Health Plan.Review of the submitted clinical evidence demonstrates the patient has chronic migraine likely complicated by medication overuse headache. She has failed standard therapy. The patient has tried a variety of short and long-acting narcotics and found Actiq affords her the best control of her headaches. Given the documented failure of other available treatments and the demonstrated improvement with Actiq, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old male who is HIV-infected and is being treated with appropriate anti-HIV therapy with good virological result. He has requested authorization and coverage for recombinant growth hormone (Serostim) for management of AIDs related wasting and weight loss. He reports that at 188 pounds he is more than 10% below his ideal weight of 220 pounds. He also states that his records include documentation of a normal serum testosterone while on testosterone therapy. There is a level of 125 ng/dL (low) in December 2005, and elevated levels in April and June 2005.At issue is whether Serostim is medically necessary for treatment of the patients medical condition.The patient does not meet medical necessity criteria for use of recombinant growth hormone. Based on the information provided, it appears the ideal body weight for a male who is 70 tall with a large frame is 160 to 193 pounds. In addition, the submitted materials include adequate documentation of normal serum testosterone while on replacement. Though the records do not document which anabolic agent was being used, there is a statement from the patients internist indicating that he was on nandrolone. Furthermore, there is no documentation in the submitted records of a lean body mass below 40%.If one assumes the patient was continually on testosterone replacement from April 2005 through August 2005, his weight has fluctuated only by about 5%. No information has been provided regarding the patients diet and there is no reason to believe the weight loss represents failure of testosterone therapy. Furthermore, a recent article by Storer, et. al. demonstrates that recombinant growth hormone and nandrolone are of equal efficacy in the management of AIDs-associated weight loss.The criteria set forth by the Health Plan for authorization of Serostim are medically appropriate and consistent with widely accepted recommendations. Since the submitted evidence demonstrates the patient does not meet these criteria, 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 44-year-old woman with a diagnosis of infertility and four failed IUI cycles. It appears that she was then given ovum donation in two cycles, first via a fresh embryo transfer and then with a frozen embryo transfer. Both cycles resulted in pregnancy but ended in first trimester miscarriages. She was referred to a reproductive endocrinologist who initiated a workup for immunologic testing for recurrent pregnancy loss. A TH1:TH2 ratio was found to be elevated as well as CD19+ 5+ B-1 cells. IVIG therapy was recommended and given. The patient has requested reimbursement for IVIG therapy she received in September 2005 as well as prospective authorization for IVIG with a future pregnancy. The patient does have a diagnosis of recurrent pregnancy loss in the first trimester. The etiologies for this problem include chromosomal, uterine structural, ovulatory and immune factors. The treatment for immune factors and their efficacy is currently highly controversial. Although a few studies have shown modest benefit in properly characterized patients with repeated pregnancy loss, others have not. Thus, no clear efficacy has yet been shown. According to the 2004 Practice Committee Opinion of the American Society for Reproductive Medicine, IVIG treatment for recurrent miscarriage is an experimental treatment: For the management of recurrent spontaneous pregnancy loss IVIG is an experimental treatment. Based on the evidence available to date, there is insufficient data demonstrating the efficacy of IVIG in this clinical setting.For the reasons set forth above, I have determined the therapy at issue was/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 48-year-old woman who presented with a palpable abnormality in the right breast. Digital mammogram in February 2006 showed questionable increased density in the upper half of the right breast. Corresponding ultrasound showed a highly suspicious mass at the 10:00 position. Subsequent ultrasound-guided biopsy showed infiltrating ductal carcinoma with associated DCIS. The patient was referred for an MRI of the breasts for surgical planning. At issue is whether the MRI was medically necessary for evaluation of the patients breast cancer.Magnetic resonance imaging of the breast is a newer means of imaging for breast cancer. Peer-reviewed literature (including American College of Radiology guidelines) have shown that MRI of the breast is medically appropriate under certain conditions including determinations of the extent of biopsy proven infiltrating ductal cancer and to evaluate for additional sites of breast malignancy within the ipsilateral and contralateral breast. Magnetic resonance imaging of the breast in these situations allows proper surgical planning including consideration of conservation breast surgery versus mastectomy. For this patient with infiltrating ductal carcinoma, an MRI of the breast was medically necessary for purposes of surgical planning and appropriate treatment of her condition.Based upon the information set forth above, I have determined the MRI at issue was medically necessary for evaluation 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 42-year-old female with a history of knee pain with grinding and clicking for six months. There is no history of prior trauma. Physical exam showed a positive McMurrays test. Clinically, there is concern of a meniscal tear. MRI of the knee has been requested to evaluate the patient for possible meniscal tear.  The Health Plan has denied this request indicating an MRI is not medically necessary in this clinical setting.Upon review of the submitted clinical information, the patient meets medical necessity criteria for an MRI of the knee. According to National Imaging Associates (NIA) guidelines on knee MRI, knee pain persisting for greater than three days with physical findings of meniscal injury including positive McMurrays sign is an accepted diagnosis for an MRI of the knee. As this patient has had knee pain for six months and was found to have positive McMurrys sign on physical exam, an MRI of the knee is medically appropriate and indicated. Therefore, I have determined the requested MRI is medically necessary for evaluation 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 47-year-old male with knee pain who has undergone Hyalgan injections three times in the past five years. He wishes to undergo a forth series of injections. The Health Plan has denied authorization for the requested injections indicating they are not likely to be effective and therefore are not medically necessary.The use of Hyalgan and other hyaluronic products is common in the orthopedic community for treatment of joint pain. However, studies have not shown any benefit with multiple series of Hyalgan injections. The patient has already received three series of Hyalgan  a forth series is not medically indicated. Given that there are no long-term, prospective studies demonstrating the effectiveness of another series of Hyalgan in this clinical setting, I have determined the requested injections 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

This patient is an eight -year-old male with a diagnosis of autism who has been receiving speech therapy since 2002. A review of the speech therapy records demonstrates progress in expressive language skills; the most recent testing in August 2005 indicates his expressive language skills are within normal limits. The patients pragmatic language skills continue to be delayed. The goals for pragmatic skill development include communication with a partner in asking questions, transitioning topics, sustaining attention on topics and non-verbal communication during a conversation.  They are also working on the rate of speed for speech, \th\ sounds and social speech. The patients mother has requested reimbursement for the speech therapy provided in October 2004.  The Health Plan concluded the therapy at issue is not medically necessary, and denied her request.The clinical records from the speech therapist indicate there are continued deficits in the patients pragmatic speech, but that he is making progress.  I reviewed the literature to determine what standardized testing is available in the area of pragmatic speech and found very little. The Pragmatics Profile of the CELF-4 used in this case appears to be the most accurate test available.  Pragmatic speech delays are a primary delay in children with autism. When working with these delays, treatment success is measured in years not months. The therapist in this case has documented objective evaluations and gains sufficient to conclude the patient has benefited from his previous therapy and is likely to benefit from continued therapy.   Periodic retesting using the Pragmatics Profile, or a newer evaluation tool if available, should occur at six-month intervals to evaluate for continued improvement.Based upon the information set forth above, I have determined the therapy at issue 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 29-year-old female who has requested authorization for a hysterectomy because of pelvic pain. She has undergone extensive workup without any evidence of a gynecological etiology for her complaints.  The Health Plan has denied authorization for the requested hysterectomy on the basis that the procedure is not medically necessary.The patient has seen numerous gynecologists and the general consensus has been that she has no indication for a hysterectomy. The submitted medical records including physical exams, laparoscopy and sonograms do not indicate any pathology that would substantiate a need for surgery. As such, it is not likely a hysterectomy will be beneficial for the patient and therefore, it is not medically warranted. Accordingly, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 35-year-old female with a history of miscarriage and premature delivery due to a premature rupture of membranes at 24 weeks of twins with perinatal demise of both. She has a history of irregular menstrual cycles and required fertility medication with IUI for conception. A note in the history confirms the diagnosis of polycystic ovarian syndrome. Another notation reports an elevated serum homocysteine level, but no documentation of this has been provided. The patient was referred to a reproductive endocrinologist who initiated a workup for immunologic testing for recurrent pregnancy loss. Antithyroid antibodies and NK cell assays were positive, and the patient was homozygous for MTHFR. Levoxyl, low dose aspirin, prometrium, Lovenox, metformin and high dose folic acid were prescribed for preconception purposes and for pregnancy. A subsequent pregnancy was naturally conceived. The reproductive endocrinologist continued to follow the patient through the first and second trimesters. Lymphocyte immunophenotype assays and NK cell assays by flow cytometry and THI:TH2 cytokine ratios were obtained, some on a serial basis. IVIG therapy was given. During this time a mildly elevated NK killing capacity was found. At issue in this case is whether these immunologic assays were medically necessary for evaluation and treatment of the patients condition.This patient was given a diagnosis of recurrent pregnancy loss in the first and second trimester. A clear diagnosis of polycystic ovarian syndrome is noted. The referral to a reproductive endocrinologist was within the standard of care. Metformin treatment for this syndrome is also within the standard of care. During the workup, testing for auto and alloimmune disorders was performed, uncovering evidence of homozygous MTHR and antithroid antibodies. Both of these are associated with recurrent loss in the medical literature. Further testing during pregnancy for NK cell activity during the pregnancy and its treatment is not presently within the standard of care, as there have been no clear benefits shown. The American College of Obstetrics and Gynecology states in its Practice Bulletin that: in the absence of a proven effective treatment, tests for determination of the percentage of circulating NK cells in women with recurrent pregnancy loss is not beneficial. Given that the NK assay and cyclometry studies at issue are without clinical benefit in this setting, the Health Plans denial is appropriate.Based upon the information set forth above, I have determined the services at issue were 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 24-year-old male with a reported weight loss of over 100 pounds 4 years ago. There is no reference to what his weight was four years ago, but he weighed 227 pounds at age 14 and now weighs 155 pounds. The patient complained of a discharge from the umbilicus with a foul odor and itching. His primary care provider (PCP) indicated the umbilicus was infected and prescribed an unspecified cream for belly button. The cream was presumably a topical antibiotic. The patient was referred to a general surgeon who noted an over 80 pound weight loss and recommended a plastic surgery consultation. The patients PCP requested authorization for a plastic surgery referral, which was denied by the Health Plan for lack of medical necessity.Two 5x7 photos are enclosed which do not demonstrate a pannus resting below the symphysis pubis or a chronically infected umbilicus.  Additionally, there are no records of office visits demonstrating active physician involvement in treating the infected umbilicus or clearly documenting the condition of the belly button and noting the medicines that have been tried and failed to control the patients symptoms of odor, burning and itching.  In summary, the clinical indications do not demonstrate that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.