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

The patient is a 17-year-old male who was placed in an alternative classroom setting due to his psychiatric and behavioral problems. He reports abusing methamphetamine and marijuana as well as obtaining money to supply him with drugs by prostitution. There is a possible history of sexual abuse in the past. Several months ago the patient was placed on a 5150 hold because of his acute intoxication and threats to use a gun on himself. He was hospitalized and residential treatment was recommended. The patient was discharged from the hospital but did not enter residential treatment. His discharge medications included an antidepressant. His psychotic ideation cleared when he was withdrawn from the methaphetamines. A request has been made for authorization and coverage for residential treatment services. The Health Plan indicates the patient does not require 24-hour supervised care and therefore the requested services are not medically necessary. Though there is a strong suggestion of a dual diagnosis in this case (major depression with chemical dependency) it is difficult to sort out if the depressive symptoms are secondary to the methamphetamine abuse or instead preceded the use of amphetamines. The customary treatment for patients such as this patient is to initiate chemical dependency treatment while monitoring the level of depression and compliance with the patients prescribed medications. There is no evidence the patient has tried and failed any community-based treatment. Furthermore, the Health Plan has offered partial hospitalization services for the patients continuing psychiatric needs. Alternative treatment options of a chemical dependency program and a partial hospitalization program with individual and family therapy are appropriate for treatment of the patients chemical dependency and psychiatric issues. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 35-year-old female who was diagnosed with rheumatoid arthritis in February 2005 with a rheumatoid factor markedly elevated at 441. She tried several medications including Enbrel, Remicade and then Humira. Humira combined with methotrexate and prednisone at 40mg every other week did not control her rheumatoid arthritis but Humira once a week along with the other medications did stabilize the patients condition. The medical records document active disease at the time of diagnosis with an ESR of 109. On Humira once per week, the patients ESR decreased to 20 and her CRP was 1.68 (March 2006). When the frequency of Humira decreased to every other week, the patients CRP rose to 3.33 and her ESR rose to 42 (June 2006).  A September 2005 MRI demonstrated erosion of the metacarpal joints and the patients provider noted active synovitis on physical examination in June 2006.  The patient was treated with weekly Humira until April 2006 when there was a change in her Health Plan.  Her rheumatologist noted that the patients rheumatoid arthritis did improve with Humira at 40mg once per week.  The patient has requested authorization for Humira injections at a frequency of once per week.  The Heath Plan denied the request based on a determination that the requested dosage/frequency is not medically necessary.The patient has very active and aggressive rheumatoid arthritis. There are markers of poor prognosis with elevated rheumatoid factor and erosive changes on MRI. The patient showed improvement with Humira once per week, but not at an interval of once every two weeks. Continued treatment at the requested frequency of once per week has the potential to mitigate the patients symptoms and to prevent further joint damage. It is the standard of care within the rheumatology community to prescribe for maximum benefit to the patient. Therefore, 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: Overturned Decision of Health Plan

The patient is a 65-year-old female with type 2 diabetes mellitus who is also morbidly obese according to her provider.  She had significant improvement after a short trial of Byetta with a weight loss of 13 pounds and a decrease in her hemoglobin A1c of 0.3%. The patients hemoglobin A1c rose by 1% after Byetta was discontinued.  The patients provider has requested authorization for continued treatment with Byetta. The Health Plan denied the request citing a lack of medical necessity.Two important goals in the treatment of type 2 diabetes are weight reduction and optimal blood glucose management. In this case, the patients initial response to Byetta was consistent with those goals as she lost 13 pounds and improved her hemoglobin A1c by 0.3%. During her brief trial of Byetta, her hemoglobin A1c was initially above the maximum ADA goal of 7.0% (7.1%) and with the medication it dropped to within the ADA goal range (6.8%). Without Byetta, the patients blood glucose control deteriorated and her hemoglobin A1c was again above the ADA goal at 7.8%.  Continued treatment with Byetta is medically appropriate and likely to improve the patients management of her type 2 diabetes.Based upon the information set forth above, 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 10-year-old male born prematurely at 31 weeks with resultant cerebral palsy with spastic quadriplegia. He is status post adductor tenotomies in 1999 and underwent hamstring lengthening and varus derotational osteotomies in 2005 with removal of hardware in 2006. He has received occupational and physical therapy since he was an infant.  He has been on monitor therapy for the last few years because of failure to progress with both therapies. A request has been made for authorization to attend intensive inpatient rehabilitation at the Euromed Rehabilitation Center in Poland to attempt to improve functional abilities. Specific functional goals are not outlined.  The Euromed Rehabilition Center uses intensive physical and occupational therapy in conjunction with a patented device called the Adeli Suit for neuromuscular reeducation.  At issue is whether treatment at the Euromed Rehabilitation Center is medically necessary for the patients cerebral palsy. Though there is anecdotal evidence that patients and families who attend programs such as the one offered by the Euromed Rehabilitation Center feel the experience was a positive one and that the patient gained from the experience, there is no objective scientific data that such programs result in significant functional gains. There are reports of subjective improvements and improvement in motor strength and range of motion immediately and up to one month post session.  However, most of the patients show a return to baseline within one to two months post treatment with or without follow-up standard therapies.  Based on the scientific data available to date, 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: Upheld Decision of Health Plan

The patient is a 64-year-old woman who has apparently been receiving Botox injections about twice yearly. The one included treatment note indicates a dosage of 150 U. This is within the range of doses that are currently identified as successful in treating refractory migraine. She appears to be receiving the Botox injections from a plastic surgeon.No information is submitted about any relevant clinical details other than a reported lack of success with acute treatments  analgesics, three different triptans, and Migranal. The submitted notes are from her internist, nephrologist, and plastic surgeons. There is no evidence the patient has been evaluated by a neurologist or other headache specialist. No information is given about baseline headache pattern, frequency, or impact. No evidence is given that the patient has had trials of any standard preventive medications or response to the same.At issue in this case is whether Botox therapy was/is medically necessary for treatment of the patients medical condition.This patient reportedly has migraines of unstated frequency and impact. She reportedly has not had good relief with several acute, abortive therapies. Migraines often warrant preventive therapy. There are a variety of preventive options available. Though there is evidence from randomized, double blind, placebo controlled trials that Botox is useful as preventive therapy (both for episodic and chronic migraine) and has good tolerability, standard preventives are beneficial for a large number of migraine patients. Botox is presently being used in those patients with poor response to standard preventives. Potential Botox candidates are those with disabling primary headaches with: inadequate response to conventional treatments, unacceptable side effects from existing treatment or contraindications to standard preventive treatments No documented objective evidence has been presented to suggest that this patient fits any of these criteria. The patient should be evaluated by a neurologist or other headache specialist to determine her headache pattern, review her response to standard preventives if they have been used or to initiate a trial of such agents. Based upon the information 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: Upheld Decision of Health Plan

The patient is a 43-year-old male who is status post lumbar surgery for decompression and fusion. His orthopedist prescribed a thoracolumbosacral orthosis (TLSO) to assist with his postoperative rehabilitation. The patient has requested reimbursement for the cost of the device. The Health Plan denied his request based upon a determination that the TLSO was not medically necessary.The efficacy of a TLSO following lumbar decompression fusion surgery has not been established. No prospective study has been conducted to support its general use. There is no evidence that the use of a TLSO was likely to result in an improved clinical outcome for this patient. Therefore, I have determined the device at issue was not medically necessary for the patients postoperative rehabilitation. 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 requesting authorization for a bariatric surgery consultation. She has a body mass index (BMI) of 36.9. She reports chronic heartburn, back pain and knee pain, and her provider noted a family history of diabetes. The patient also reports that she has tried various dietary weight loss programs, medications and exercise without successful long-term weight reduction. The patients provider has recommended a consultation with a bariatric surgeon for consideration of weight reduction surgery.The patient does not meet the recommendations set forth by the NIH for consideration of weight loss surgery. These criteria are based on the relative risks associated with an operative intervention at a particular BMI versus the risks associated with a non-operative approach. Given the patients BMI and comorbidities, non-surgical methods are likely to be more beneficial for this patient. Therefore, I have determined the requested consultation 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 29-year-old female who has had the diagnosis of a bipolar disorder for the last six years. She has had multiple psychopharmacological interventions and a course of 11 ECT treatments in 2005. The last note concerning her current condition was dated February 2006 and was from an in-plan psychotherapist. The note states that the patient remains in a severe vegetative state with recurrent major depression without suicidal ideation.  The patient stated to her therapist that she did not see the point in continuing life.  The therapist stated that the patient did not wish to continue ECT due to severe pain and memory loss.  A return visit was scheduled for three months. The patient also sees a private therapist in the community and a psychiatrist in the community.  A note from the patients psychiatrist states that he has been managing the patients medication for five years.  He continues to see the patient one time a month.  He states that the patient remains severely depressed, meets the DSM IV criteria for a major depression and is now a candidate for VNS therapy.  The Health Plan has denied coverage for VNS therapy on the basis that its use for refractive depression is not medically appropriate given the insufficient quantity and quality of information supporting its efficacy.There is no doubt that the patient has had only transient response to multiple modalities of treatment that include: psychotherapy, pharmacological interventions, and ECT for the treatment of an atypical bipolar disorder. She is currently experiencing vegetative symptoms with no treatment recommendations from the Health Plan except for a follow-up appointment in three months. She is also receiving treatment from a non-plan therapist and psychiatrist. It is not clear how often she is seeing her psychotherapist or the type of psychotherapy she is receiving.  Her psychiatrist is treating her for 30 minutes each month.Although the patient has attempted multiple standard therapies with little or no benefit, the medical necessity of VNS therapy cannot be determined without the following additional information: the patients most recent progress notes from the Health Plan provider; a summary of the patients treatment and progress from the non-plan psychotherapist; a treatment summary from Cedars-Sinai concerning the impact of ECT treatments; and the alternative treatment options offered by the Health Plan. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. If the above-mentioned additional information is reviewed and demonstrates that the patient has exhausted all available standard therapy without success, then there is a possibility a trial of VNS therapy may be indicated and the patients request should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 44-year-old male with a chronic history of low back and right flank pain. Since 1995 he has had various tests for these complaints including an IVP, CT scan, nuclear medicine renal scan, barium enema, endoscopy and MRI. The only positive exam was the MRI of the lumbar spine showing mild degenerative disc disease. The patient has been evaluated by specialists in gastroenterology, urology, orthopedic surgery and behavioral medicine. The patient has also received acupuncture for the pain. He is a bodybuilder and has a history of steroid use. The patient is requesting a PET scan for further evaluation of his pain.The submitted clinical information provides no indication for a PET scan. PET scan is neither a screening test nor is it indicated for pain of unknown etiology. No CMS (Centers for Medicare and Medicaid Services) or NOPR (National Oncologic PET Registry) indications for PET scan include pain. Therefore, I have determined the requested diagnostic procedure is not medically necessary for evaluation 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 16-month-old male whose parent wished him to be circumcised in the immediate neonatal period. However, there was concern for hypospadias and he could not have a circumcision prior to an evaluation by a pediatric urologist, which occurred several weeks later. The patient was found to have normal penile anatomy and is now medically cleared for circumcision. His parent wishes to have the circumcision performed at this time and has requested authorization from the Health Plan. The Health Plan denied the request, citing a lack of medical necessity.The American Academy of Pediatrics 1999 Task Force on Circumcision concluded that parents should determine what is in the best interest of the child after being counseled regarding the potential benefits and risks of this elective procedure. That is the situation in this case - the parent wishes to have her child circumcised. The Health Plan would have authorized the procedure as a covered benefit in the neonatal period, but although the parent wanted it performed then, concern for a potential penile deformity precluded circumcision at that time. The patient is currently in an appropriate condition to have the procedure performed. The circumcision, which was delayed during the neonatal period due to medical reasons, should be authorized and performed. Therefore, 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: Upheld Decision of Health Plan

The patient is a 43-year-old male with a history of low back and right leg pain beginning in 2000. His provider noted the pain was increased by standing or walking. Imaging studies confirm a disc pathology at L4-5. Several conservative treatment approaches were attempted and apparently epidural steroid injections were effective for the patients back pain, but not the severe leg pain.  The patient consulted with a non-Plan provider who recommended endoscopic lumbar discectomy and the procedure was performed in June 2006. The patients request for reimbursement of the cost of the procedure was denied by the Health Plan citing a lack of medical necessity.Endoscopic discectomy is an investigational procedure without scientifically established clinical benefit. While some clinicians do advocate for the procedure, conclusive proof of efficacy remains elusive. This procedure is associated with significant complications and there is a high incidence of revision.  As the patients condition was amenable to more standard treatment modalities, I have determined the procedure at issue was 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 62-year-old male with hypertension (145/91) and hyperlipidemia (LDL 179) in February 2006. He has a prior history of mild aortic regurgitation and aortic valve sclerosis. His EG shows left axis deviation or left anterior hemiblock. He underwent a treadmill test in April 2006. He went six minutes on a Bruce Protocol and the test was interrupted as non-ischemic. He was again hypertensive (148/97 at rest) and had a hypertensive response to exercise (166/100). The patient underwent an echocardiogram in May 2006, which showed E to A reversal on diastolic mitral inflow tracings, septal wall thickening (1.21 cm) and mild aortic insufficiency (AI). All of these echocardiographic findings are consistent with hypertensive heart disease. The echocardiogram was read as no change from January 2002.The patients main symptom is that of dyspnea on exertion; angina or chest pain is not noted in the progress notes. The patient apparently wishes to pursue alternative management rather than medicines to treat his hyperlipidemia and systemic hypertension and therefore has requested a referral to a cardiologist for a second opinion regarding his heart disease with additional testing as needed. The patients provider has recommended treatment of hyperlipidemia and systemic hypertension as well as follow-up by echocardiogram in three years. At issue is whether the requested referral is medically necessary for treatment of the patients condition.It is within the standard of care for patients with mild aortic regurgitation, little or no LV dilation and normal LV systolic function to be followed on a yearly basis. Yearly echocardiogram is not necessary unless there is clinical evidence that regurgitation has worsened. Routine echocardiogram can be performed every two to three years in such patients. Routine re-evaluation in asymptomatic patients with mild valvular regurgitation having stable physical signs and normal LV site and function is considered Class III according to the ACC/AHA guidelines (i.e., it is not recommended). Similarly, mild aortic stenosis or sclerosis is simply observed. There is no further cardiology intervention required for this patient at this point. The recommendations of the patients provider are medically appropriate. AHA antibiotic prophalaxis can be considered along with observation unless new signs or symptoms arise.If the patient cannot achieve JNC 7 goals for systolic hypertension (140/80) or NCEP III target LDL (100-130), then pharmacologic intervention is necessary. Uncontrolled hypertension can worsen AI, and untreated hyperlipidemia can lead to CAD. His provider has recommended pharmacologic treatment and this should strongly be considered in this case particularly in light of the failure of alternative treatment and diet.For the reasons set forth above, I have determined the requested referral 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 51-year-old male who is status post left total knee replacement. His postoperative care included physical therapy and two interventions for manipulation of the knee joint under anesthesia due to limited range of motion. The patient indicates a CPM machine was prescribed after the second manipulation. The Health Plan denied the patients request for reimbursement for the cost of the device based upon a determination that is was not medically necessary.There remains conflicting evidence as to the benefit of a CPM machine immediately following total knee replacement.  However, there is no evidence in the literature to support the delayed application of a CPM machine following manipulations for postoperative stiffness. There is no indication that the device resulted in an improved clinical outcome for this patient. Therefore, I have determined the device at issue was not medically necessary for the patients postoperative rehabilitation. The Health Plans denial should be upheld.