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

The patient is a 52-year-old woman with bilateral breast implants who was referred to a plastic surgeon for evaluation of chest pain. The patient has had chest pain intermittently beneath the right breast since a fall from a horse approximately four years ago. The evaluation by the plastic surgeon revealed bilateral Baker I soft implants that appeared to have been placed through axillary incisions. The patient has requested authorization and coverage for removal of the breast implants. The Health Plan has denied the request on the basis that the requested procedure is not medically necessary.Review of the submitted records shows that the patients previous mammograms and chest x-rays did not demonstrate etiology for the patients reported pain. Thus, there is no evidence that removal of the implants will provide the patient with relief. Furthermore, there is no evidence that the requested procedure is being sought to improve function. Based upon the information provided, it appears removal of the patients breast implants has been requested for personal reasons and is not medically indicated. Therefore, I have determined that the requested procedure 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 46-year-old woman who has requested authorization and coverage for fat grafting of an abdominal defect. In May 2003, the patients provider noted the patient had a left anterior abdominal wall budge that was 4x3cm along the left vertical incision line. Mild tenderness was noted but there was no infection, erythema, or hernia. In August 2003, the patient underwent abdominal scar excision over 13cm in length with adjacent tissue transfer reconstruction. The submitted photographs reveal a generalized abdominal bulge consistent with excess weight rather than a localized bulge and depressed scar. The Health Plan has denied authorization and coverage for fat grafting surgery on the basis that it is not medically necessary.Review of the submitted evidence indicates that fat grafting surgery is not medically necessary. The submitted evidence reveals no functional deformity. In addition, evidence of conservative treatment with weight loss has not been provided. Furthermore, the patient has already undergone scar revision surgery. Thus, the requested procedure is likely to provide only limited improvement. 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 26-year-old male with complete T12 spinal cord injury. The patients family is requesting inpatient rehabilitation therapy. The submitted information includes no evidence of a physician request for inpatient services. Recently, the patient was noted to be independent with catheterizations, pressure relief, and upper extremity dressings. On 4/1/04, it was noted the patient required minimal assistance with lower extremity dressing. Upon discharge from the hospital, it was noted the patient required minimal assistance with self-care except for shower transfers. The physical therapy evaluation of 3/27/04 indicated the patient required moderate assistance for bed mobility, supine to sit, and toilet. The patient apparently needed assistance to get his legs off bed for sliding board transfer. The patient appears to be safe at home with assistance from caregivers. A request has been made for inpatient rehabilitation therapy. The Health Plan has denied the request on the basis that additional inpatient therapy is not medically necessary.An inpatient rehabilitation program is not medically necessary for the patient to achieve goals of independent function. The patient appears to be safe at home with assistance from caregivers. It is not necessary that the patient be independent to be a candidate for in-home rehabilitation therapy. It is only necessary that the patients caregivers be able to safely care for him. With continued in-home or outpatient rehabilitation therapy the patient is likely to achieve independence with transfers and bed mobility. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary. Therefore, the Health Plans denial should be upheld. However, based upon the submitted records it appears the patient requires a more intensive in-home rehabilitation program than he has been receiving.  The patient should receive at least three hours a day of in-home rehabilitation therapy with a dedicated team approach to therapy. The outpatient day treatment previously recommended by the Health Plan would be a safe and appropriate alternative.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a four-year-old male with speech delay that is primarily expressive. The patient was diagnosed with childhood apraxia of speech by two speech pathologists. The patient was also seen by a neurologist who obtained an electroencephalogram (EEG) that showed abundant multifocal epileptiform abnormality in the left central and parietal region. The patient has been receiving speech therapy since March 2003 with documentation of significant progress.Upon review of the therapy reports from the patients speech pathologists, there is documentation that the patient has achieved good gains in therapy given the abnormality of the patients EEG.  The EEG revealed epileptiform activity that appears to be located on the left parietal area where speech activity is formulated. Thus, there is an indication that there may be a pathophysiologic basis for the patients delayed speech. However, the submitted information provides no clinical follow-up from the patients neurologist with specific recommendations regarding treatment of the abnormal EEG. 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 at this time. Therefore, the Health Plans denial should be upheld at this time. However, if there is documentation from the patients neurologist that the patients EEG activity is clinically significant, both prior and continued treatment should be authorized based upon the neurologists recommendations for ongoing care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 45-year-old male with an apparent history of attention deficit hyperactivity disorder (ADHD) and associated symptoms for many years. The patients past treatment has including Strattera, Lexapro, Effexor, and stimulants without apparent benefit. No other medications or treatment is mentioned. According to the patient, Provigil helps decrease his ADHD symptoms. A request has been made for authorization and coverage for Provigil. The Health Plan has denied the request on the basis that Provigil is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Though Provigil has been used for multiple off-label illnesses and indications, reports of the efficacy of Provigil for treatment of adult ADHD are anecdotal. In addition, the records submitted do not provide evidence of any formal evaluation of the patient for ADHD (e.g., psychiatric testing, TOVA screening, etc.). Furthermore, there is no indication that the patient has undergone a trial of combinations of stimulants and selective serotonin reuptake inhibiting drugs and/or tricyclic antidepressants. Nor do the submitted records indicate that all stimulants have been prescribed without success. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 40-year-old male with a history of polysubstance abuse and depression. The patient has had multiple acute hospitalization admissions from November 2003 through March 2004. On 3/11/04, the patient was admitted for acute services due to depression and a suicidal plan. Though the patient was authorized to receive acute services until 3/18/04, the patient left the acute hospital and entered a residential treatment program on 3/16/04. The patient remained in the residential treatment program until 3/22/04. The Health Plan indicates the patient was not an appropriate candidate for residential treatment services as of 3/16/04.It is evident from the included documentation that the patient had a long history of substance abuse and non-compliance with various types of mental health treatment. According to the admission note dated 3/16/04 from the Discovery Program, the patient was acutely psychotic. The appropriate medical intervention would have been treatment in an acute care psychiatric facility, most likely on a locked unit and under involuntary circumstances. Thus, based upon the information provided, residential treatment services were not medically indicated for the period in question. Therefore, I have determined that the requested services were 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 48-year-old man with hepatitis B with precore mutant. A liver biopsy apparently showed stage III fibrosis. It appears the patient has also been treated with lamivudine, developing YMDD mutation. The patient has undergone one year of treatment with Hepsera. A request has been made for continuation of Hepsera. The Health Plan indicates that continuation of Hepsera is not medically necessary.Hepsera has been approved by the Food and Drug Administration for treatment of the patients medical condition. It has been noted that acute exacerbation of hepatitis B is seen after discontinuation of this medication. Multiple studies have shown that Hepsera is a safe and effective treatment for hepatitis B. The consensus among the gastroenterology community is that the duration of therapy should be more than a year. Cessation of therapy should be based upon improvement of the stage of liver disease, development of hepatitis B surface antibody, and elimination of hepatitis B DNA and hepatitis B surface antigen. In light of the clinical information submitted, continuation of Hepsera is medically necessary and indicated for this patient.Based upon the information set forth above, 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 46-year-old woman with a family history of breast cancer involving her mother and sister. On a recent mammogram suspicious microcalcifications were identified in the central aspect of the right breast. A stereotactic biopsy was attempted but the calcifications could not be targeted. A follow-up mammogram in three months was recommended. The patient has requested authorization and coverage for a nuclear scan of her breast to further evaluate for cancer. The Health Plan has denied the request.There is no nuclear medicine breast scan at this time that is used to diagnose primary breast cancer. In the past, technetium-99m-sestamibi scintimammography was evaluated as a possible diagnostic test for breast cancer. However, it became clear that this test was not sufficiently sensitive for the diagnosis of small breast cancers (sensitivity of approximately 80%). FDG-PET scan, which is another nuclear medicine scan, also is not sufficiently sensitive to diagnose small, primary breast cancers. The lower sensitivity is likely caused by a minimum size requirement of approximately 1cm for detection by PET scan and a relatively normal to minimally increased metabolic rate for certain tumor types (e.g., lobular carcinomas and ductal carcinoma in situ). Thus, there is no evidence that the nuclear breast scan requested by the patient is medically indicated.Based upon the information set forth above, I have determined that the requested scan 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 50-year-old female with a history of fen-phenormin and Redux use who was diagnosed with asymptomatic mild to moderate aortic insufficiency. The patient was seen by her network cardiologist who recommended a repeat echocardiogram in one year, then yearly. The patient saw an out-of-network provider who recommended three follow-up visits and an echocardiogram every year or every other year to follow-up with the severity of aortic insufficiency. The patient has requested authorization and coverage for follow-up care from the out-of-network cardiologist. The Health Plan has denied the request.This patient falls within the classification of asymptomatic mild to moderate aortic regurgitation with normal left ventricle chamber size. In concordance with ACC/AHA guidelines for the management of patients with valvular heart disease, yearly echocardiograms for the reevaluation of asymptomatic patients with mild to moderate aortic regurgitation, stable physical signs, and normal or near normal left ventricle chamber size is a Class III indication. Thus, there is evidence and/or general agreement that routine surveillance echocardiograms are not useful or effective. Routine clinical follow-up to assess for changes in physical signs or symptoms development however is indicated; the timing and intervals routinely vary among practice patterns to monitor for changing physical signs and or symptoms change. Both cardiologists appear to address a follow-up visit, and though it is spelled out more clearly in the out-of-network cardiologist recommendations, there is no significant difference in the two clinical follow-up approaches to this patient.Therefore, I have determined that the patients request for follow-up care with an out-of-network cardiologist is not medically necessary since the portion of the services that differ are not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old female postoperative from repair of a rotator cuff in March 2003 that resulted in an unfavorable scar (staged to be keloid). This was initially treated with steroid injections with persistent unfavorable result. The patient was then seen by a plastic surgeon who evaluated the scar and proposed excision/revision of the scar. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is not medically necessary.The records from the patients plastic surgeon do not describe any functional limitation related to the scar. The patients complaints were related to appearance and pain. No plan of pain modification was proposed. Thus, there is insufficient evidence that the requested procedure is medically warranted. Furthermore, the requested scar revision would have serious limitations as keloid removal by any method has a significant chance of recurrence. 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 38-year-old female who is requesting a total knee replacement. The patient apparently injured her knee in 1996 and continues to have pain. X-rays do not reveal significant arthritis in the knee. The patients provider does not believe the patient is a candidate for total knee replacement.With regard to total knee replacement, the patient is considered very young. An indication for total knee replacement is severe arthritis. This patient does not have significant arthritis in the knee. As such, there is no medical indication for this patient to undergo total knee replacement. 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: Overturned Decision of Health Plan

The patient has complete spinal cord injury and tertraplegia due to hyperextension of his neck after a fall. He received two courses of inpatient acute rehabilitation therapy in a skilled nursing facility (SNF). He progressed well in the second acute hospital-based rehabilitation, probably because he had made some neurologic recovery. He was discharged to another SNF on 2/6/04. A request has been made for continued inpatient rehabilitation services. The Health Plan has denied the request on the basis that the requested services are not medically necessary.Review of the information provided demonstrates that the patient no longer required acute inpatient rehabilitation therapy as of 2/6/04. However, it appears the patients course of rehabilitation ended abruptly upon transfer to another SNF. Though the patient was near the end of his rehabilitation program he had not completed the program. Based on the submitted evidence, as of 2/6/04 the patient required daily skilled inpatient rehabilitation therapy for a period of four weeks. Furthermore, outpatient therapy was not indicated at that time as there was no appropriate discharge planning in place for the patient.Therefore, I have determined that daily skilled inpatient rehabilitation therapy was medically necessary after 2/6/04. As such, the Health Plans denial should be partially overturned. Given the length of time since the cessation of inpatient rehabilitation therapy, the patient should undergo an evaluation at his current SNF to determine his capabilities with the environment and to ascertain whether he is at maximum potential. If the examining provider determines that additional inpatient rehabilitation therapy is medically indicated, the patient should receive four weeks of daily skilled inpatient rehabilitation therapy. However, at that time, the patient should be reevaluated by his physician to determine if further skilled inpatient rehabilitation therapy is needed.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 47-year-old female with a multiple year history of progressive fatigue, weakness, and malaise. In addition, the patient has a prior history of hot thyroid nodule treated with radioiodine ablation with resultant hypothyroidism. She is currently over medicated with thyroid hormone replacement as evidenced by suppressed thyroid stimulating hormone. She has had multiple tests performed without definitive diagnosis. She has had less than adequate growth hormone stimulation testing but with resultant normal values that have been interpreted by her physicians as inadequate. The patients provider has recommended a six to twelve month trial of growth hormone, which the Health Plan has denied.The Health Plans denial should be upheld. The growth hormone stimulation test used is inaccurate. Thus, it appears there has been much misinterpretation of the hormone data. The thyroid test results indicate over-medication not pituitary hypofunction. Low estradiol and testosterone are expected in a post-menopausal woman (as indicated by her markedly elevated follicle-stimulating hormone (FSH) results). The high FSH level indicates normal pituitary gonadotropin function for a post-menopausal woman. Her bone density is average for her age though it is concerning that she lost spine and hip density from one measurement to the next. This may be due to her early (but not premature) menopause. It is not noted when she started and for how long she took Fosamax and its timing related to the bone mineral densities. Furthermore, the multiple random cortisol and ACTH tests are meaningless due to the moment-by-moment variations of these hormones. No measure of 24-hour urine free cortisol, the gold standard, is noted.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 30-year-old female who is seeking reimbursement for duodenal switch surgery. The patients body mass index (BMI) prior to surgery was 56.2. In addition, the patient has a number of comorbid conditions including hypertension and gastroesophageal reflux disease (GERD). The Health Plan has denied reimbursement for the duodenal switch procedure.The duodenal switch procedure has a track record greater than 15 years. The anticipated complication associated with other malabsorptive procedures (i.e., distal gastric bypass, jejunoileal bypass) has not been encountered with the duodenal switch. At the 2003 American Society of Bariatric Surgeons meeting held in Boston, Massachusetts, scientific papers were presented, which indicated there is growing evidence that protein malnutrition is a much larger problem post gastric bypass than was initially suspected. This is due to patients inability to consume normal meals after the gastric bypass procedure. Furthermore, there is sufficient data to show that duodenal switch has a far more superior long-term outcome when compared to gastric bypass. Therefore, the duodenal switch procedure was medically indicated for treatment of this patients super morbid obesity.Based upon the information set forth above, I have determined that the procedure at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 57-year-old female with recurrent ventral hernia who has failed vertical banded gastroplasty. The patients body mass index (BMI) is 50. The submitted information indicates there was previous use of Marlex mesh for the patients hernia repair. The patients providers have recommended gastric bypass surgery with duodenal switch. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is considered investigational.There is now adequate data to demonstrate that duodenal switch is a more appropriate weight loss procedure for certain surgical revisions. Salvage from failed vertical banded gastroplasty involves conversion to Roux-en-Y gastric bypass or duodenal switch gastric bypass. In many cases, dense upper abdominal adhesions make conversion to Roux-en-Y gastric bypass untenable. Therefore, the duodenal switch is the medically indicated and necessary procedure for appropriate treatment of the patients condition. 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.