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

The patient is a three-year-old female with significant autism. She has been treated with applied behavioral analysis, with reported benefit. The patients parent has requested reimbursement for the past therapy as well as authorization and coverage for continued therapy. The Health Plan has denied this request on the basis that applied behavioral analysis was/is not medically necessary.Review of the relevant published literature on autism and its treatment reveals that the most effective treatment consists of applied behavioral analysis. It is a well-researched, evidence-based technique of intervention for children with autism spectrum disorders. Applied behavioral analysis uses an intensive, behaviorally based approach to intervention often referred to as discrete trials instruction, among other strategies. In the case of this patient, the submitted clinical information demonstrates she has shown some improvement with applied behavioral analysis. As such, the therapy was medically indicated and should be continued for one year with re-evaluation by the patients provider at the end of the one-year period. Accordingly, I have determined the therapy at issue was/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 35-year-old woman with new onset of headache and facial pain in March 2006. Records from June 2006 indicate the patient had breakthrough pain on Neurontin 3000mg a day and Topamax 150mg a day. Neurontin was initially beneficial but lost its effectiveness. The patient had an allergic reaction to Tegretol. She was initially on Klonopin without documented benefit. As of June 2006 the patients pain was worse and she was evaluated for gamma knife radiosurgery for trigeminal neuralgia. The pain description by the treating neurologist suggests the pain eminates from the occipital region into the temporal parietal region with some involvement of the eye. There was no mention by her treating neurologist of a trigger point in the cheek.At issue is whether gamma knife radiosurgery is medically necessary for treatment of the patients condition.The patients head and facial pain syndrome as described is very atypical for trigeminal neuralgia, as is the patients age. Upon review of the submitted records, the diagnosis of classic trigeminal neuralgia is not confirmed. Rather, the presence of pain in the occipital region and temple as well as the eye suggests this may represent chronic paroxysmal hemicrania or possibly SUNCT syndrome (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing). There is no mention of autonomic symptoms involving the eye.In the absence of convincing evidence of trigeminal neuralgia, gamma knife radiosurgery is not medically necessary. Other possible causes of the patients symptoms should be ruled out. A trial of indomethicin would help establish or refute a diagnosis of chronic paroxysmal hemicrania; if this condition were to be ruled out, a trigeminal nerve block would be appropriate and might help determine if the source is the trigeminal nerve.Based upon the information set forth above, 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 46-year-old woman with severe back pain. She was initially treated with medications and rest, but her pain persisted. She underwent an evaluation with a physician and it was recommended she undergo an MRI study. The MRI was performed in March 2006 and the patient has requested reimbursement for the procedure. The Health Plan has denied her request citing a lack of medical necessity for the study.The patients physician evaluated the patient and diagnosed her with sciatica. Based upon the clinical presentation and his examination of the patient, the physician determined an MRI was indicated to further investigate the cause of the patients pain and to better plan her treatment. As the patient has persistent pain that was unresponsive to conservative treatment, and has sciatica, an MRI study was medically prudent and clinically indicated. Accordingly, 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: Upheld Decision of Health Plan

The patient is a 56-year-old female who is requesting reimbursement for a CT scan of the abdomen and pelvis, which was performed in January 2006. The progress notes dated January 2006 state that the patient was having left lower quadrant pain for the past last three weeks. There was no bleeding and no fever. On physical examination there was left lower quadrant tenderness on firm pressure. A CT scan of the abdomen and pelvis was ordered at that point. The results of the scan were mostly unremarkable. The Health Plan has denied reimbursement for the CT scan on the basis that it was not medically necessary.Review of the submitted clinical information indicates the description of pain was rather vague. There is no evidence of any red flags requiring a CT scan as a first choice in the workup of this patients abdominal pain. A pelvic ultrasound would have been appropriate as the first diagnostic procedure in this clinical setting. Given the absence of documented indications for a CT scan, and the availability of other diagnostic procedures, I have determined the CT scan at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 54-year-old female diagnosed with type 2 diabetes mellitus (DM2). She had been under poor control despite four oral hypoglycemic agents. Her hemoglobin A1c was 7.9% in February 2006. The patients endocrinologist began a trial of Byetta 5mcg twice a day in March 2006. The provider stated that after one month the patients self-monitored blood glucose levels had decreased by 20 to 30mg/dl. In July 2006 the patients hemoglobin A1c had fallen to 7.1%. The patients provider has requested authorization for Byetta, 10mcg twice daily. The Health Plan denied the request based upon a determination that the medication is not medically necessary.The patients blood glucose was not well controlled on glipizide, metformin, Glyset and Actos. Patients who are not well controlled on oral agents will generally progress to insulin therapy. Byetta, which is at least as effective as insulin in improving blood glucose control, may have an advantage in patients such as this patient, whose weight is a concern. Treatment with Byetta is associated with weight loss as opposed to insulin, where treatment frequently causes further weight gain. When Byetta, 5mcg twice a day, was added to her regimen of oral agents, the patients blood glucose levels improved and she lost weight according to her provider. Exenatide is presently indicated as adjunctive therapy to improve glycemic control in patients with DM2 who are taking metformin and/or a sulfonylurea, but have failed to achieve adequate diabetic control. The manufacturer has applied to the FDA for approval of the use of Byetta with thiazolidinediones and insulin. This reflects how Byetta is currently being prescribed in the medical community. 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: Overturned Decision of Health Plan

The patient is a 13-year-old female with idiopathic short stature. The records indicate growth below the 3rd percentile for many years at a low normal rate. Between 2002 and 2004, the patient grew at a rate of 2 per year and this appeared to continue thereafter. Her mid-parental height target is 53. In November 2005, before GH therapy was started, the patients predicted adult height, based on her height of 44 58 and a bone age of 12 years, was 4912 at best. The prior work-up showed no clinical evidence of Turners syndrome. The patient had normal thyroid levels, a normal GH stimulation test, and a normal pituitary on MRI with an incidental pineal cyst. She grew 1 in the first three months of GH therapy.  The patients pediatric endocrinologist submitted a request for authorization of GH therapy. The request was denied by the Health Plan citing a lack of medical necessity.Based on the clinical evidence, the patient fulfils the FDA criteria for the use of GH therapy in the treatment of idiopathic short stature. The indications are that she could not achieve a normal adult height of over 411 without GH therapy. Indeed her projected height of 4912 falls well below her genetic potential of 53. Additionally, the patients low IGF-1 level raises the possibility of GH insufficiency. The patients initial response to GH therapy strongly suggests that GH therapy is of benefit in her particular case. Therefore, I have determined the therapy at issue was/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 54-year-old female who had 27-year-old silicone breast implants. Bilateral capsulectomy with implant removal was performed in December 2004. The operative report indicated that both implants were severely damaged with leakage of silicone outside of the silicone shell. Silicone granulomas were also present on the left. These findings are in contrast to an apparently benign pre-operative mammogram. The patient developed complications in the left breast (operative report indicates right breast) and a capsulectomy revision was performed in January 2005. The patients request for reimbursement for surgical procedures performed in December 2004 and January 2005 and related services was denied by the Health Plan based upon a determination that the procedures were not medically necessary.Although not recognized preoperatively, the operative note from December 2004 clearly describes bilaterally ruptured silicone implants. Removal of such implants is consistent with the recommendations of the FDA Advisory Panel and the breast implant manufacturer. The advisory states The diagnosis of rupture of a gel-filled breast implant is important because the release of silicone gel and fluid into the tissues may result in local complications. An intracapsular rupture may become extracapsular, and both are generally agreed to indicate the need for removal of the implant.  The American Society of Plastic Surgeons (ASPS ) supports this recommendation and it is their position that broken or failed implants, infection, implant extrusion, siliconoma, granuloma, or interference with the diagnosis or treatment of breast cancer are indications for reoperation. This patient had both ruptured implants and silicone granulomas. The implant removals were medically necessary. The bilateral capsulectomies were medically necessary as well as the literature suggests that retained capsules following silicone implant explantation can interfere with mammography and can lead to cysts and seromas.  Lastly, the capsulectomy revision performed in January 2005 was also medically necessary to treat the patients non-healing breast wound. This condition was presumably due to residual free silicone, and the wound was unlikely to close without removal of the foreign material. Ancillary services and pathology related to the capsulectomies should also be considered medically necessary.Based upon the information set forth above, I have determined the procedures at issue were 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 42-year-old female who had bilateral mammograms and breast sonograms in April 2005. Bilateral simple cysts were present with probable benign small complex cysts seen in both breasts. A six-month follow-up exam was suggested. MRI of the breasts was performed in June 2005, which showed two small masses on the right and one on the left and ultrasound-guided biopsies were suggested. In July 2005 biopsies of nodules in the right breast at 9 oclock and 12 oclock were performed, which showed adenosis and focal apocrine metaplasia. Follow-up MRI and ultrasound of both breasts was recommended in six months. A bilateral breast ultrasound in October 2005 showed no suspicious nodules with the previous complex cysts either stable or resolved. Bilateral mammograms and breasts sonograms were obtained in April 2006 showing a new complex cyst at 3 oclock, which was aspirated under ultrasound guidance in May 2006. Cytology findings were benign. The patient has a family history of breast cancer is an aunt diagnosed at age 45.A breast MRI has been recommended for further follow-up. The Health Plan has denied coverage for the requested MRI on the basis that it is not medically necessary in this clinical setting.There are several indications for MRI of the breast including pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high risk patients, and problem solving. High risk patients are those with a personal history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene. High risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar, and prior mantle radiation.This patient has no indication for an MRI of the breast. The several biopsies performed showed no cancer or atypia. Her family history of an aunt with breast cancer is inadequate evidence of a genetic predisposition. Continued follow-up mammograms and ultrasounds are appropriate in this setting. The requested breast MRI is not medically indicated at this time.Based upon the information set forth above, I have determined the requested MRI 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

This patient is a 50-year-old male with a long-standing history of degenerative disc disease of the mid and lower lumbar spine. The patient has requested an MRI of the lumbar spine to determine if he is a suitable candidate for artificial disc replacement. The patient takes hydrocodone for pain, but there is no record of conservative therapy such as physical therapy or NSAIDs. There is no evidence of a recent visit to a spine specialist (i.e., neurosurgeon or orthopedist) or the neurological symptoms or findings associated with his chronic back pain. The plain films of the lumbar spine submitted for review are from 1994 and 2001.  The patients request for authorization of an MRI of the lumbar spine was denied by the Health Plan, citing a lack of medical necessity.There is no documentation suggesting the patient has been recently evaluated by a spine specialist, or documentation of neurological symptoms/findings or recent physical therapy. MR imaging of the lumbar spine is medically appropriate when a patient has severe back pain that does not improve with conservative therapies, has significant neurological symptoms/findings (i.e. foot drop) or when a patient is being considered for surgery and has recently been seen by a surgeon. The patient does not meet any of these criteria at this time and therefore MR imaging of the lumbar spine is not medically appropriate. 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 53-year-old female who has requested authorization and coverage for pre-surgical interscalene nerve block of the brachial plexus. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for the patients repeat rotator cuff surgery.Review of the submitted medical documentation indicates the patient is a 53-year-old female who is status post two rotator cuff repair procedures and she is scheduled to undergo a third repair. She is seeking pre-surgical interscalene nerve block of the brachial plexus. The documentation provided indicates the anesthesiologist and orthopedic surgeon feel this procedure will significantly decrease the patients post-operative pain following the procedure. The block will be given in addition to general anesthesia. The literature indicates that a pre-surgical interscalene nerve block allows for improved patient comfort post shoulder surgery and reduced time to discharge. In this particular case, the patient will undergo her third rotator cuff repair and maximal pain control should be instituted to avoid the development of frozen shoulder/chronic pain syndrome. Therefore, I have determined 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 51-year-old female who is status post a motor vehicle accident with neck and arm pain due to disc bulging, facet arthropathy and occipital headaches. She is being treated with the medication Lyrica in addition to Tylenol with Codeine, Naprosyn and occipital nerve blocks. At issue is whether Lyrica is medically necessary for treatment of the patients medical condition.At this time Lyrica has been studied and has been approved by the Food and Drug Administration in the use of diabetic neuropathy and post hepatic neuralgic pain. Lyrica has not been well studied or proven effective or medically appropriate for non-specific neck pain or whiplash injuries status post a motor vehicle accident. As such, there is insufficient evidence supporting the use of Lyrica in this clinical setting. There are other medications/modalities available for the management of this patients pain. Accordingly, 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 21-year-old female who was reportedly doing well in college prior to her admission to residential treatment. She had a history of once daily bulimic episodes since adolescence and also reported the use of enemas. It appears she had maintained her weight within normal parameters for her height. The patient participated in the program with individual therapy on average three times per week. Her request for reimbursement for the residential treatment services provided from December 2005 through January 2006 was denied by the Health Plan citing a lack of medical necessity.The medical records provided were reviewed in their entirety. The patient had no identified co-morbid medical or psychiatric diagnoses and her weight was within the normal range for her height. There is no record of participation in an intensive outpatient treatment program before her elective admission to the specialized residential treatment program for eating disorders.  There is no indication of failed treatment at the outpatient level, in fact her provider noted that outpatient treatment attempts have been partially effective. According to the American Psychiatric Association guidelines for the treatment of bulimia nervosa the patient did not require treatment at the residential level of care. 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 38-year-old female with a history of alcohol abuse who was referred for residential treatment. Her home life was described as very difficult and she had reportedly failed numerous outpatient attempts at sobriety. The patients admission diagnoses were alcohol dependence and major depression and her current stressors included her marriage and remodeling of her house which necessitated temporary living arrangements. The patient had been drinking a bottle of wine per night, last doing so in April 2006; there were no reported symptoms of withdrawal. During treatment, the patient participated in therapy and was treated with Klonopin, 1mg decreased to 0.5mg, and Trazodone, up to 75mg per day. The patient was described as anxious, but there are no documented symptoms of anxiety or depression. The patient was discharged from residential treatment in May 2006. Her request for reimbursement was denied by the Health Plan based upon a determination that residential treatment services were not medically necessary.The submitted record does not indicate a severity of illness, either from an alcohol or a depressive standpoint, which would have necessitated residential treatment. The patient was apparently able to stop drinking on her own nine days prior to her residential treatment admission and there is no record that outpatient treatment was attempted as a first line approach. Additionally, despite the stated failure of numerous outpatient programs, there is no information as to the sort of programs the patient had participated in or the reasons for their failure. All told, there appears to be no clinical indications for residential treatment. Therefore, 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 45-year-old woman with a history of severe migraines who has been treated with low dose Botox for four years. She and her physician indicate it is helping, but there is no documentation of change in the headache frequency, severity, or use of acute medication. The clinical notes do suggest the patient has been using increasing amounts of Imitrex and has been suffering worsening headaches. At issue is whether Botox is medically necessary for treatment of the patients condition.Botox is not medically necessary for this patient based on the information provided. The submitted records do not demonstrate a substantial improvement in the patients headaches with the use of Botox. Furthermore, the records do not document the failure of multiple standard preventive medications. The records do suggest the patient may have an element of medication overuse headache. The submitted clinical records do not adequately document the patients previously failed preventive medications; nor do they establish that the patient has improved with Botox. As such, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.