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

This patient is a 16-year-old male diagnosed with dysthymic disorder, oppositional defiant disorder, ADHD, and marijuana abuse who was admitted to residential treatment after nine weeks in a wilderness camp setting. He was described as verbally defiant with his parents, inclusive of spending up to 12 hours per day playing violent video games, staying up late and then sleeping in, faring poorly in school, and having a constantly argumentative stance. In one instance when most defiant, he reportedly pulled a knife on his mother.  At the time of admission to residential treatment, neither he nor his family were involved in outpatient treatment. Chart notes describe the patient as afflicted with the aforementioned diagnoses, supported by formal testing, but also include an assessment of pronounced narcissism. Family dynamics were also of relevance as the parents differed in their approach to the patient and the patient took full advantage of the parental discord in that regard. One particularly telling note describes the patient as compliant and cooperative in the therapeutic environment but goes on to say that much of the problem lies in the family dynamic. Patient tends to want to argue and manipulate to get his way. Sees no need to have structure at home. The parents have reinforced this behavior by allowing him to escape responsibility and giving in to the pressure that he puts on them to get his way. The patient was not a management problem while in residential treatment.  He was treated with a variety of psychotherapies but received no medications. The patient ultimately left the facility against medical advice.  The Health Plan denied the fathers request for reimbursement for the services based upon their determination that they were not medically necessary.The fact that the patient did not appear to be a management problem while in the residential treatment milieu is not particularly surprising given that the primary arena of conflict was with his parents. He was portrayed as narcissistic, but not inordinately difficult to handle. A trial of partial hospitalization could reasonably have been attempted prior to residential treatment. Similarly, given the disunity in the parents approach to the patient, and the patients efforts to split them when the opportunity presented, family therapy was obviously indicated and could have occurred on an outpatient basis. In fact, had the patient remained at home with his parents, the impetus for successful family therapy may have been greater. 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: Overturned Decision of Health Plan

The patient is a 32-year-old female with a history of osteoarthritis and right shoulder pain.  An arthroplasty was performed in July 2005 to repair a tear in the glenoid labrum.   Apparently, despite postoperative physical therapy, she still had limited range of motion two months after surgery.  The patients orthopedic surgeon prescribed a CPM machine, which she used for about two weeks. The patients request for reimbursement was denied based upon the Health Plans determination that the CPM machine was not medically necessary.In this clinical situation, physical therapy was not successful and the patient could not achieve full range of motion in her right shoulder postoperatively.  She was also unable to tolerate a Dynasplint due to the pain.  The CPM machine was an appropriate way to help the patient regain her full range of motion following her surgery and was medically indicated. Therefore, I have determined the equipment at issue was 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 33-year-old male who underwent surgery on his right knee for anterior cruciate ligament (ACL) reconstruction and meniscectomy in August 2004. Postoperatively, his orthopedic surgeon prescribed a cold therapy unit, which he utilized for two weeks or so.  The patients request for reimbursement was denied based upon the Health Plans determination that the Thermal Therapy Device was not medically necessary.The device in question is commonly prescribed after knee and shoulder surgery to help decrease postoperative swelling and alleviate pain. The device is superior to ice packs placed intermittently in that the cooling is continuous, it can be used around the clock and it is comfortable and efficient. Most surgeons in the community consider the cold therapy unit an important component in postoperative recovery and prescribe the device because of its success in pain relief and reduction of swelling.  Therefore, I have determined the device at issue was 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 16-year-old male with Aspergers syndrome. His parents are requesting laboratory testing in conjunction with the Buttar Autism Treatment Protocol.  The record does not include evidence of acute changes in the patients clinical condition or laboratory data suggestive of mercury exposure from vaccines or other sources. The Health Plan previously authorized screening tests for thyroid, iron, magnesium, mercury, lead etc. but apparently the laboratory work was not performed.  The parents request for  authorization of the laboratory testing included in the Buttar Autism Treatment Protocol was denied by the Health Plan based upon their determination that it is not medically necessary.A review of the scientific literature revealed no articles related to mercury and autism published by the proponents of the autism treatment protocol at issue and the related testing. There is no evidence that the Buttar Autism Treatment Protocol has a proven benefit, and as a result the necessity of any related procedures is dubious.  Therefore, I have determined the requested laboratory testing procedures are not medically necessary for evaluation and treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This case involves a 13.5-year-old female with idiopathic/familial short stature who is being followed by a pediatric endocrinologist. She was 4 9.5 tall in October 2005 and had a bone age read at 13 years in July 2005.  Her predicted adult height was 410.5. Her parents were 56 (father) and 55 (mother) giving her a potential height of 53. Her workup information included a normal in-utero karotype of XX, normal IGF-I (284), normal IGFBP-3 (4.2), normal thyroid testing and robust growth hormone (GH) responses to arginine-clonidine stimulation testing. The Health Plan denied authorization for GH therapy on the grounds that it is not medically necessary.Although the patient does not have a growth hormone deficiency, she does meet the FDA criteria of July 2003 for the use of growth hormone therapy in the treatment of idiopathic short stature. It is predicted she will not achieve an adult height of 411 and is unlikely to reach her mid-parental height prediction. Since GH therapy was begun relatively late in her adolescent, the endocrinologist intends to use Lupron along with GH therapy to delay the closure of the epiphyses and extend the growth period. The use of GH therapy in this clinical setting is medically appropriate and indicated.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: Overturned Decision of Health Plan

A fifty-seven year-old female with hepatitis C is requesting authorization and coverage for liver transplantation.  Reviewers Findings:  The reviewing physician found that liver transplantation is medically warranted and should be authorized.   The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 64-year-old man who was referred for evaluation due to long-standing problems with focusing, procrastination, reading, distractibility with difficulty staying on topic when talking with people, and poor organizational skills. He also noted a habit of biting his nails, playing with his hands, and eating when stressed. The patient tended to obsess over things such as his weight or playing computer games for long hours. By the end of his evaluation, inclusive of the SPECT and CT scans, he was diagnosed with rule out attention deficit hyperactivity disorder (ADHD), depression  not otherwise specified, and generalized anxiety disorder. Recommendations for treatment included Wellbutrin, Lexapro and Adderall.At issue is whether the SPECT and CT scans were medically necessary for evaluation of the patients medical condition.There is nothing about the patients history or clinical exam that mandated a SPECT or CT scan in order to formulate a meaningful differential diagnosis. Based upon the clinical information available prior to the SPECT and CT scans, there was an array of standard treatments available, which could have afforded the patient relief. The SPECT and CT scans added no clinical value in the diagnosis and management of this patients condition. Therefore, I have determined the diagnostic procedures at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 37-year-old female with leg pain.  She was referred to a vascular surgeon, who performed photoplethysmography and concluded that she needed high ligation and stripping of the left saphenous vein. There is no mention that compression stockings were used or that other studies, like venous duplex, were performed. The record does not provide much detail as to clinical symptoms or physical exam findings. The patient has requested authorization for the recommended procedure.  The Health Plan has denied this request based upon a determination that saphenous vein stripping is not medically necessary.Photoplethysmography is a rudimentary method, which uses a transducer that emits infrared light into the dermis. The back-scattered light is measured by a photodetector and displayed as a line tracing.  This is not a very accurate way of measuring the presence or absence of venous insufficiency.  The results have not been standardized and it is very hard to quantify the readings. This procedure is not particularly helpful in evaluation of the problem or making a determination as to the most appropriate intervention.  At this time, neither the patients symptoms nor her varicies have been adequately evaluated.The recommendation to return to the primary care provider for a trial of conservative therapy is a reasonable one.  If symptoms persist the patient should be re-referred to a vascular surgeon for a venous duplex study.  Todays technology offers more accurate and sophisticated diagnostic methodology than photoplethysmography provides. The standard of care requires a venous duplex study for evaluation of greater saphenous vein (GSV) insufficiency and assessment of the deep veins before proceeding with any type of invasive surgical intervention.  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: Upheld Decision of Health Plan

The patient is a 46-year-old male with previously diagnosed ADHD who is afflicted with inattention to detail, procrastination, inefficiency in planning and completing tasks, frequently misplacing items, and distractibility due to thoughts and movement in the peripheral vision. He also noted longstanding low self-esteem, excessive feelings of guilt, and negative feelings about the future. Finally, he noted a tendency to ruminate as well as suffer periods of extreme irritability, snap reactions, and subsequent depression along with hypersensitivity to perceived criticism.  At the time of the SPECT scans, he was taking Adderall 30 mg and Paxil 20 mg. His formal psychiatric evaluation identified a mood disorder with characteristic emotional swings from depression to irritability possibly that of a dysphoric mania type, diagnosed as mood disorder NOS. He was also felt to have a coexisting attention deficit disorder. Recommended treatments included Lamictal, Strattera and Lexapro.  The patient requested reimbursement for the SPECT scans performed which the Health Plan denied based upon a determination that the diagnostic procedures were not medically necessary.There is nothing about the patients history or clinical exam that is in any way enigmatic. Based on his symptoms, one could well consider him to be suffering from a bipolar-spectrum disorder as well as possible comorbid ADHD. Treatments for either of these disorders would thereby follow very standard guidelines. A SPECT scan in this setting does not add clinical value. Therefore, I have determined the diagnostic procedures at issue were not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 32-year-old female with diabetes.  The record indicates that she injects Lantus and Novolog insulin four times a day. The dose of both types of insulin is not documented nor is there documentation of any oral medications used to control her diabetes. The patient appears not to have long-term complications or hypoglycemic unawareness.  The blood sugar log kept by the patient from August 2005 through November 05 shows close to adequate control. There are two morning blood glucose levels of 60 and a few of over 200.  In May 2005 her hemoglobin A1C was 7.1%. In September 2005 the patient had a blood glucose of 311 recorded by the lab and her hemoglobin A1C was 9.2%.  There is no recent hemoglobin A1C recorded. There was a period of time from the end of August until early September that the patient did not inject Lantus insulin for two weeks without a notable change in her daily glucose values.  The patient has requested authorization for an insulin pump, which was denied by the Health Plan as not medically necessary.In general, there are standard criteria for insulin pump eligibility: Type I diabetes mellitus, poor control on a regimen of multiple injections, severe blood glucose fluctuations, hypoglycemic unawareness and long-term complications.  The patient indicated that she had Type II diabetes. There is no C-Peptide level documented, so it is assumed that the patient is correct and she does not have Type I diabetes. Her blood sugar levels off of Lantus insulin did not differ from those recorded when she was using Lantus.  Over a three-month period of time she had very few low blood sugar levels, and a small number over 200.  There is no mention of hypoglycemic unawareness or long-term complications of diabetes in the record. The patient appears to be fairly well controlled on her present course of diabetic management.If there is documented evidence the patients C-Peptide level is low (less than 0.9) the patients request should be reconsidered.  Based upon a review of the record provided, this patient does not meet the criteria for an insulin pump.  Therefore, I have determined the requested device 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 3-year, 10-month-old female who was born the product of a triplet gestation and has a history of developmental delays.  She did not walk until two to two and one half years of age. The patient has had difficulty with both fine and gross motor skills.  In the July 2005 occupational therapy (OT) evaluation of gross motor skills it was noted that she was unable to jump in place or jump forward, could not descend stairs without crawling, and could not maintain balance while standing on either her left or right leg alone.  In the area of fine motor skills, the therapist noted that the patient used a palmar grasp for writing and was not consistently able to use a pincer grasp for picking up objects.   She was also unable to fasten a one-inch button. It was recommended that the patient continue with occupational therapy, and her parent has requested authorization.  The Health Plan had denied this request based upon their determination that continued OT is not medically necessary.I have reviewed the occupational therapy evaluation from July 2005, the reports from the infant program, and the October 2004 progress report from the behavior consultant. All of the assessments document significant delays. In the report provided by the behavior consultant, the patient is described as having a limited attention span, distractibility, echolalia, sing-songy language, splinter skills, no eye contact, no interaction with peers, perseverative play and rigidity in her routines.  Although there is no formal diagnosis of autism, these symptoms are associated with the autism spectrum as are the fine and gross motor skill delays. It is not reasonable to conclude that the patients developmental delays are of the type commonly seen in multiple births or that they will self correct within a reasonable number of years. 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: Upheld Decision of Health Plan

This patient is a 3-year 10-month old female who is the product of a triplet gestation and was born at 35 12 weeks.  She has a history of developmental delay and began receiving occupational therapy (OT) in May 2004. The goals of therapy addressed gross motor skills (including climbing stairs, independently jumping and running) and fine motor skills (visual motor accuracy, visual perceptual skills, motor planning, in-hand manipulation skills and hand strength). The September 2004 report states the patient is independent in self-feeding with a spoon, can pierce food with a fork, and drink independently from a cup. The progress report also indicates work in the area of sensory processing. The patients parent has requested coverage for additional OT and the Health Plan has denied the request based upon their determination that it is not medically necessary.I have reviewed both the July 2005 OT evaluation and the September 2004 OT progress report. Each report stated that the child is delayed in fine and gross motor skills. At age 40 months, the July 2005 report assessed motor skills as significantly delayed with an age equivalency of 23 months. The report however, did not refer to specific areas of the standardized testing that substantiated this assessment.  In fact, in its more detailed description of gross motor skills, which included proprioception and the vestibular system, the report described the patients performance as within normal functional limits for a 3-year 4-month old child.   The reports description of fine motor skills included stringing beads, holding a pencil with tripod grip, stacking 12 blocks, and fastening and unfastening one-inch size buttons.  The patients performance was also within normal limits for this skill set. She is described as being able to make both horizontal marks and vertical strokes but unable to make a plus sign, which is consistent with age appropriate norms.  It is not uncommon for children of multiple births to have some mild motor delays which self-correct within the first five to seven years of life.  The submitted records document no significant motor delays that would require continued therapy.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: Overturned Decision of Health Plan

The patient is a 44-year-old female who presented to her primary care providers in January 2005 with a diagnosis of infertility. A referral in September 2005 to the Health Plan infertility clinic was made. A hysterosalpingogram was ordered and performed, and was normal. Serum FSH levels were drawn twice, one week apart, and were in the normal range (less than 5 mlU/ml). The patient requested donor intrauterine insemination (IUI). Subsequent visits revealed that the patient was told that further treatment with IUI was not indicated, and that the pregnancy rates were 0% because of her age and obesity. She was advised to pursue in vitro fertilization treatments with donor eggs. The patient has requested coverage for IUI which the Health Plan has denied based upon a determination that it is not medically necessary.This patient has the diagnosis of age related infertility. Women over the age of 40 have a dramatically reduced chance for either spontaneous or treatment pregnancy due to ovarian resistance. However, spontaneous and treatment pregnancies are possible. The overall pregnancy rate for either in vitro fertilization (IVF) using the patients eggs, or IUI, in this age group is less than 5%. In the case of this patient, FSH levels were in the normal range. This reflects the possibility of pregnancy with treatment, as compared to an elevated FSH that would prove severe ovarian resistance beyond the age itself, and offer little to no chance for treatment success. The Health Plans committee states that the better treatment option is egg donation and this is in agreement with an ASRM Committee Opinion. However, this is only partially true. While the Committee Opinion supports the option of egg donation, it also lists controlled ovarian hyperstimulation with IUI as an alternative. The patient is seeking appropriate alternative care that has the potential to result in pregnancy. As such, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.