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

The patient is a 42-year-old man with a history of chronic neck pain and sleep disorder. The patients chronic neck pain secondary to degenerative disc disease status post laminectomy and fusion has been treated with pain medications including hydrocodone, Oxycontin, Methadone, and Percocet. The patient was subsequently weaned off all opiates. In October 2001, the patient was started on buprenorphine, which adequately managed his pain. The patient also had increasing symptoms of sleep disorder for which he was tried on benzodiazepines, Ambien, anti-epileptic drugs, tricyclics, chlorhydrate, phenobarbital, and antihistamines. However, the medications used either had significant side effects or did not have any effect on his sleep. The patient was started on Xyrem in August 2003, which improved the patients sleep disorder thus allowing him to be more functional. The patient has requested authorization for buprenorphine and Xyrem. The Health Plan has denied the request on the basis that the requested medications are not medically necessary.Review of the submitted clinical records demonstrates the patient has done well on his current regimen of medications--buprenorphine for chronic neck pain since October 2001 and Xyrem for sleep disorder since August 2003. He has failed numerous other treatments for chronic pain and sleep disorder. The patient continues to be followed by the provider who started him on buprenorphine and Xyrem. The evidence suggests the patient will continue to benefit on his current regimen as it allows him to be more functional. Therefore, continuation of treatment with buprenorphine and Xyrem is medically indicated. The patient should be closely followed by his provider since both medications are highly controlled substances. Based upon the information set forth above, I have determined that the requested medications are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 44-year-old man who has had two cysts, one of the anterior forehead and the other of the left temple for approximately 13 years. The patient states that the cysts are occasionally painful. The patient wishes to have the cysts surgically excised. The Health Plan has denied authorization for the requested procedure indicating that it is cosmetic in nature.The Health Plans denial should be overturned. The patient states that the cysts on his forehead and temple are sometimes painful. In cases where cysts are painful, surgical excision is medically indicated to improve function. Surgical excision of the patients symptomatic cysts is medically reasonable and appropriate and is not cosmetic in nature. 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 44-year-old female with a body mass index (BMI) of 38. She has some obesity related comorbidities, but does not have any severe comorbidities such as diabetes or intractable hypertension. She wishes to undergo gastric bypass. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary.The Health Plans denial is correct. This patient does not meet nationally accepted medically necessary criteria for weight loss surgery. With a BMI of 38 and no severe comorbidities such as diabetes or hypertension, weight loss surgery is not medically indicated or necessary for this patient. The patient should make further attempts at conservative weight loss and behavior modification prior to considering surgery. 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 14-year-old male who weighs 490 pounds. The patient has comorbid conditions including obstructive sleep apnea, asthma, gastroesophageal reflux disease, and depression. It has been recommended that the patient undergo a Fobi pouch procedure. The Health Plan has denied authorization for bariatric surgery for the patient based on his age.Gastric bypass surgery is not medically indicated for this patient. The Fobi pouch procedure has upward of a 30% failure rate long-term. The risk of failure is even greater in the super morbidly obese (patients with a BMI greater than 50). Furthermore, the revision of Fobi pouch and gastric bypass is difficult and unsuccessful long-term in cases in which the vagus nerve has been transected. Given the patients age and BMI, the option of having the patient wait until the age of 17 to undergo gastric bypass surgery is medically reasonable and appropriate since there is no scientific data to demonstrate the long-term effects of bariatric surgery on children, particularly the impact of weight regain post gastric bypass.Based upon the information set forth above, 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 is a 49-year-old female who had a four-month history of pelvic pain. In December 2003, an ultrasound revealed a 4.6cm dermoid cyst of the right ovary. A CA-125 was normal. The patient required a surgical procedure to remove the cyst due to the possibility of complications that could occur. Her provider recommended a mini-laparotomy. The patient consulted another provider who recommended a laparoscopy, which the patient ultimately decided to undergo. The Health Plan has denied reimbursement for the laparoscopy at issue. The Health Plan states that a mini-laparotomy is essentially the same operation as a laparoscopy.The type of cyst involved in this case can be removed by three distinct procedures. First, a laparotomy may be performed. A laparotomy involves a vertical incision from the umbilicus to the pubic area or a horizontal incision just above the pubic area that is approximately six to seven inches long. Both of these approaches would constitute major surgery. The second surgical option is a laparoscopy. A laparoscopy entails making a less than one-inch incision at the umbilicus and one or two incisions less than one inch each in the lower abdomen. This procedure is considered an outpatient procedure and is less traumatic due to the amount of tissue manipulation and recovery time that is involved.The third surgical option is a mini-laparotomy. A mini-laparotomy can be considered somewhat equivalent to a laparoscopy if it is performed in the manner of a bilateral tubal ligation, i.e., a one to three inch incision is made and delivery of the tubes or in this case the ovary is performed through the incision with retractors without complete visualization of the pelvic area. If it was the patients providers intention to perform the procedure in this manner it might be said that the mini-laparotomy was equivalent to a laparoscopy. However, a mini-laparotomy can also be considered as merely involving a shorter incision than a regular laparotomy, e.g., four to five inches instead of six to seven inches. In this case, the trauma and recovery period are perhaps somewhat improved, but certainly not comparable to the laparoscopy.Based upon the recovery time stated in the informed consent given by the provider who recommended the mini-laparotomy it appears his definition of mini-laparotomy was of the latter variety and therefore, akin to a more major procedure. Also, there was some notation that a mini-laparotomy had never been scheduled by these physicians before. In contrast, the provider who performed the laparoscopy clearly indicated a recovery time consistent with the less invasive procedure. Furthermore, while it has been stated that a laparotomy was needed because the ovary needed to be removed (rather than removal of the cyst only) an ovary can indeed be removed by a laparoscopy.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: Upheld Decision of Health Plan

The patient is a 54-year-old male who underwent removal of a 5mm prolactinoma in 1999.  In 2003, the patient was subsequently found to have normal pituitary function except for HPA axis, which was not noted to be tested. He was obese prior to surgery and gained substantial additional weight over the next several years. In May 2003, based on a low normal IGF-1, an endocrinologist suggested growth hormone (GH) replacement. A preoperative test (arginine) was performed with a limited response (increase) in GH levels. On the basis of this test the patient was diagnosed with adult growth hormone deficiency and GH replacement therapy was recommended. The Health Plan has denied authorization for Genotropin GH therapy on the basis that it is not medically necessary.The patients prolactinoma was small; its removal did not lead to hypopituitarism. The patients data indicates normal pituitary function, as far as was tested. IGF-1, even if low, is not an adequate test of GH deficiency unless it is very low and even then it is only suggestive. The patients level was minimally low or low normal, which is common in obesity. In addition, an isolated arginine stimulation test is not recognized as adequate to diagnose adult growth hormone deficiency. Furthermore, obesity, in and of itself, does not indicate decreased muscle mass. To document adult growth hormone deficiency in this patient an insulin tolerance test and/or a combined arginine/GHRH test would be necessary. At this time, there is no evidence that Genotropin GH therapy is medically indicated for this patient.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. 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 excessive daytime sleepiness who has been evaluated by her physician and has undergone an all night polysomnogram. The results of the polysomnogram revealed mild obstructive sleep apnea. No evidence of narcolepsy was found. Provigil has been recommended by the patients sleep expert for treatment of the patients symptoms. The Health Plan indicates that Provigil is not medically necessary for treatment of the patients condition.The Health Plans denial should be overturned. The patient has failed treatment with Ritalin and Dexedrine due to side effects. In addition, there is question as to the need and efficacy of nasal CPAP for treatment of mild obstructive sleep apnea. Furthermore, Provigil is considered to have a role in the treatment of patients who have obstructive sleep apnea with excessive daytime sleepiness. Therefore, 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: Overturned Decision of Health Plan

The patient is a 43-year-old male with erectile dysfunction that has responded to treatment with oral Viagra. The patient is also taking Trazodone at bedtime for anxiety, insomnia, and depression. He also has an elevated serum cholesterol level. The Health Plan has denied authorization and coverage for Viagra on the basis that it is not medically necessary.The patient has two medical conditions that may cause erectile dysfunction: hypercholesterolemia and anxiety/depression. Treatment with a PDE5 inhibitor is medically necessary for this patient. Viagra is accepted primary therapy for the treatment of erectile dysfunction. The submitted records indicate the patient has erectile dysfunction and that use of Viagra has been effective. Thus, use of Viagra is medically indicated. However, the patient is also taking Trazodone for treatment of his anxiety, depression, and insomnia. Trazodone is not a tricyclic type of antidepressant, but it has been reported as having the potential side effect of priapism. Therefore, the patients use of Trazodone should cease prior to treatment with Viagra and he should be prescribed a different medication for treatment of his behavioral health problems.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. However, Trazodone should be discontinued prior to authorization of Viagra.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 28-year-old male with a history of depression and manic-depressive disorder. The patients provider has noted the patient is profoundly depressed with decreasing appetite, short-term memory problems, and lack of psychosocial support. The patients provider has recommended partial hospitalization. The Health Plan indicates the patient can be treated appropriately as a less intensive level of care.The Health Plans denial should be overturned. The submitted clinical information demonstrates that the patient remains profoundly depressed with multiple vegetative signs. The patient is on a complex medication regimen. In light of the severity of the patients symptoms, outpatient treatment is not sufficient. Partial hospitalization services are medically appropriate and indicated in this case. Therefore, I have determined that the requested services are 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 status post gastric bypass surgery and weight loss of over 100 pounds. She underwent an abdominoplasty and hernia repair in January 2004. The patient has requested approval for a bilateral thigh lift and a lipectomy. At issue is whether the requested procedures are medically necessary for treatment of the patients medical condition.The submitted photographs document a well-healed abdominoplasty scar and saddlebag deformity of regional lipodystrophy. The submitted medical records document no evidence of intertrigo, rashes or ulcer in the thigh area. Thus, there is no evidence of any functional impairment. Based upon the clinical information provided, bilateral thigh lift and lipectomy are cosmetic in nature. Therefore, I have determined that the requested procedures are 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 61-year-old female with a history of back pain after a work-related injury in 1992. After failing conservative treatment, the patient underwent a multi-level spinal fusion (L2-S1) in February 2001. The patients symptoms improved somewhat for a period of one year after surgery but were then exacerbated by a fall in November 2002. The patient failed to obtain relief from a sacroiliac neurotomy performed in January 2004. The patient has been on methadone, Vicodin, and Neurontin. She has requested authorization for Botox injections. The Health Plan has denied the patients request on the basis that Botox therapy is not medically necessary for treatment of the patients back pain.In the case of this patient with failed back syndrome who is status post multi-level spinal fusion and status post sacroiliac neurotomy, there is no evidence that Botox injections will be effective in providing her with pain relief. Botox therapy has not been shown to be beneficial for patients such as this patient. It is more likely the patient will receive long-term benefit from physical therapy than from Botox injections. Though the patient has been told to avoid heavy lifting, she should be able to participate in physical therapy. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 59-year-old male who has been diagnosed with hepatitis C. He was initially treated with interferon and ribavirin in 1998 with complete viral remission. He was treated again in 2001 due to a relapse. In 2003, the patient began a course of Peg-Intron with ribavirin, which he has been on for one year. An additional six months of therapy has been requested.It is not the standard of care to extend a course of Peg-Intron with ribavirin beyond 12 months. The Food and Drug Administration indication in terms of length of therapy is quite clear. There is no prospective, peer-reviewed study showing benefit in treating patients for 18 months rather than 12 months. Thus, an extended course of Peg-Intron with ribavirin therapy is not likely to benefit the patient and is not medically indicated. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old man who was found to have a PSA of 3.0 on 1/14/04. A palpable nodule of 8mm was noted at the right apex of the prostate. Three biopsy specimens from the right apical prostate nodule revealed a Gleason score of 3+4 in one-third of the core. In March 2004, the patients provider recommended standard radiation therapy or radical prostatectomy. The patient was seen in consultation by another provider for consideration of proton beam therapy. It was recommended the patient receive daily treatments for eight weeks. The patient wishes to undergo proton beam therapy rather than conventional radiation therapy. The Health Plan has denied authorization and coverage for proton beam therapy on the basis that it is not medically necessary.The patient is a 53-year-old man with a PSA of 3.0, T2a, and Gleason score of 3+4=7. Based on Partins Tables, there is a 50% chance the cancer is confined to the prostate, a 41% chance of capsular involvement, a 7% chance of seminal vesicle involvement, and a 2% chance of pelvic lymph node involvement. In light of this, the patient is not a good candidate for a localized therapy. The patient is likely to experience the most benefit from neoadjuvant hormone therapy for three months followed by a reevaluation with PSA and DRE. If the patient has a good response to neoadjuvant hormone therapy, he could then be treated with conventional radiation therapy. If the patient has no response to neoadjuvant hormone therapy, proton beam therapy may be an acceptable alternative. At this time, proton beam therapy is not medically indicated.Based upon the information set forth above, I have determined that the requested therapy 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 37-year-old female status post cardiac arrest on 1/24/04. The patient experienced documented ventricular fibrillation in the field and was cool and cyanotic. Down time until initiation of CPR was estimated at six to seven minutes. She experienced hypotension and required advanced cardiac life support, defibrillation (three times) and multiple medications. Post arrest the patient remained in a coma and was noted to have seizures, myoclonus, and cerebral edema. The patient evolved gradually to a coma vigil state. Recent neurologic exams of the patient show open eyes, tracking eye movements, stimulus-induced myoclonus, but otherwise non-responsive. Imaging studies demonstrate the development of cortical ribbon abnormalities, especially in occipital areas bilaterally. EEG studies show diffuse cortical dysfunction. Seizure activity was not detected. Neurological diagnoses include anoxic ischemic encephalopathy; stimulus sensitive myoclonus; and persistent vegetative state. A recent medication trial with Amantadine did not appear to result in any significant change.A request has been made for median nerve stimulation therapy. The Health Plan has denied authorization for the requested therapy on the basis that it is not medically necessary for treatment of the patients condition.Upon review of the sparse medical literature relevant to this case, there are no type 1 studies demonstrating efficacy of median nerve stimulation therapy. In the few studies that have been reported the number of subjects involved is insufficient to draw conclusions that would be considered statistically significant. While not specific for median nerve stimulation therapy in coma, the Cochrane analysis in 2002 fails to identify effectiveness of multi-sensory stimulation programs in the literature. Many of the cases cited in anecdotal reports are related to coma from hemorrhage or trauma. Only a minority of cases involve anoxic encephalopathy. Thus, there is no reliable scientific literature on which to base treatment with median nerve stimulation in coma or persistent vegetative states. More research is needed to confirm or deny its efficacy. In addition, the patients sensitivity to stimuli producing myoclonus is likely a relative contraindication to its use as well.Based upon the information set forth above, I have determined that the requested therapy 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 52-year-old female who has been experiencing chest pain with activity, numbness of extremities, and shortness of breath. She was found to have minimally suppressed TSH but normal FT4. These tests results were confirmed. The results of a thyroid scan and uptake performed in December 2003 were normal. In addition, the results of thyroid UF3 performed in December 2001, and again in January 2004, were normal. A request has been made for a thyroid scan. The Health Plan has denied the request on the basis that a thyroid scan is not medically necessary for evaluation of the patients medical condition.The patient has a multiplicity of symptoms. The patients symptom complex is not characteristic of thyroid dysfunction. In addition, all studies of the patients thyroid have been normal including physical exam. She has minimally suppressed TSH with normal free T4, ultrasound, and UF3. Thus, there is no evidence that a thyroid scan is medically indicated. Therefore, I have determined that the requested thyroid scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.