Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 44-year-old female with degenerative disc disease. She has had a positive discogram at L5-S1. Her provider is recommending a disc replacement at this level. The Health Plan considers this procedure experimental. The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement as the best available treatment for this patient. Artificial discs are currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is no evidence supporting the safety and efficacy of a two level disc replacement, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 44-year-old female with degenerative disc disease. She is seeking authorization for artificial disc replacement utilizing the Charite III disc. The Health Plan has denied this request because it considers the artificial disc replacement experimental. The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300 patient FDA regulated investigational device exemption trial with long-term follow up is underway. Without the results of this trial the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 44-year-old female with degenerative disc disease at L5-S1. Artificial disc replacement has been recommended. The patient is status post laminotomy in 2000 and has persistent pain. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, 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 with end stage renal disease (ESRD) who is a candidate for renal transplant. The patients sister does not share the patients blood group but is willing to donate a kidney to the patient so that the patient may obtain a living donor kidney transplant. The patient is seeking authorization for an incompatible living donor kidney transplant. The Health Plan has denied this request.Current literature clearly indicates that all types of renal transplant are superior to dialysis. In addition, living donor transplants are superior to cadaveric transplants. Furthermore, given current modes of immunosuppression, a living incompatible transplant will most likely have superior results to a cadaveric transplant. A renal transplant is the most clinically appropriate and medically indicated procedure for this patient. The proposed living incompatible donor transplant will be more beneficial and is more appropriate than continuing the patient on dialysis. 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 54-year-old male with morbid obesity and chronic obstructive pulmonary disorder (COPD). The patients pulmonologist has requested authorization for a power-operated vehicle (POV) for the patient. The pulmonologist states the patient has shortness of breath while lying down and walking short distances. The patient was noted to have oxygen desaturation, but not low enough to qualify for supplemental oxygen. The pulmonologist was also working up the possibility of interstitial lung disease. A letter from the patients primary care physician restated the patients medical causes for shortness of breath, which included morbid obesity (BMI greater than 60), emphysema, coronary artery disease, and advanced arthritis. Spirometry from 12/14/04 interpreted by the pulmonologist noted no change in the FVC or FEVI and no evidence of obstruction by possible restrictive lung disease. According to notes from an office visit on 12/14/04, the patient is to be evaluated for bariatric surgery.The Health Plan has denied authorization for the POV indicating the patient should undergo evaluation by a physiatrist.The patients pulmonologist and PCP both recommended use of a POV in order to alleviate the patients shortness of breath. There are multiple medical reasons for the cause of the dyspnea including COPD, coronary heart disease, possible interstitial lung disease, and deconditioning associated with morbid obesity. The Health Plan has denied coverage for a POV indicating the patient was not adequately evaluated for the equipment. The Health Plan is correct. The patient should undergo formal evaluation by a physiatrist, ideally a pulmonary rehabilitation medicine specialist. The submitted documentation does not demonstrate a POV is medically necessary at this time. Therefore, I have determined that the requested equipment is not medically necessary for the patients mobility. 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 with a body mass index (BMI) of 40.6 who is seeking authorization for weight loss surgery. The information provided indicates she has not undergone a psychological examination. The Health Plan has denied authorization for the requested surgery because there is no evidence the patient has undergone a supervised weight loss program.With a BMI of 40.6 the patient meets nationally accepted guidelines for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 48-year-old female with a 33-year history of bulimia nervosa and bipolar disorder who was admitted to residential treatment on 12/27/04 for treatment of the former. At that time the patient had been restricting calories, binging on donuts and ice cream, engaging in reflex vomiting two to three times a day, and exercising about an hour to an hour and half a day. She presented to residential treatment with a regimen of Trazadone, Seroquel, Celexa, Cymbalta, and Wellbutrin SR. Though she had been treated with Depakote in the past, there is no other record of treatment with mood stabilizers, such as Lithium or Lamictal. She noted struggling not only with bulimia, but also with depression, part of which was related to having lost her job and coping with five adopted children, one of whom has epilepsy.Review of the submitted treatment notes indicates the patient mostly struggled with depression, not bulimic episodes though admittedly ruminated about feeling fat. Regardless, none of her psychotropic medications were changed and she was thereby treated via the various psychotherapies offered. In addition to feeling anxious and depressed, many of the notes point to the patient feeling rather angry and having a pessimistic perspective. There is no documentation regarding her binging or purging while in the program and post-meal observation was apparently discontinued by 1/24/05. The patients stay was denied beyond 1/25/05 and she was referred to a partial hospitalization program. The patient has requested authorization and coverage to return to residential treatment level of care. Review of the records provided reveals a prevailing affective and character pathology, the latter initially considered as that of borderline and obsessive-compulsive disorder origins. However, it appears this was given little attention during the course of the patients residential treatment. In addition, given her diagnosis of bipolar disorder, her medication regimen seems rather askew. It appears a mood stabilizer would have been appropriate rather than a multitude of antidepressants. Based upon the information provided, treatment focused on bulimia rather than mood-related problems. The submitted records include little documentation pertaining to the patients bulimia while in residential treatment, in contrast to the actual plethora of documentation pointing to mood-related problems. At the time of her discharge the patient was stable from a purely eating disorder standpoint. Partial hospitalization services, which have been authorized by the Health Plan, are medically reasonable and appropriate for treatment of the patients bulimia. She can also receive treatment for her bipolar disorder and character pathology in a partial hospitalization program. The submitted documentation does not demonstrate that residential level of care is medically warranted.Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old male who has a history of osteoarthritis in both knees and spondylolisthesis at L4-5. In addition, the patient also states he has poor circulation and chronic lung problems. The records state the patient is unable to operate a manual wheelchair long distances because of upper extremity pain. The Health Plan has denied the patients request for a power-operated vehicle (POV) on the basis it is not medically necessary.The records submitted do not state an actual diagnosis for the patients chronic lung problems. In addition, there is no documentation stating whether the patient is ambulatory in his home. Nor is there documentation indicating whether a POV can be used inside the patients home. Based upon the information provided, I have determined that the requested equipment is not medically necessary for the patients mobility at this time. However, if there is documentation the patient is able to use a POV for mobility inside the home and is unable to ambulate within the home, the patients request for a POV should be reconsidered. As such, the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 40-year-old female with working diagnoses of rheumatoid arthritis, severe headaches, and complaints of temporomandibular joint (TMJ) pain and crepitus. Based upon the information submitted, no history and physical examination and no imaging has been performed with respect to the patients TMJ complaints. Furthermore, no evaluation has been performed to determine whether there is a possible link between the patients TMJ complaints and her headaches. Moreover, there appears to be no treatment plan in place for this patient. The patient is seeking a consultation with an oral surgeon for evaluation of her condition. The Health Plan has denied this request.Given the patients complaints, a complete evaluation is necessary to obtain a proper diagnosis and development of an appropriate treatment plan. Such an evaluation would involve evaluation of the patients temporomandibular joints, her muscles of mastication, and her dental occlusion. Therefore, a referral to an oral surgeon is medically appropriate and indicated. As such, I have determined the requested consultation is 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 30-year-old male with a history of hyperhidrosis status post endoscopic thoracic sympathectomy. Since the procedure, the patient has experienced compensatory hyperhidrosis. This is a known possible side effect of thoracic sympathectomy. The patient now wants to undergo a reverse sympathectomy. The Health Plan has denied this request.There is no evidence to support authorization of a reverse sympathectomy. There is no data supporting the long-term efficacy and safety of the procedure. Indeed, the patients provider indicates he has performed a small number of these procedures with varying degrees of success. Given the lack of data supporting the safety and efficacy of the requested procedure, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 47-year-old male who has a long history of progressive back and leg pain. He has tried medications, physical therapy, and chiropractic all without any sustained relief. A CT scan performed in February 2005 showed lumbosacral spine discogenic bulge at mid L3-4, focal disc herniation at L4-5, and almost total obliteration of disc space at L5-S1. His physician has recommend the patient undergo disc replacement at L5-S1. The Health Plan has denied coverage for artificial disc replacement indicating the requested procedure is considered investigational.The patient is a male with multi-level degenerative disc disease with chronic low back pain. He has not had improvement with conservative measures. Unfortunately, artificial disc replacement is of unproven efficacy for the treatment of chronic low back pain. The long-term results of this procedure are not yet known. Further studies are needed to determine outcomes beyond two years. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 2: The patient is a 47-year-old man with a diagnosis of degenerative disc disease. He has requested coverage for artificial disc replacement surgery. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational.There is little data supporting the long-term efficacy of artificial disc replacement. There is presently at least a 35% failure rate associated with this procedure. Additionally, revision remains a potentially life threatening proposition. At present, the efficacy of disc replacement remains unproven. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 47-year-old male who has a long history of back pain caused by degenerative disc disease. He has undergone several conservative management therapies, which have not produced relief for his pain. The patient has requested authorization and coverage for artificial disc replacement surgery. The Health Plan indicates the efficacy of artificial disc replacement has not been established.Artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 45-year-old female who has a history of diabetes mellitus and right side breast cancer. Records also reveal she is post gastric bypass and skin reduction surgery. She has bilateral shoulder pain and has been diagnosed with adhesive capsulitis. The patient reports she has benefited from physical therapy in the past. The Health Plan has denied authorization for additional physical therapy on the basis it is not medically necessary.Review of the daily progress reports of the physical therapist shows there were no gains in range of motion from 9/7/04 through 12/6/04. There is no documentation of objective improvement in strength or in functional activities. Notes indicate the patient had good knowledge of a home program. It was stated the patient was discharged because 85-90% of treatment goals were met. Thus, the patient reached a plateau in physical therapy and additional therapy is not indicated based on the records provided. 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 14-year-old female with recent onset of headaches, dizziness, photophobia and phonophobia. The history does not suggest seizures. The patients neurologist suggested the patient undergo an MRI and EEG. An MRI was approved, but the Health Plan denied authorization for the requested EEG on the basis it is not medically necessary.There is no role for EEG in the evaluation of headaches or migraines. There is no history suggesting seizure or other neurologic problem that EEG will help to sort out. The recommendation of EEG to assess brain cortical activity does not constitute medical justification for the EEG. There is no clinical indication for EEG in this setting. Therefore, I have determined that the requested EEG 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

The patient is a 61-year-old man who developed symptoms of bowel obstruction in February 2004.  In May 2004 a colonoscopy was performed, which revealed a large colonic mass at 30cm from the anal verge that appeared malignant. A biopsy was obtained, which did not show malignancy. A CT scan revealed a mass of 11x13 cm in the sigmoid colon contiguous with rectosigmoid and having invaded the dome of the bladder. Air was also described in the bladder suggestive of direct involvement of the urinary bladder with rectovesicular fistulous formation. The CT scan suggested diverticular disease. Surgery was recommended, but the patient refused and requested an oncologic referral.Both the medical oncologist and the radiation oncologist recommended an operative approach as the main approach initially to determine the grade and the stage of the cancer. The patient refused. The patient requested proton beam therapy and agreed to start chemotherapy initially and external beam irradiation subsequently. Chemotherapy was started on 6/7/04. Radiation therapy was started on 9/13/04. The patients symptoms improved.Surgery was again recommended when a CT scan of 1/5/05 showed significant regression in the size of the tumor from 8-9cm on 5/24/04 to 4-5cm. The fistula to the bladder persisted with the pressure of air in the bladder. The patient has no imaging evidence of distal metastases.There is no objective evidence of the type and the grade of this cancer. The stage of the cancer is not determined and this can only be done surgically. Thus, the precise location or extension of the patients cancer is not known. Proton beam therapy is primarily used on proven and documented cancer in confined organs and with confined margins, e.g., the prostate gland. The sigmoid colon and the bladder dome do not meet these criteria. In addition, given the size of sigmoid cancer it is generally associated with extensive lymph node metastases, which would be impossible to adequately treat with proton beam therapy. As such, the medical community has not used proton beam in cancers of the sigmoid colon. 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 54-year-old female who has a history of facial cellulitis. This is due to a long healing process. She has a noted deformity on the left side of her nose measuring 1cm at its widest point. Her plastic surgeon has recommended she under go an excision and reconstruction with bilobed flap. The Health Plan has denied this request indicating the requested procedure is cosmetic in nature and not medically necessary.The patient is requesting scar revision of the left side of the nose. The photograph demonstrates a 1cm depressed scar. This does not interfere with nasal function. This acquired deformity is cosmetic in nature. In addition, scar revision entails the creation of a new scar. A bilobed flap will cause additional scarring on the thick sebaceous skin of the nose. As such, if this were deemed a reconstructive procedure there is high probability there would only be minimal, if any, improvement in appearance. 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.