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

The patient is a 63-year-old male with low total testosterone and low normal free testosterone levels. Based on this information, the patients primary care physician has recommended testosterone patch or gel replacement treatment to enhance the patients quality of life and to avoid future complications. The Health Plan has determined testosterone replacement therapy is not medically necessary for treatment of the patients medical condition.Testosterone replacement therapy is medically indicated for treatment of documented postpubertal hypogonadism regardless of the cause. Based upon the clinical information provided, there is not clear evidence of hypogonadism. For example, it is not known whether the patient has undergone a genital exam. In addition, no measure of gonadotropin, prolactinomas (PRL), etc. has been provided. Furthermore, it appears the testosterone results are potentially incompatible in that although the patient appears to have significantly low total testosterone, he has a low normal free testosterone, a barely normal free testosterone, and weakly bound testosterone. Sex hormone-binding globulin is also low normal. Thus, the results do not appear to be consistent. Further evaluation and diagnostic workup is needed in order to confirm the patients diagnosis.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patient should be evaluated by an endocrinologist to confirm if the patient has hypogonadism. If the endocrinologist confirms a diagnosis of hypogonadism, the patients request for testosterone replacement therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old male with bilateral Tarlov cysts on S2 nerve roots. The patient reports a history of back and leg pain. The patient has undergone an orthopedic consultation and multiple neurosurgical consultations. He wishes to undergo surgical removal of the Tarlov cysts. The Health Plan has determined the requested procedure is not medically necessary for treatment of the patients medical condition.Review of the submitted materials indicates the patient has received multiple evaluations and diagnostic procedures. The submitted records include no evidence that the patients Tarlov cysts are causing either his back or leg pain. The requested procedure is not likely to have any effect on the patients symptomatology. There is no medical indication for operative intervention in this patient. Therefore, 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 55-year-old female who underwent gastric bypass in 2001. The patient has an overhanging pannus, which she reports is prone to infection. The patient has requested authorization and coverage for an abdominoplasty for treatment of her pannus. The submitted evidence does not demonstrate the patient has severe, visible skin irritation/ulceration resulting in a functional impairment. Excoriation and ulceration is not evident in the submitted photographs. Based upon the information provided, the patients abdomen shows findings consistent with deep and subcutaneous fat. In cases such at this, the requested procedure is cosmetic in nature and is not medically indicated. 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 53-year-old male with a history of profound hearing loss bilaterally, status post placement of cochlear implant in 1994. The patients current external processor was repaired in March 2004. It is reportedly functioning satisfactorily. The patient is requesting an ESPrit 3G, which is a new external processor that offers some advantages over its predecessor. The Health Plan has denied authorization for an ESPrit 3G speech processor on the basis that it is not medically necessary.Though the new ESPrit 3G external cochlear implant processor is more sophisticated than the patients current processor, it is not paramount to the function of the cochlear implant. Furthermore, the submitted evidence indicates the patients current processor is functional and working effectively. There is no indication the ESPrit 3G processor will improve the patients function. As such, there is no medical indication for use of the ESPrit 3G processor at this time. Therefore, I have determined that the requested equipment is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 21-year-old female with debilitating chronic pelvic pain since 1999. She has had multiple gynecologic surgeries for diagnosis and palliation without success. She has been treated with a GnRH medication for endometriosis. She has had a negative urologic and GI workup. She has been managed pharmacologically by a pain specialist with only limited relief and has also had trigger point injections, which were not effective. She was evaluated at a pain management clinic where she was diagnosed with myofascial pain syndrome and then referred for pelvic floor physical therapy (pelvic floor therapy). She continued pelvic floor therapy for approximately six months. The patient initially seemed to respond to the therapy, but more recently has not responded, apparently due to an exacerbation of her depression. A request has been made for continued pelvic floor therapy. The Health Plan has denied the request citing lack of medical necessity.This is a very complex case involving a very complicated patient. The American College of Obstetrics and Gynecology Practice Bulletin states that observational studies suggest that various physical therapy modalities are effective, e.g., manual therapy of trigger point in the pelvic floor showed improvement of pain in 65-70% of cases. Although this data is extracted from urologic studies, which were uncontrolled, and nonrandomized, the ACOG does recommend physical therapy as an option for the treatment of chronic pelvic pain.Review of the submitted records indicates the patient has received extensive workup and treatment for any gynecologic condition that could cause chronic pelvic pain (endometriosis, adhesions, etc.). Given the absence of other treatment options and the patients initial response to pelvic floor therapy, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The patient should resume pelvic floor therapy with re-evaluation by her gynecologist after three months of therapy. In addition, her depression should be addressed and effectively treated. The patient should also continue to see her pain management specialist for pharmacologic treatment.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 25-year-old female who has requested authorization and coverage for a full body scan. The patient has a history of chronic pelvic pain, dysmenorrhea, and menorrhagia. She has undergone three pelvic sonograms, most recently in 2003, with normal results. In February 2003, the patient underwent a hysteroscopy and D&C with negative results. In 1999, she underwent a laparoscopy, which was also negative. She did have an abnormal pap smear, for which she received treatment. The Health Plan has denied authorization for a full body scan on the basis that it is not medically necessary for evaluation of the patients pelvic pain. The patient wishes to undergo a full body scan to rule out any cancer. This request has no bearing on the pursuit of a diagnosis and treatment of the patients problem. There is no medical indication for a full body scan to rule out gynecological disease. Under certain circumstances, a pelvic MRI or CT scan can be considered if ordered by a physician.A patient in whom abnormal bleeding and pelvic pain persists requires a more thorough workup both for the pain and bleeding. Such a workup would include, but not be limited to, referrals to specialists such as a gastroenterologist to rule out gastrointestinal pathology such as polyps or irritable bowel syndrome; an urologist to rule out interstitial cystitis or a renal problem; a neurologist to rule out a neuromuscular problem with referral pain; and an endocrinologist to rule out thyroid or other endocrine diseases.In addition to the above, consideration can be given to producing amenorrhea with a gonadotrophin releasing hormone agonist to explore the possibility of undiagnosed endometriosis. If the symptoms disappear with this regimen, the treatment can be continued. Also, a repeat laparoscopy can be considered. Referral to a gynecologic oncologist may also be appropriate.In summary, a full body scan is not medically necessary for the diagnosis and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 15-year-old female with severe open bite deformity secondary to maxillary hypoplasia and mandibular hypoplasia. She also has lip incompetence secondary to microgenia. There is also documentation of temporomandibular joint arthralgia. X-rays confirm the severity of the facial skeletal deformity and the dysfunctional dental malocclusion. The patients provider has recommended the patient undergo Lefort I osteotomy, bilateral sagittal split ramus osteotomy, and an osteotomy of the inferior border of the mandible. The Health Plan has denied authorization for oral surgery on the basis that it is not medically necessary.The submitted x-rays reveal an obvious open bite deformity. The patients dental occlusion is completely dysfunctional. This problem is a skeletal developmental deformity and cannot be managed without orthognathic surgery. The patient has been diagnosed with temporomandibular arthralgia, which is quite common with this deformity. The discomfort and dental occlusal dysfunction secondary to skeletal deformity are medical problems and confirm the medical necessity for treatment. Therefore, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1The patient is a 54-year-old morbidly obese, type 2 diabetic who is suffering bilateral knee pain, low back pain, and neck pain. The patient has MRI confirmation of advanced degenerative joint disease. Ligaments and tendons of his left and right knees are grossly intact. Meniscal derangement is complex. Based upon the submitted records, the patient is independent with activities of daily living and driving. It has been recommended the patient undergo prolotherapy. The Health Plan has denied authorization for prolotherapy on the basis that it is considered experimental.The efficacy of prolotherapy for patients such as this patient has not been established. The ligament/tendon structure of the patients knees is grossly intact. In addition, the patients morbid obesity complicates any treatment approach for his knees including total replacement. Furthermore, conventional treatment with quarterly cortisone injections has been successful in relieving the patients pain. Therefore, I have determined that the requested therapy 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 2The patient is a 54-year-old obese male with bilateral knee arthritis. The patients pain has been refractory to physical therapy and pain management. The patient wishes to undergo prolotherapy for treatment of his knee pain. The Health Plan has denied authorization for the requested therapy on the basis that it is considered experimental. There is no peer-reviewed, case-controlled literature demonstrating the safety and efficacy of prolotherapy in the treatment of arthritis of the knee. Prolotherapy introduces a chemical irritant to cause proliferation of the tissue. There is no documentation regarding dose and tissue response and safety of this therapy. Furthermore, there is no evidence demonstrating that prolotherapy stabilizes joints. Therefore, I have determined that the requested therapy 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 3The patient is a 54-year-old male with long-standing degenerative joint disease, resulting in knee pain. A request had been made for prolotherapy. The Health Plan has denied the patients request indicating the requested therapy is considered experimental.Prolotherapy is of unknown efficacy. There are no long-term, prospective studies that show the therapy to be effective. Furthermore, long-term risks and complications are not known. The requested therapy cannot be recommended given the lack of information regarding its usefulness and effectiveness. Therefore, I have determined that the requested therapy 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 14-year-old female with a recent history of risky behavior. She has been exhibiting acting out behaviors since the age of 10. She has a history of running away from home and drug and alcohol abuse. Recently, the patient was placed on a 5150 psychiatric hold after she assaulted a family friend who attempted to prevent her from running away. On 7/16/04, the patient was admitted to a residential psychiatric treatment facility. The submitted treatment notes indicate the patient is not suicidal. On 8/10/04, the patients psychiatrist noted there was no need for psychotropic medication. A request has been made for continued residential psychiatric treatment services. The Health Plan indicates the submitted documentation does not demonstrate continued residential psychiatric treatment is medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The submitted records do not demonstrate that the patient is suicidal or a danger to others. It appears the patient participated appropriately during residential treatment and evidenced no self-destructive behavior or high-risk taking behavior. Furthermore, the patients provider indicates the patient does not require psychotropic medication. The patient is cooperative with therapy and her family is supportive. Thus, the submitted evidence does not demonstrate the patient continues to require residential psychiatric treatment services. Transition to a lower level of care is medically reasonable and appropriate.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. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 58-year-old obese woman with a fracture to her right ankle. She has had some progress with physical therapy, particularly with bed mobility. However, the patient has not progressed with transfer and still requires two-person transfer. Based upon the submitted information, the patients progress with parallel bars is not clear. The patient has requested authorization and coverage for continued daily inpatient skilled therapy. The Health Plan has denied her request on the basis the requested therapy is not medically necessary.The submitted documentation does not provide compelling evidence the patient has reached her skilled rehabilitation plateau. Although the patient did not progress with transfer ability, there is evidence she progressed slowly but consistently with occupational therapy. There is potential for continued benefit in this case, particularly if the patient has been able to progress with parallel bars. In the absence of evidence the patient has plateaued with occupational therapy, continued daily inpatient skilled therapy is medically indicated. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should be fully re-evaluated in two weeks to determine if continued daily skilled inpatient rehabilitation therapy is indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 62-year-old female with long-standing breast augmentation problems. The patients provider has requested authorization for removal of the suspected ruptured implants and capsulectomy. In addition, the patients provider has requested authorization for bilateral replacement of the implants and mastopexy to the redundant skin/breast. The patients provider previously replaced the patients implants (1983) and performed a bilateral mastopexy with implant exchange (1992). There is MRI evidence documenting bilateral capsular contracture and implant rupture. The Health Plan has authorized removal of the implants and capsulectomy. However, the Health Plan has determined replacement of the implants and mastopexy are cosmetic in nature.The submitted documentation demonstrates the medical necessity for removal of the ruptured implants and capsulectomy. This will aid in the detection of suspicious lesions on mammography in the future. The implants are subpectoral and the result of removal is marginally predictable from a cosmetic standpoint. Breast implant insertion and mastopexy would be performed for the purpose of aesthetic improvement and therefore, these procedures are cosmetic in nature. As such, 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: Overturned Decision of Health Plan

The patient is a 30-year-old female who has a history of menorrhagia and dysmenorrhea. She has an abnormal pelvic exam and pelvic ultrasound. Her uterus is enlarged and contains areas seen on the ultrasound, which are most likely myomas. She has failed medical management (birth control pills and pain medications). The patient has requested authorization for a hysterectomy. The Health Plan has denied the request on the basis that the requested procedure is not medically necessary for treatment of the patients medical condition.The patient has an enlarged uterus. The ultrasound showed abnormalities in the echo pattern of the uterus, which the radiologist diagnosed as probable early myomatous degeneration. Since the patients uterus is enlarged to a 12-weeks size it is reasonable to assume that this enlargement is secondary to uterine myomas. The patient has tried birth control pills to treat her menorrhagia; however, the birth control pills did not result in improvement. There is no evidence that increasing the dose of birth control pills or using Depo-Provera would improve menorrhagia in women with myomas. ACOG Practice Bulletin on Surgical Alternatives to Hysterectomy in the Management of Leiomyomas states that based on good and consistent scientific evidence, hysterectomy provides a definite cure for women with symptomatic leiomyomas. This bulletin also states that although endometrial ablation appears to be an effective option in controlling menorrhagia in women without leiomyomas, further studies are needed in women who have clinically significant leiomyomas.Therefore, because there is no evidence the alternative treatment options would be effective in this case and in light of ACOGs evidence that a hysterectomy would provide a definitive cure for this patient, 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: Overturned Decision of Health Plan

The patient is a 42-year-old female five years postoperative from craniotomy, which was performed to salvage a bleeding intracranial aneurysm that left the patient with multiple cranial nerve deficits on the ipsilateral side of her face. The submitted documentation indicates the only restorative procedures performed were placement of weight in the left upper eyelid to protect the eye, and augmentation of the left vocal cord to prevent aspiration and improve phonation. The patient has requested authorization for a plastic surgery consultation, which was determined by the Health Plan to be cosmetic and not medically necessary.The record lacks evidence of any discussion of facial reanimation or possible need for protection of facial function (drooling, dry eye, corneal ulceration, intraoral trauma from chewing, etc.) subsequent to the craniotomy. Plastic, otolaryngological, and maxillofacial surgeons are trained to evaluate and treat these problems. Whether the patient would benefit from nerve cable cross facial grafts or dynamic or static sling procedures cannot be determined without the appropriate consultation. The requested consultation is reconstructive in nature under California law and should be authorized.  Based upon the information set forth above, I have determined that the requested consultation 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 who has regained weight after gastric bypass surgery in June 2001. The patient indicates her weight regain started as the result of the stress of family problems. The patient wishes to undergo repeat gastric bypass surgery and therefore, has requested authorization for a gastric bypass surgery consultation. The Health Plan had denied the patients request on the basis that gastric bypass surgery is not medically indicated. The Health Plans denial should be upheld. Given the patients history of weight regain following her initial weight loss surgery, it is expected that the patient will continue maladaptive eating behavior with a repeat procedure. There is no evidence of a specific problem relating to the prior procedure. The only indication for a revision procedure would be the presence of a gastrogastric fistula. It is likely that the patient will receive greater benefit from dietary counseling and treatment for stress and anxiety than from repeat weight loss surgery. Therefore, I have determined that the requested consultation is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.