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

This patient is a 5 year 9 month old male with a diagnosis of autism. He has been receiving speech therapy twice per week since May 2002. He has been working on expressive language and pragmatic language during this time.  He is followed by a developmental pediatrician, a pediatric psychiatrist and a pediatric neurologist. All of these physicians have recommended the patient receive ongoing speech therapy twice per week.The patients parent has requested reimbursement for the speech therapy the patient received as of January 2006 as well as prospective authorization for continued speech therapy. The Health Plan has denied this request on the basis that speech therapy is not medically necessary for this patient.Upon review of the speech therapy reports it appears the therapy is primarily focused on expressive language delays, which are educational in nature. However, when evaluating the handwritten notes it is clear the context of the therapy is primarily directed toward pragmatic speech, which is more functionally based speech and affects the patients ability to function in the community and not just in the classroom. Given the documented evidence of improvement from the patients three physicians as well as the evidence of improvement in the speech therapy progress notes, the therapy at issue is medically warranted. The patient should continue to be followed by one of his physicians every six months. In addition, his speech therapist should provide an evaluation every six months documenting the patients progress using objective measures. Based upon the information set forth above, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 51-year-old female who initially complained of stress urinary incontinence (SUI) with coughing in November 2004.  At that time she was instructed to perform kegel exercises. The patient returned to her provider in March 2006 reporting no improvement in her SUI.  She was prescribed an electrical pelvic floor stimulator. The patient purchased the device and is now requesting reimbursement.  The Health Plan denied her request citing a lack of medical necessity.There is no question that behavioral therapies such as bladder training, pelvic muscle rehabilitation and biofeedback have a place in the treatment of SUI. In fact, these modalities are usually recommended as first-line conservative management prior to consideration of surgical treatment. It is true evaluation of the success of these various approaches to the treatment of incontinence is difficult as there is often overlap in the types of incontinence (stress, urge and mixed). At the present time there are differences in how behavioral therapies are conducted and there is little agreement in the medical community as to a quantifiable endpoint. Patient satisfaction or the patients perception of improvement is often the best measure of success. Nonetheless, behavioral modifications have been reported as resulting in 50% to 70% improvement or reduction in incontinence episodes. The electrical pelvic floor stimulator has been found to produce a similar rate of improvement when compared to other behavioral therapies. In this case, kegel exercises did not effectively relieve the patients symptoms and the electrical pelvic floor stimulator was a reasonable next step in the conservative management of her SUI.  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: Overturned Decision of Health Plan

The patient is a 56-year-old male who has a history of ulcerative colitis - in remission, cirrhosis secondary to primary sclerosing cholangitis, non-Hodgkins lymphoma - in remission and multiple sclerosis. He has been recommended for a liver transplant. He reports marked fatigue and usually remains at home in bed. The patients attending physician recommends Provigil for treatment of the patients marked fatigue. The patient also experiences erectile dysfunctions for which he has been advised to take Viagra.At issue in this case is whether Provigil is medically necessary for treatment of the patients medical condition.Provigil is appropriate for treatment of fatigue secondary to certain chronic medical conditions including fibromyalgia, chronic fatigue syndrome, narcolepsy and multiple sclerosis. The patient has a serious liver condition and multiple sclerosis resulting in marked fatigue. Based upon the information provided, there are no contraindications to Provigil. In light of the patients diagnoses and his debilitating fatigue, Provigil is medically reasonable and appropriate in this setting. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old female who had a weight of 282 pounds and a body mass index (BMI) of 45.5 when evaluated for bariatric surgery. Her comorbid conditions include asthma and sleep apnea. She has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The patient has selected the Lap Band procedure as her treatment of choice for surgical weight loss. The Health Plan denied authorization and coverage for the Lap-Band procedure citing a lack of medical necessity.With a BMI of approximately 45.5 and comorbid conditions such as asthma and sleep apnea, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. However, the current scientific data shows that the Lap-Band is inferior to other surgical alternatives in terms of excess body weight loss. The weight loss with the Lap-Band is typically 50% of excess, as compared to 60-70% with Roux-en-Y and greater than 60% with the duodenal switch. A patient who weighed 282 pounds would need to lose between 100 and 125 pounds to reach a BMI close to 25 for a successful outcome. If in fact the Lap-Band procedure results in the loss of 50% of excess body weight, the patients BMI would remain at approximately 37, which is still considered morbidly obese by some standards. Given the above information, further investigation of other surgical weight loss procedures would be worthwhile in order to secure optimal weight loss. 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. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 59-year-old male who presented with stage IV non-small cell lung cancer in August 2004. He received external beam radiation therapy for metastatic disease to his spine. This was followed by Cyberknife radiosurgery and then surgical resection. This was then followed by systemic chemotherapy for progressive disease. Recently, the patient was diagnosed with a single right parietal brain metastatic lesion. The options discussed were Cyberknife radiosurgery alone versus whole brain radiation therapy with Cyberknife boost. The patient wishes to proceed with Cyberknife radiosurgery without whole brain radiation. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary in this clinical setting.This patient with stage IV lung cancer has been treated aggressively to date, especially for the spinal metastatic disease. According to patients provider, the spinal metastatic disease in the rib and the adrenal nodule can be appropriately treated. The patients problem of single brain metastatic disease can be adequately treated locally with Cyberknife radiosurgery. The literature submitted for review provides sufficient support for the use of Cyberknife radiosurgery in patients such as this patient with a single brain metastasis. The patient is an appropriate candidate for the procedure and it should be authorized. Accordingly, 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 39-year-old female with type I diabetes, peripheral neuropathy and lower extremity pain. Her provider noted she is not able to walk more that one half mile. The provider also reports she cannot propel a manual wheelchair due to weakness, fatigue and carpal tunnel syndrome. The record did not include an objective assessment of the patients strength, range of motion, or mobility skills. The patient has requested authorization for a power-operated vehicle (POV). Her request was denied by the Health Plan based upon a determination that the equipment is not medically necessary.The records provided for review are not supportive of the patients need for a POV. There is no specific evaluation of the patients mobility and no clear indication of the need for a POV within the home.  In January 2006 the patients provider noted that she is able to walk up to one half mile. Upper extremity weakness is noted, however medical necessity criteria for a POV requires that the patient be bed or chair bound without the equipment. As that is not the case for this patient, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 6 year 10 month old male with a diagnosis of autism. He has been receiving speech therapy intermittently from the Swain Center since August 2004. He has also been receiving speech therapy twice a week for 25 minutes from the school district. The Swain Center is recommending the patient continue to receive private speech therapy twice weekly in addition to the therapy provided by his school. At issue is whether the requested speech therapy is medically necessary for the patients diagnosis of autism.The Health Plans denial should be upheld. Upon review of the submitted clinical information, including the physical therapy evaluations, the recommended goals for the patient address receptive and expressive language deficits, which are educationally-based goals, rather than pragmatic language goals and functional community skills.  Furthermore, the submitted records demonstrate that over the last six months, none of the goals listed have been fully met and daily notes document little progress. Thus, it is unlikely that the requested therapy will result in measurable improvement in the patients functional status. 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 32-year-old female with a body mass index (BMI) of 40.5 and comorbidities including hypertension and obstructive sleep apnea. She has failed medical management of her obesity and wishes to undergo weight loss surgery. The patient and her provider believe the Lap-Band is the most appropriate procedure for treatment of her obesity. The Health Plan has denied authorization and coverage for Lap-Band surgery.The Health Plans denial should be upheld. Based upon the submitted nutritional analysis, it appears the patient does not make appropriate food choices, has failed numerous diets, and does not control portion sizes. Furthermore, the patient is quite young. Patients such as this patient often fail gastric restricted procedures like the Lap-Band and may not tolerate a foreign body for 40 to 50 years. A restrictive/malabsorptive approach is more medically appropriate in this clinical setting and is likely to be more effective. 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 32-year-old female with a history of upper back pain and asthma. She consulted with a plastic surgeon who noted the anticipated reduction in breast size was not likely to alleviate her back pain. There is no evidence of intertrigo or bra strap grooving in the photographs submitted for review. The patient has requested authorization for reduction mammaplasty. This request was denied by the Health Plan citing a lack of medical necessity.The patients primary complaint is upper back pain. According to Gonzalez, et al, symptomatic macromastia is best defined as a pain complex in three or more anatomic areas. The incidence and severity of headache, neck pain, shoulder pain, back pain, breast pain and painful bra strap grooving in the group of patients with symptomatic macromastia was more than three standard deviations greater than in the age-matched control group. This patient has medically documented pain in only one area. Additionally, a breast reduction of 100 to 200 grams is minimal and below the 5th percentile on the Schnur Table, which would indicate the reduction is primarily for cosmetic reasons. The photographs provided do not show significant breast hypertrophy or bra strap grooving. Finally, after an evaluation of the patient, the consulting plastic surgeon did not believe the proposed breast reduction would significantly improve her back pain. For the reasons citied 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 56-year-old female with a 20 to 30-year history of insomnia and excessive daytime somnolence. Based on a sleep study performed in April 2006, she also has mild obstructive sleep apnea. Her insomnia is managed with sedatives/hypnotics, such as Ambien. She reports that Provigil has been beneficial in reducing her daytime somnolence. She has not undergone a trial of CPAP to date. At issue is whether Provigil is medically necessary for treatment of the patients condition.Provigil has been the subject of peer-review and is considered an acceptable treatment modality for hypersomnolence. In the case of this patient, a polysomnography showed mild obstructive sleep apnea. The consensus of the treating physician is the obstructive sleep apnea is probably not significant in the patients hypersomnia. However, the patient also has insomnia. The medication prescribed for the patients insomnia is likely a contributing cause of her hypersomnolence. As such, Provigil is not clinically indicated or warranted for this patient. It is likely that behavioral modification will be more effective in this particular clinical setting. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 62-year-old male who had a middle cerebral artery stroke in April 2006 followed by an occipital-parietal hemorrhage in April 2006. He transferred to the acute rehabilitation setting in April 2006. The level of rehabilitation progress achieved with physical therapy is unclear, but apparently was minimal as he required maximal assistance upon admission to the skilled nursing facility (SNF) in May 2006 with a dense right hemiparesis and significant deficits. PT, OT and ST report progress while he was receiving services at the SNF, but the level of progress with PT is not clearly documented. On the other hand there was clear progress with OT and ST, although quite modest as would be expected. With OT he had improvement in lower body dressing and in grooming progressing from a requirement of moderate assistance to a requirement of minimal/moderate or minimal assistance. ST reports the patient was initially unable to generate any distinct sounds, but was able to produce consonant and vowel sounds in combination and respond appropriately, though nonverbally, to inquiries with the benefit of therapy.The patient has requested authorization for skilled nursing facility services including OT, PT and ST. The Health Plan denied the request based upon a determination that the services are not medically necessary.The patient had a severe stroke resulting in severe deficits. The degree of functional recovery is likely to be modest and the rate of recovery will be slow. However, he was progressing with OT and ST and there is some evidence he was progressing with PT, but the specifics are not entirely clear. It does not appear from the records that the patient had yet achieved his maximal functional recovery, and the preponderance of evidence showed that he was progressing modestly. Rehabilitation services should be resumed and continue for as long as there is demonstrated functional gain.Based upon the information set forth above, I have determined 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 59-year-old man who had a flexible sigmoidoscopy four years ago without any evidence of polyps. He is asymptomatic, but has a family history of colon cancer in his mother, which was apparently diagnosed at the age of 83. A colonoscopy has been requested. The Health Plan has denied authorization for the proposed colonoscopy on the basis that it is not medically necessary at this time.Given the information provided, a colonoscopy four years following the patients flexible sigmoidoscopy is not medically warranted. Based on his family history, the patient is at average risk for colon cancer per American College of Gastroenterology and American Gastroenterology Association guidelines. He has no symptoms or complaints at this time. A colonoscopy is not indicated until next year, which will be five years from the time of his previous screening. Therefore, I have determined the requested colonoscopy 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 41-year-old female with excessive upper arm skin due to her obesity and subsequent weight loss. The patient complains of arm rashes and chafing, but the records do not include any office notes that objectively confirm a history of rashes. In addition, the records do not document a workup for arm pain or a need for analgesics. The Health Plan has denied coverage for the requested brachioplasty on the basis that it is not medically necessary for treatment of the patients condition.The submitted records do not establish medical necessity for the proposed brachioplasty.  The procedure has been proposed as a treatment for recurrent infections, but the records do not include objective evidence to verify the reported history. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin infections in the arm folds. Furthermore, the submitted photographs do not document cellulitis, ulcerations or rashes. The submitted physician letter indicates that the patient has failed conservative treatment, but it is not clear if the conservative treatment was for the pannus or arm infections. The records do not include office notes that document evaluation and treatment of persistent arm rashes by an internist or dermatologist.  The medical records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. Given the absence of objective evidence of uncontrollable and recurrent intertrigo the patient does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss. The records do not document the failure of medically supervised conservative therapy to control this patients arm intertrigo. 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

This patient is a three-year-old male with a history of speech and language delays.  His hearing has been tested and was determined to be normal.  The patient has been evaluated by two speech therapists and found to have mild receptive and moderate expressive language delays. There are no other developmental delays documented in the record provided for review. The patient has a history of behavioral issues which are believed to be related to his speech difficulties. His speech therapist noted good eye contact and cooperation during the evaluation.  The therapist suggested that the patients multiple ear infections are the cause of the speech delays, but there is no documentation of treatment for ear infections in the records from July 2005 through June 2006. The patients parent has requested authorization for speech therapy.  The Health Plan denied the request based upon a determination that speech therapy is not medically necessary.In reviewing the physician medical records for this patient there is no evidence of recurrent ear infections or intermittent hearing loss. The hearing evaluation included in the record shows the patients hearing is within normal limits. As such, I see no medical indication for speech therapy. The delays in this case appear to be developmental in nature and the parent may wish to pursue ancillary speech therapy services through the school system. Based upon the evidence provided for review, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.