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

The patient is a 57-year-old woman who has a stage T3,N0,M0 carcinoma of the rectum. This is an invasive carcinoma. The tumor measures 3.5 cm x 1.6 cm and is located on the anterior wall of the rectum extending from 2 cm above the dentate line to 5 cm superiorly. Transrectal ultrasound reveals the tumor extends to the perirectal fat. The recommended treatment plan includes pre-operative chemoradiation to try to shrink the tumor for a more complete tumor resection. It has been proposed that the patient receive intensity modulated radiation therapy (IMRT) as opposed to external radiation therapy. The Health Plan has denied coverage for IMRT on the basis it is not medically necessary for treatment of the patients condition.In this clinical setting, all publications currently support 512 weeks of external beam irradiation or 5000 cGy in 512 weeks in combination with chemotherapy, preoperatively. Though IMRT is superior to external radiation because of its ability to deliver a higher dose without increased side effects, in this case the dose is fixed at 5000 cGy in 512 weeks. Additionally, the toxicity of conventional 5000 cGy to the pelvis has been well studied for all pelvic tumors and is well tolerated by most patients. As the side effects of radiation of pelvic tumors are similar to those experienced in patients with rectal tumors, it is likely that external radiation therapy will be well tolerated in this patient. In summary, IMRT has no significant role as a preoperative modality. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 38-year-old female who sustained a crush injury to her ankle. She has had multiple surgeries. The patient received aggressive chiropractic management in the past and wishes to continue to receive chiropractic services. The Health Plan has denied reimbursement for the chiropractic services the patient received from July 2004 onward on the basis the services were not medically necessary. Additionally, the Health Plan has denied authorization for future chiropractic services.The patient has received a long-term course of chiropractic care for her left ankle/foot pain and associated complaints. The chiropractic records provided do not support the need for continued chiropractic services as of July 2004. Initial and progressive examinations are void. In addition, there is no evidence the patient has participated in a home program for self-care of balance, strength and stabilization. The submitted records do not document gradual resolution of the patients symptoms or stabilization. Furthermore, a treatment plan has not been provided. There is no evidence of a therapeutic endpoint; lasting benefit of care is not projected or documented in the records provided. Based upon the submitted clinical evidence, the chiropractic services received from July 2004 onward were not medically warranted. Moreover, there is no justification for additional chiropractic services at this time.As set forth above, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is an eight-year-old male with a history of chronic and recurrent otitis media. Although no documentation regarding otitis media has been submitted, it is documented that the patients hearing screen was normal. In addition, notes from speech therapy document the patients gross and fine motor skills are within normal limits. Standardized testing included the CELF-4, which was within the average range. The articulation evaluation demonstrated a mild lisp. Speech therapy has been recommended once a week for 12 weeks. The Health Plan has denied authorization for the requested therapy. Limited evidence has been submitted to support the requested therapy. There is little evidence that the patients mild articulation disorder is related to the otitis media he experienced as an infant. Furthermore, with a normal hearing screen it is less likely the patients articulation disorder is associated with otitis media. Moreover, there is no evidence the patient could not receive appropriate therapy from his school-based therapist. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 36-year-old male with a history of polio. He requires use of a left knee ankle foot orthosis (KAFO) for ambulation. The patient reports the KAFO he has been using causes leg irritation and needs to be replaced. The Health Plan has denied authorization for a replacement KAFO on the basis it is not medically necessary. As an alternative, the Health Plan has authorized repair of the patients current KAFO.A newly constructed KAFO is clinically appropriate and necessary for this patient.  It is a superior option to repair of his prior brace and meets community standards for coverage. The patient is likely to achieve better functional results with a new device than with repair of the prior brace. As such, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a six-year-old male with a history of otitis media documented by his primary care provider on four occasions. The primary care physician has also documented normal hearing. Additional medical history includes a cyst underneath the tongue. The patient has been receiving speech therapy since May 2004. Over the last several months the patient and his therapist have been working on [R] sounds with only mild success. A request has been made for authorization and coverage for continued speech therapy. The Health Plan has denied this request indicating the requested services are not medically necessary.Although the primary care provider documented four bouts of otitis media over a seven-month period, the submitted documentation does not indicate whether this included effusion. March 2005 is the only time a transient loss of hearing is documented in the submitted records. Thus, there is insufficient evidence the patients delays are medical in nature. Furthermore, despite the June 2005 note from the speech therapist stating the patient made some gains in [R] sounds, there is little to indicate the patient has demonstrated significant gains. It appears limited progress has been made over the last six months. Moreover, the standardized tests performed show no deficits outside of the normal range. For these reasons, 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 44-year-old female with a body mass index (BMI) of 44.8. In addition, the patient has a number of comorbidities including hypertension and diabetes. The patient also reports multiple failed attempts at conservative weight loss. The patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. The patients provider has recommended the patient undergo gastric bypass with duodenal switch. The Health Plan has denied this request.With a BMI of 44 and comorbidities such as hypertension and diabetes the patient meets nationally accepted criteria for consideration of weight loss surgery. There is significant data supporting duodenal switch as an appropriate procedure for this patient. Furthermore, the patient has undergone a full evaluation and it has been determined that duodenal switch is the appropriate weight loss procedure. 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: Overturned Decision of Health Plan

The patient is a 64-year-old female weighing 270 pounds with a body mass index of 43.6. She has multiple co-morbid conditions including diabetes mellitus, asthma, hypertension hypercholesterolemia, and urinary stress incontinence. The patient has tried and failed multiple attempts at weight loss. She has obtained psychological clearance for weight loss surgery and wishes to undergo gastric bypass with duodenal switch. The Health Plan has denied coverage for the duodenal switch procedure, but indicates alternative surgical procedures are available.The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the medical literature to support the use of duodenal switch to accomplish this goal. The literature shows that duodenal switch has a superior long-term outcome when compared to Roux-en-Y gastric bypass. Consequently, duodenal switch is an accepted and necessary procedure for this patients medical condition. 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

A 54-year-old male had cataract surgery on his right eye in 1996 and on his left eye in 1998. The patient has been experiencing pain in both eyes. Despite several visits to ophthalmologists, the exact cause of the pain has not been identified. The patient has requested removal of the ocular implants. The Health Plan has denied this request on the basis that the requested procedure is not medically necessary.Though the patients vision is intact, he wishes to have the ocular implants removed. Review of the submitted clinical notes indicates an anterior chamber lens was implanted in the right eye. Use of an anterior chamber lens is not typical. However, there is no evidence of any issue with the patients vision or any description of corneal edema. There is no clinical justification for removal of the ocular implants at this time. The risks associated with the proposed procedure exceed any potential benefit that is likely to be obtained. 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 49-year-old female with a multiplicity of complaints. She has been receiving human growth hormone treatment for an unknown duration of time with an equivocal response. The patient has a history of chronic fatigue, sleep disturbances, panic attacks, pain, and decreased cervical range of motion. Laboratory studies revealed an IGF-1 level of 77. A request has been made for authorization and coverage for growth hormone therapy. The Health Plan has denied this request indicating growth hormone therapy is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical records reveals no conclusive evidence of growth hormone deficiency or any pituitary dysfunction for that matter. The patient has refused definitive growth hormone testing. Her symptoms are nonspecific and her IGF-1 is not diagnostic of adult growth hormone deficiency. As such, there is no clinical indication for continuation of growth hormone therapy in this case. Accordingly, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This case concerns a 10 year and 6 month old male who is taking Concerta and Ritalin for attention deficit disorder.  He was referred for an endocrinology consultation because of slowing growth. The patient had an MRI of the brain in November 2004, which was normal and unchanged from a previous study in 2002. Growth hormone (GH) provocative testing showed a normal peak level response of 11.5 ng/ml to L-dopa, but an apparently inadequate response to clonidine of 1.6 ng/ml at 60 minutes. The patients IGF-1 level was low at 105 and thyroid tests were normal.  Bone age essentially matched the chronological age at 9 years. Records from one year ago indicate a height at the 3-5th percentile and a projected adult height of 55` (according to the non-retarded table in the Gleulich and Pyle wrist and hand atlas). A more recent bone-age study was read as retarded, which would imply an improving height prediction. The growth rate curves for some years appeared to be normal along the lower percentiles, however there were short-interval measurements last year that suggest a decreased height velocity of 2.4 cm per year.A request has been made for initiation of growth hormone therapy, which has been denied by the Health Plan. At issue is whether the requested therapy is medically necessary for treatment of the patients condition.The submitted records did not include the heights of the parents or make reference to birth history with weight and length measurements. In general, the height velocity measurements provided were inadequate to accurately judge the actual growth rate over time despite data for one short interval. There were no references in the submitted materials to a workup for other causes of short stature, and the record lacked data on pubertal development status. Thus, there is insufficient evidence growth hormone therapy is medically warranted at this time. If, however, future growth measurements better document an actual growth retardation and demonstrate a significant deficit in adult height prediction (with respect to the parent's height), the issue of growth hormone treatment should be revisited.On the basis of the information provided, 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 an 11-year 4-month old male with short stature. He was a full-term baby who was small for gestational age (SGA) weighing only five pounds. He has not shown catch-up growth. He attends a special educational school. In October 2004, the patient was evaluated by an endocrinologist who noted the patient was 113.5 cm tall (4.5 SDs below the mean) and weighed 19.6 kg (below the 3rd percentile). The patients IGF-1 was 133 and IGFBP-3 levels were normal. He had good growth hormone responses to argine and clonidine at peaks of 15ng/ml, thereby ruling out growth hormone deficiency. His parents height is listed at 150 cm (mother) and 168 cm (father). The patients bone age was 9 years at age 10 years and 5 months. His growth velocity was 3 cm per year. He was started on growth hormone therapy in April 2005. His thyroid tests were normal. A SHOX gene test was contemplated but it is unknown if the test was performed. The patients adult height prediction falls short of 5'.At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.Based on the submitted clinical information, the patient does not have growth hormone deficiency. However, the patient has been diagnosed as SGA and has not exhibited catch-up growth. Additionally, the patient has a family history of short stature. The patient apparently does not have features of Russell-Silver Syndrome. SGA is an approved indication for growth hormone therapy. A trial of growth hormone therapy is medically reasonable and appropriate in this clinical setting and should be authorized. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 20-year-old male who has at least a four-year history of severe cystic acne of the face and neck. Oral antibiotics and topical benzoyl peroxide, retinoids, Tazorac and antibiotics have been ineffective. A course of Accutane was discontinued because of a severe inflammatory reaction, which necessitated oral prednisone. The patient became depressed and started seeing a psychiatrist. A dermatologist recommended Smoothbeam laser therapy. The patient also has severe scarring.The Health Plan has denied coverage for the proposed therapy on the basis that the patients condition is cosmetic rather than medical in nature. Additionally, the Health Plan indicates the efficacy of the requested therapy has not been established. This patient has a documented medical condition. Severe inflammatory cystic acne is painful and can cause severe disfiguring painful scarring with pitted skin, and hypertrophic and/or tunnel scars. The submitted clinical information documents severe disfiguring inflammatory cystic acne. This can be assumed to be a major factor in the patients apparent clinical depression. There is also documentation that all other means of treatment have been tried and have failed.The articles presented validate the appropriateness and medical necessity of Smoothbeam laser therapy for severe cystic acne resistant to all other forms of treatment. The patient is an appropriate candidate for Smoothbeam laser therapy and therefore, the treatment should be authorized.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 66-year-old male with a diagnosis of prostate adenocarcinoma in 1997. He had a Gleason score total of 9 on biopsy and his PSA was approximately 7. He was then treated with hormonal therapy and radiation therapy. His PSA reached a nadir near zero, but began to rise in 2004, reaching levels of 14.9, 20.1, and 31 (according to different physician reports) with hormonal therapy changes and with ketoconanole. The submitted information indicates a bone scan performed around January 2005 was reportedly negative. In addition, an abdominal and pelvic CT scan performed in May 2005 showed no metastatic disease or prostatic enlargement. The results of a Prostascint scan reportedly showed uptake in the prostatic bed and in the aortocaval region. An oncologist has suggested consideration of salvage (radical) prostatectomy, and the patient wishes to undergo this procedure. A consulting urologist has recommended against the proposed procedure but has recommended treatment with chemotherapy.At issue is whether a salvage prostatectomy is medically necessary for treatment of the patients medical condition.The patient was diagnosed prostate adenocarcinoma with a Gleason score total of 9 approximately eight years ago. He was treated with radiation therapy and ongoing hormone therapy. His response as measured by PSA was initially excellent, falling to a nadir near zero until 2004 when his PSA began to rise, increasing to levels of 20.1-31 according to various reports. Imaging studies included a bone scan and a CT scan of the abdomen and pelvis. These were both negative for metastatic disease. A Prostascint scan demonstrated prostate cancer in the prostate and in the aortocaval retroperitoneal lymph node region.If there were no evidence the cancer had spread, then salvage prostatectomy could be considered despite its difficulty and risk of complications (as well as the possibility of failure to control the cancer). However, such is not the case with this patient. The cancer is very high grade with a Gleason score total of 9. This is statistically correlated with surgical failure. The patients PSA has been quite elevated, in the 20 to 30 range, even with hormonal deprivation therapy. This is a level that is also statistically correlated with surgical failure. The Prostascint scan, which measures prostate specific membrane antigen (PSMA) has demonstrated prostate cancer outside the prostate itself, and in the retroperitoneal lymph nodes of the aortocaval region. This would be outside the area that would be removed with salvage prostatectomy surgery.Based on the PSA and imaging studies, and even with the benefit of hormonal therapy, there is presumptive evidence that the prostate cancer has metastasized, and therefore, the patient will not benefit from a salvage prostatectomy. Rather, the patient should be considered a candidate for chemotherapy to treat his prostate cancer. In conclusion, 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: Overturned Decision of Health Plan

The patient is a 49-year-old man who has a PSA of 16.6 and a Gleason score of 3+4=7. His bone scan and CT scans of the pelvis and abdomen are both negative for metastases. The patient is sexually active. His prostate is 19cc (reasonably small). The cancer is mostly on the right side of the prostate. The patients prostate cancer occupies 20-50% of the right lobe. The patient has obtained consultations from multiple providers; he has decided high definition radiation and external radiotherapy with implants is the most appropriate treatment for his condition. The Health Plan has denied authorization for the proposed therapy on the basis it is not medically necessary for treatment of the patients medical condition.This patient has marginally advanced prostate cancer with close to 50% of the volume of the right lobe being involved. Review of the record indicates the patient is sexually active and has a relatively large volume of cancer. HDR and external radiation can offer a biologically equivalent dose to the prostate of 12,000 to 14,000 cGy whereas external radiation with 3DCRT can only deliver 7200 cGy. Recurrence with high definition radiation and external radiotherapy with implants is less than 2% (locally). Furthermore, the alternative of surgery has a very high chance of leaving the patient impotent, negatively affecting his quality of life. For these reasons, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 61-year-old female who sustained a fractured right femur and is status post open reduction and internal fixation. She also has a complex medical history, which includes atrial fibrillation, hypertension, diabetes mellitus, coronary artery disease, hypothyroidism and schizophrenia. She needed maximum assistance with bathing and dressing. She also required assistance with transfers and ambulation, as she was unable to ambulate by herself. She made no progress during her stay in August 2005 so occupational therapy was discontinued. The patient is seeking coverage for further SNF services.The patient is clinically stable. The patient has no on-going daily skilled nursing needs and there is no documented progress with physical therapy or occupational therapy. In addition, there is no evidence that currently the patient is able to benefit from physical or occupational therapy. Because the patient is clinically stable, has no daily skilled needs, and is not benefiting for rehabilitation therapy, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.