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

The patient is a 59-year-old overweight/obese male. The patient had been evaluated by his general surgeon and has had mammography without significant findings. The main symptoms seem to be pain, which has not responded to antibiotic therapy. The patient has also been seen by his provider for evaluation of gastroesophageal reflux disease for which he was initially prescribed cimetidine and then Protonix. The patient has requested bilateral mastectomy, which the Health Plan has denied on the basis that it is not medically necessary. Gynecomastia is a common problem, which can be related to drugs (including cimetidine), hormonal imbalances, genetic conditions, exogenous hormones, and obesity. After evaluation for treatable causes of gynecomastia, surgical procedures are possible. In the case of this patient, the submitted evidence does not include photographs of the pathology or a description of the size of the breasts and degree of ptosis. Based upon the submitted documentation it cannot be determined whether the patient needs a breast reduction for gynecomastia or simple breast tumor excision. As such, there is no evidence that the requested procedure is medically indicated for treatment of the patients gynecomastia.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The patient is a 40-year-old man with severe degenerative joint disease of the right hip. The patient engages in a high level of activity. The patient has consulted an orthopedist who has recommended a hip surface replacement arthroplasty. The Health Plan has denied authorization for the requested procedure indicating that it is considered investigational.At age 40 a surface replacement arthroplasty is a better option than a conventional total hip replacement because it spares more bone for revision hip surgery. This is an important concept in younger patients who require total hip replacement at less than 50 years of age. Additionally, the submitted literature lends great support and credibility to the procedure. It is certainly the best available option for relatively young total hip replacement candidates at the present time. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a six-year-old male diagnosed with autism spectrum disorder, including significant speech and language delay. He has been in individual speech and language therapy since April 2001. A report from the patients speech therapist in November 2003 indicated the patient experienced significant improvement in all areas. The Health Plan indicates that continued individual speech therapy is not medically necessary due to a lack of documented functional progression over the past three to six months.Intense speech and language therapy is often helpful in the treatment of autism spectrum disorder. The patient has been in individual speech and language therapy since April 2001. The detailed and thorough speech and language therapy progress reports document significant functional progress, specifically in the areas of gestures, play, and language comprehension and language expression. The submitted existing evidence suggests that the patient is making progress and that continued individual speech therapy is medically indicated. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The patient should receive three-60 minute sessions of speech therapy per week. The patients progress should be reevaluated at least quarterly and should be continued as long as significant functional progress is demonstrated. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is an 18-year-old male who has undergone tibial eminence fracture surgery. A custom knee brace has been requested as prophylactic treatment against further injury during sports activities. The Health Plan has denied this request indicating that a functional brace used on a prophylactic basis is not medically necessary for the patient.A custom knee brace is not medically necessary for the patient. It has not been clearly established that custom braces offer any additional advantages over standard braces. Thus, a custom brace is not medically indicated. However, given the patients level of physical activity, a standard ACL brace should be authorized. Therefore, I have determined that although a custom knee brace is not medically necessary for treatment of the patients medical condition, a standard ACL brace is medically necessary and should be authorized. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 45-year-old woman with a history of a vertical banded gastroplasty (VBG). Since the VBG the patient has experienced persistent erosions and reflux. The patient wishes to undergo a salvage operation involving the duodenal switch procedure. The Health Plan has denied authorization for the requested procedure, but has authorized a Roux-en-Y gastric bypass (RYGB).The surgeon embarking on revisional surgery after failed VBG needs the option of the duodenal switch procedure depending on the intraoperational findings. The upper abdomen may be so scarred that it would be difficult, if not impossible to take down the VBG and convert to RYGB. Additionally, the duodenal switch procedure offers the advantage of resecting the stomach away from the original site, reducing acid secretion, and creating more malabsorption. Furthermore, duodenal switch requires less postoperative dietary restrictions. Moreover, the recent report by Anthone, et al. demonstrates the safety and efficacy of the duodenal switch procedure. Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 48-year-old female who is two-years post bariatric procedure for morbid obesity. She has lost a stated 130 pounds and has a significant abdominal panniculus with symptoms of severe intertrigo and an associated ventral hernia. The patient was seen and evaluated by a plastic surgeon who recommended an extensive panniculectomy with abdominal wall reconstruction (hernia repair) through an inverted T incision using a reinforcing mesh. The Health Plan has denied authorization for the recommended procedures on the basis that the procedures are not medically necessary.The submitted medical records and photographs document the severity of the patients problem. The patients pannus hangs well below the pubis, is raw from intertrigo, and interferes with activities of daily living. In addition, there is documentation of an abdominal hernia. Given these factors, all indications for surgical intervention are met. Furthermore, medical management to alleviate the intertrigo is likely to be of little or no benefit as the problem of the patients severe panniculus is a mechanical one. The pannus must be held away from the underlying abdominal and pubic skin to eliminate the moisture and pressure in order to allow the area to dry. The only practical mechanical solution is to remove the hanging pannus via an abdominoplasty with panniculectomy. In addition, simultaneous repair of the ventral hernia is medically indicated.Based upon the information set forth above, I have determined that the requested procedures are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a seven-year-old male with multiple diagnoses relating to cognition with a primary diagnosis of attention deficit hyperactivity disorder (ADHD). The patient has been seen by a speech therapist who has documented a significant speech and cognitive delay. Additionally, neuropsychological testing has been performed. The patients neuropsychologist recommended ongoing speech and language therapy. The Health Plan indicates that continued speech therapy is not medically indicated.Based upon review of the pre-and post-speech therapy documentation, it is apparent the patient has regressed is some areas despite therapy. In addition, there is not sufficient literature evaluating speech therapy as a primary treatment for ADHD. Typically, medications are used as the primary treatment for this disorder with speech therapy used as an adjunctive therapy. Therefore, I have determined that additional speech 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. However, the patient should be evaluated by a developmental pediatrician or pediatric psychiatrist to determine if medications are warranted. If it is determined that medications are warranted, the request for additional speech therapy should be reconsidered, as it may be an appropriate adjunct therapy. However, given the patients previous evaluations, additional speech therapy without use of medication is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old woman with hepatitis C who has been treated with Pegasys and Rebetol for 48 weeks. The patients provider has recommended prolonging the therapy past this point since some positive response was noted after the addition of amantadine. Apparently the patient failed the first therapy on 2001, relapsed in 2002, and attempted this regimen for a third time. The Health Plan has denied the patients request for continued treatment with Pegasys, Rebetol, and Procrit on the basis that the requested therapy is not medically indicated. The use of Pegasys in this patient with the above course of therapy is not the standard of care and is not medically indicated. Review of current medical literature reveals no adequate, prospective double-blinded studies involving non-responders who have relapsed after the next course of therapy. There is no conclusive data on whether such patients should be treated again, and if so for how long. Since continued treatment with Pegasys and Rebetol is not medically indicated, there is no medical justification for the use of Procrit. 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: Overturned Decision of Health Plan

The patient is a 50-year-old woman with neck and back pain who has received medical work-up for causation. Results showed a negative EMG and lumbar spine x-rays were within normal limits. The patients orthopedist determined the patient has a curve alteration of her cervical spine with degenerative disc disease and joint changes. The orthopedists diagnosis was acute lumbosacral muscle strain. The patient has been receiving chiropractic care for several months with benefit. In addition, the patient received two physical therapy sessions. These sessions included hot packs, massage, and ultrasound. The patient was referred to a neurologist though no neurological losses were noted in the submitted records. Physical therapy has been recommended for the patient. The patient does not wish to receive additional physical therapy and has requested authorization for chiropractic. The Health Plan indicates the patient should attempt physical therapy before pursuing chiropractic.The primary treatment approach of chiropractic is manipulation, which is contrary to the physical therapy the patient has received. Chiropractic is effective for treatment of patients with spinal degenerative conditions and acute lumbosacral muscle strains. Based upon the patients submitted history, findings, and diagnosis, chiropractic is medically appropriate and indicated for treatment of the patients condition. The patient should receive chiropractic care for an additional six-week period. 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: Upheld Decision of Health Plan

The patient is a 51-year-old woman with an extensive history of orthopedic and spinal surgery. Her treating physician variously labels her underlying condition as rheumatoid arthritis, psoriatic arthritis, degenerative joint disease, seronegative spondyloarthropathy, B27-positive rheumatoid arthritis, and fibromyalgia. The patient has been treated with an array of agents including DMARDs, prednisone in fairly high doses, three biologic agents, methotrexate, leflunomide, cyclophosphamide, narcotic pain medications, anti-anxiety agents, and antidepressants. The submitted information indicates that at one point the patient was simultaneously taking methotrexate, leflunomide, Enbrel, and Kineret, but still required prednisone between 20 and 60mg daily for benefit. The records only detail subjective changes with all of the regimens described. A request has been made for intravenous Rituxan therapy. The Health Plan has denied the request indicating that a diagnosis of rheumatoid arthritis or any type of inflammatory arthritis has not been established.The requested therapy is not medically indicated. There is no objective clinical evidence or laboratory data presented in the providers frequent office notes from June 2002 to September 2003 to clarify the patients diagnosis. No clinical evidence has been presented to support a diagnosis of rheumatoid arthritis, psoriatic arthritis, spondyloarthropathy or any inflammatory joint disorder. Furthermore, the patients reported lack of response to extensive and aggressive treatment raises the possibility that no inflammatory illness is present. Indeed, there are patients with severe and recalcitrant inflammatory joint disease who do not respond well to current therapies, leading to continuing interest in b-cell inhibition, and other mechanisms, such as IL-6 antagonism. However, the submitted clinical records provide no objective evidence that such is the case with this patient. Rather, the record is suggestive of a somatoform pain disorder with underlying degenerative disc disease. Such conditions would be expected to show no response to aggressive treatment aimed at an inflammatory joint disorder.Therefore, in the absence of a clear diagnosis of any inflammatory disease, or even undefined joint inflammation, treatment with Rituxan is not medically indicated. As such, 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 56-year-old woman who has requested authorization for palatopharyngoplasty. The patients provider indicates the patient has a history of daytime sleepiness and an elongated uvula and soft palate. The submitted information does not include any other clinical history or physical information regarding the patient. The patient underwent polysomnogram evaluation that revealed marked reduction in sleep efficiency with total REM sleep time being reduced to half an hour. Except for during this short period of REM, the patients AHI was 4.4. During REM only, AHI was found to be 25. Significant increase in periodic limb movement was noted. There was also notation of the presence of snoring. There were no findings of obstructive sleep apnea.The patients provider indicates the patient cannot tolerate CPAP due to claustrophobia. Therefore, the patients provider has recommended palatopharyngoplasty. The Health Plan indicates that the requested procedure is not medically indicated as it is not likely to be effective for treatment of the patients condition.The procedure of palatopharyngoplasty is appropriate for treatment of primary snoring, for which its efficacy is stated to be 80-90 percent. The requested procedure is also indicated for patients diagnosed with obstructive sleep apnea who have anatomy conducive to this procedure and who have failed a trial of CPAP or BiPAP. The efficacy of palatopharyngoplasty for treatment of obstructive sleep apnea is generally stated to be around 50 percent. Although this patient does have a snoring problem, there is no documentation of actual obstructive sleep apnea. Palatopharyngoplasty is not medically indicated in the absence of documented evidence of obstructive sleep apnea. 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 61-year-old woman who has sustained multiple fractures. Her primary physician has diagnosed osteoporosis. The patients DEXA scan of October 2003 reveals osteopenia. A request has been made for daily Forteo injections. The Health Plan has denied the request on the basis that Forteo is not medically indicated for treatment of the patients diagnosis.Based upon the information provided, the patient would benefit from treatment of osteopenia/osteoporosis. Fosamax is a medically reasonable and appropriate treatment for the patients condition. There is no scientific evidence that use of Forteo on a daily basis for two years would be more beneficial than the use of Fosamax. Furthermore, Forteo has not been shown to speed fracture healing. As such, I have determined that 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 49-year-old woman who has experienced pain in her shoulder for 1.5 years. Upon examination, the patients provider indicated the patient had acromioclavicular joint arthritis and a possible rotator cuff tear. The patient has requested authorization for an MRI. The Health Plan has denied her request indicating that an MRI is not medically necessary.An MRI is medically reasonable and appropriate in this case. The patient would benefit from a complete work-up of her shoulder including x-rays and an MRI to determine the cause of her pain. An MRI is medically indicated in order to evaluate the rotator cuff, labrum, and other soft tissue components not visualized by x-rays. Therefore, I have determined that the requested MRI is medically necessary for evaluation of the patients medical condition. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 41-year-old man who has requested authorization for Levitra or Viagra for treatment of erectile dysfunction. The Health Plan has denied the patients request indicating that he has no clear etiology for the erectile dysfunction. Additionally, the Health Plan indicates treatment for erectile dysfunction as a result of psychogenic impotence is not medically necessary.Viagra and Levitra are accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. Treatment that is successful and acceptable to the patient and his partner is appropriate therapy. In the case of this patient, the submitted information does not document an adequate history or evaluation to establish a diagnosis of erectile dysfunction. Although it has been noted that the patient has taken Viagra with benefit, there is not sufficient clinical data from which to establish a diagnosis of erectile dysfunction.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. However, if documented evidence of a physical examination is provided with sufficient clinical data to establish a diagnosis of erectile dysfunction as well as the underlying etiology, then the patients request for Levitra or Viagra should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 35-year-old woman with a history of abnormal bleeding. A sonogram revealed a thickened endometrium. An endometrial biopsy was normal. The patient was given Provera, and oral Prometrium to help control the bleeding. These apparently produced side effects. She was then given Crinone gel, which is a vaginal gel that contains progesterone. The Health Plan has denied authorization for Crinone gel indicating that it is not medically indicated because it is not being used to treat infertility or secondary amenorrhea.The use of Crinone gel is not medically necessary. Other tests should be performed to rule out possible causes for the patients abnormal bleeding. The patient did undergo a sonogram, which showed a thickened endometrium. However, the submitted information does not indicate whether the sonogram was performed premenstrually. A sonogram performed premenstrually can show a thickened endometrium. Thus, a repeat sonogram after the end of menses may be indicated. If the endometrium is still thick, a sonohysterogram can be performed to rule out the presence of polyps. In addition, a D & C and hysteroscopy with directed biopsies would be appropriate.If the results of these tests are negative, the use of birth control pills for a three to six month period is appropriate. Birth control pills are known to decrease the thickness of the endometrium, especially if taken continuously. Although the patient is concerned about her family history of breast cancer, the use of birth control pills for this short span of time would not pose a danger. Another possibility would be for the patient to receive gonadotropin releasing agonist hormones to produce amenorrhea. If the patient continues to experience abnormal bleeding after the abovementioned tests and treatments, Crinone gel may be indicated. However, based upon the submitted clinical information, Crinone gel is not medically indicated at this time.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.