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

This patient is a six-year-old female with a diagnosis of attention deficit hyperactivity disorder, combined type. She has been evaluated by the school and the Health Plan psychiatrist and attended a social skills class. Autism spectrum disorders have been ruled out using the ADOS.  The patients Health Plan therapist and her school teacher have identified a delay in motor skills including fine and visual motor integration. A private occupational therapy evaluation noted the patient had difficulty with sensory processing including visual perception and visual motor skills and recommended direct occupational therapy one time per week for one hour over a period of six months.   The parents have requested reimbursement for the sensory integration occupational therapy already provided and continued authorization and coverage for on-going therapy. The Health Plan denied their request based on a determination that sensory integration therapy was not medically necessary for the treatment of the patients sensory processing deficits.I have reviewed the literature, and find no controlled clinical trials comparing standard occupational therapy with strict integration therapy.  There is little to no objective evidence that sensory integration therapy is beneficial in the treatment of ADHD and my observations from clinical experience are comparable. Therefore, I have determined the therapy at issue 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 59-year-old obese female with known lumbar stenosis with active symptoms of neurogenic claudication.  She has requested a consultation for possible abdominoplasty/panniculectomy and liposuction as a treatment for her low back pain, knee pain, recurrent urinary tract infections, and urinary incontinence.  The Health Plan has denied her request based upon a determination that a plastic surgery consultation for consideration of abdominoplasty/panniculectomy and liposuction is not medically necessary.The patient consulted with a neurosurgeon with regard to her back pain and other conditions.  She was advised that her symptoms were due to spinal stenosis and were not likely to resolve with abdominoplasty/panniculectomy or liposuction.  Based on the neurosurgeons note of December 2005, the patient had no interest in definitive surgical treatment of her intrinsic lower back problem. The likelihood of panniculectomy helping her symptoms is negligibly small. With regard to symptom relief, abdominoplasty/ panniculectomy should not be considered until after lumbar surgery is completed and reviewed for efficacy. Furthermore, the patient states she had a gradual 40 pound weight loss and saw no change in her symptoms.  If she had an abdominoplasty/panniculectomy, the additional 10-pound weight reduction would not be expected to have an impact on her lower back symptoms. In consideration of other possible medical indications for panniculectomy/ abdominoplasty or liposuction, a detailed inspection of the photographs of the patient with lateral, frontal and posterior views revealed a large midline scar from umbilicus to pubis, but no discernable pannus. The lateral photos clearly do not demonstrate a pannus with skin-on-skin contact. Even with the assumption there is a pannus, there is no documentation of uncontrolled intertrigo that would make panniculectomy medically necessary. Additionally, there is no documentation of massive weight loss or evidence of a symptomatic hernia that would require surgical intervention.  In summary, there is no indication for a plastic surgery consultation and the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a six-year-old male with a history of speech delay consisting of a phonological disorder affecting production of G, K, NG, GH, L, R and TH in all positions. He scored at the fifth percentile on the Goldsmith Fristoe 2 Test of Articulation. He has been receiving speech therapy since that time. The submitted materials include speech therapy assessments from the speech center. At issue is whether the speech therapy was/is medically necessary for treatment of the patients condition.An extensive search of the medical literature regarding the treatment of phonological disorders reveals a paucity of evidence that treatment is beneficial or even needed. There is no evidence in this case of a specific diagnosis, injury, or other impairment. As such, the patients speech problems are considered developmental rather than medical in nature. Accordingly, there is no medical justification for speech therapy given the specifics of this case. Therefore, I have determined the therapy at issue was/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 38-year-old female with symptomatic breast hypertrophy examined by her chiropractor and referred to a board certified plastic surgeon for relief of the noted symptoms of mid and upper back pain. She was examined and photographed by the plastic surgeon. A request for prior authorization was made to her Health Plan. Authorization was granted for the breast reduction, which requested an estimated amount of tissue to be removed as well as the patients height and weight. The patient underwent the procedure but the amount of tissue that the Health Plan had stipulated to was not removed. The Health Plan has subsequently denied coverage for the procedure indicating that based on the amount of tissue that was removed the procedure was not medically necessary.Reviewed were the presented medical records, letters from the patients providers and the patient and photocopies of photographs of the patient. These records and photos document that the patient indeed had large pendulous breasts and had long-standing back pain secondary to the large breasts. The breast procedure carried out was a breast reduction of moderate volume.The patient underwent the procedure to relieve her documented symptoms. It was therefore medically appropriate and indicated. The patient indicates that her symptoms were relieved by the procedure. That a smaller amount of tissue than the authorized volume was removed does not negate the medical necessity of the procedure. As such, I have determined the procedure at issue was 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 1: The patient is a 36-year-old male with degenerative disc disease. His provider is recommending artificial disc replacement at possibly more than one level. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is insufficient evidence supporting the safety and efficacy of artificial disc replacement, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 36-year-old man who has advanced disc disease at L4-5 and mild disease at L3-4 and L5-S1. His physician has recommended artificial disc replacement surgery. The Health Plan has denied authorization for the requested procedure citing a lack of proven efficacy.The proposed procedure is experimental without established long-term safety and efficacy particularly when a multi-level procedure is involved. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 3: This patient is a 36-year-old male status with degenerative disc disease. His symptoms include lower extremity weakness, numbness and foot drop. The patient has failed conservative treatment methods. His physician has recommended artificial disc replacement surgery. The Health Plan indicates the efficacy of artificial disc replacement has not been established.Artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 51-year-old woman with a diagnosis of Crohns disease. She also suffers from arthritis, which is a non-intestinal manifestation of her Crohns disease. Celebrex has been prescribed to decrease the side effects attributed to the non-steroidal anti-inflammatory drugs (NSAIDs).  The patients request for authorization and coverage was denied by the Health Plan based upon a determination that Celebrex is not medically necessary.The use of Celebrex is medically indicated for this patient with Crohns disease. Multiple studies have shown that NSAIDs may potentially exacerbate the underlying irritable bowel disease in patients such as this one. As the patient is symptomatic from arthritis due to Crohns disease, a Cox II inhibitor is a reasonable choice to treat her arthritis symptoms. 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 50-year-old female with worsening fibromyalgia.  She has been taking Suboxone to relieve symptoms of pain and fatigue and has found it effective. She recently changed Health Plans, and her request for continued authorization and coverage of the medication has been denied based upon a determination that it is not medically necessary for treatment of her fibromyalgia.Suboxone was approved by the FDA specifically to assist opioid dependent patients wean off of narcotic medications. Suboxone has not been approved for the treatment of fibromyalgia and this patients usage is not consistent with the intended purpose of the medicaton.  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: Upheld Decision of Health Plan

The patient is a 53-year-old female with depression treated with Lexapro and Effexor and a listed diagnosis of idiopathic hypersomnia. The patients provider indicates Provigil was prescribed for a diagnosis of idiopathic hypersomnia rather than for treatment of the patients depression. There is no documentation in the clinical material that the patient has had a multiple sleep latency test (MSLT). The Health Plan has denied coverage for Provigil on the basis it was not medically necessary for treatment of the patients sleep disorder.The International Classification of Sleep Disorders Diagnostic and Coding Manual lists the alternate name for idiopathic hypersomnia as non-REM narcolepsy. Idiopathic hypersomnia is a clinical variant of narcolepsy and is treated the same way. In both disorders the MSLT reveals a mean sleep latency of less than 5 minutes.  In narcolepsy there is REM sleep documented and in idiopathic hypersomnia the sleep latency is identical but there is no REM sleep documented. Provigil is FDA approved for the treatment of narcolepsy and its clinical variant, idiopathic hypersomnia. However, in the case of this patient there are no objective clinical findings (i.e., a MSLT) to substantiate the diagnosis. Thus, there was no documented FDA approved indication for the use of Provigil in this patient.Based upon the information set forth above, I have determined the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 52-year-old female with arthritis and degenerative disc disease who complains of chronic low back pain. Neither medications nor epidermal injections have relieved her symptoms.  The patient is requesting authorization for an inferential stimulation unit for pain management.  The Heath Plan denied her request based upon a determination that the device is experimental/investigational for the treatment of lower back pain.Inferential stimulation therapy is generally regarded as experimental for the management of pain syndromes. There is little in the peer-reviewed literature to support its use for chronic low back pain and it is not considered to be within the standard of care for management of that condition.  Reports of symptomatic relief are considered anecdotal and have not been substantiated through peer-reviewed, placebo-controlled trials. Therefore, I have determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 52-year-old female with chronic low back pain due to degenerative disc disease and arthritis. She has tried various treatment modalities, and has found the inferential stimulation unit most effectively manages her pain.  The patients provider has requested authorization for an interferential stimulation unit. The Health Plan has denied authorization citing the investigational nature of the device.Interferential stimulation units have not been shown to demonstrate superior efficacy as compared to more conventional treatment such as Transcutaneous Nerve Stimulation (TNS).  The requested unit is investigational for the treatment of chronic back pain.  Based on the fact that a similar effect may be achieved with a TNS unit, I have determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 52-year-old female with significant lower back pain due to a work-related injury. Her provider recommends the inferential stimulation unit to manage her pain as other approaches have failed to provide sustained relief.  The patient has requested authorization for an interferential stimulation unit.  The Health Plan considers the device experimental/investigational and has denied her request.As indicated in the records provided for review, the patient has tried both medical management and epidural injections, but has not achieved satisfactory pain relief. Based upon her positive response to interferential therapy, a three-month trial with the inferential stimulation unit is appropriate. On these facts, it is likely that the requested device is more beneficial for the treatment of her pain than standard treatment modalities. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a seven-year-old female with a history of expressive/receptive language delays and abnormal auditory processing. In March, 2006, her pediatrician documented additional symptoms, which may place the patient on the autism spectrum. The pediatrician has recommended, further psycho-educational testing to delineate the patients developmental disabilities.  The patient has been receiving speech therapy since September 2005. The submitted speech therapy evaluations indicate the patient has met 5 of 7 goals and has made progress toward the other goals. At issue is whether speech therapy is medically necessary for treatment of the patients condition.The patients diagnoses of expressive/receptive language disorder and abnormal auditory processing disorder have not been documented to have a medical basis and are generally considered educational in nature. In such cases, speech therapy is not medically warranted and is usually provided through the school system. However, the submitted evidence indicates neuropsychological testing has been recommended by the patients provider to help delineate the patients developmental disabilities. Speech therapy is considered standard of care in autistic children. If neuropsychological testing results in a diagnosis of an autism spectrum disorder such as pervasive developmental disorder  not otherwise specified, speech therapy would be considered medically appropriate and medically necessary in light of the gains the patient has been making in therapy to date.  Based upon the information set forth above, I have determined 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. If neuropsychological testing reveals a diagnosis of an autism spectrum disorder, speech therapy should be authorized. If neuropsychological testing does not reveal a diagnosis of an autism spectrum disorder, speech therapy should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 26-year-old male who sustained an injury to his knee. He underwent an ACL reconstruction. Postoperatively, a continuous passive motion (CPM device) and related pad were utilized. The patient has requested reimbursement for this equipment, which the Health Plan has denied.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. The CPM machine and related pad were medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was 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 16 year-old female who weighs 280 pounds and has a body mass index of 47. She has demonstrated various pre-diabetic conditions along with hypertension, hyperlipidemia, irregular menses, asthma and obstructive sleep apnea.  The patient is currently treated for depression and takes several psychotropic medications. Her psychiatrist recommends the Lap Band procedure.  The patients parents have submitted a request for authorization of laparoscopic adjustable gastric banding to the Health Plan.  The Health Plan does not consider this procedure medically necessary, and has denied the parents request.Lap Band studies in the United States have not produced the same results in terms of maintaining excess body weight loss (EBWL) as the European or the Australian Studies. The reason for this difference is not well defined. However, the fact remains that the Lap Band procedure does not offer the long-term results of Gastric bypass or Duodenal Switch.  Additionally, the Lap Band requires significant lifestyle changes and adjustment of the band for a limited result.  When choosing among the bariatric surgical alternatives available to an adolescent who has demonstrated closed growth plates, consideration should be given to the impact of eating behavior issues, the likelihood of long-term success, and the potential untoward side effects.  Gastric bypass and gastric banding have been associated with gastroesophageal reflux, esophagitis, solid intolerance, dumping syndrome and marginal ulceration to name a few.  I believe that for an adolescent, the potential ill effects of gastric banding outweigh the potential benefits.Based upon the information set forth 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 49-year-old female who was injured while riding on public transportation.  She has undergone a wide variety of treatments for neck and back pain including cervical fusion approximately two years ago.  She is requesting coverage for intradiscal electrothermal therapy (IDET).IDET remains a controversial treatment for degenerative disc disease. A review of the medical literature revealed there was little to no efficacy associated with the procedure. The clinical value of IDET remains questionable, and it 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 34-year-old man who has symptomatic thickening of the toenails. There is no functional impairment. There is no evidence of comorbidities such as diabetes, peripheral vascular disease or immunocompromise. A biopsy was performed revealing a diagnosis of onychomycosis. At issue is whether Lamisil is medically necessary for treatment of the patients medical condition.The diagnosis of onychomycosis is well documented. However, there is no evidence that the patient has associated symptoms or is experiencing a functional impairment. Furthermore, there is no documentation of comorbid conditions. In the absence of such evidence, 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: Upheld Decision of Health Plan

The patient is a 22-year-old female with chronic pelvic pain who is requesting coverage for Actiq for pain control. The Health Plan has denied her request on the basis that Actiq is not medically indicated for treatment of chronic pelvic pain. At issue is whether Actiq is medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. There is no documentation provided indicating medical necessity for the use of the medication, Actiq. Actiq is currently approved for management of pain due to cancer related syndromes refractory to opioid treatment. It is not generally accepted in the utilization of chronic pelvic pain nor approved for such use. Furthermore, there are no peer-reviewed studies regarding the use of Actiq in the management of chronic pain unrelated to a malignant process. The patient has a significant pain syndrome, but there are other established medications available for non-cancer related breakthrough pain. 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.