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

The case involves a 48-year-old patient who presented with the complaint of intermittent menstrual periods, which she describes as heavy and painful. The patient was also diagnosed with hypothyroidism, and although on synthroid, still has an elevated TSH.Of note, the patient has been on hormone replacement therapy (HRT) since April 2005, which was started for unclear reasons prior to the cessation of her own menses. The patient had an ultrasound that revealed a small probable intramural fibroid (1.5 cm), a normal endometrial echo complex, a normal left ovary and a surgically absent right ovary. She was referred to a gynecologist who recommended a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO) (although the record refers to the patient as having has a prior right oophorectomy) for pain and bleeding, and a Marshall-Marchetti procedure for leaking urine with cough and sneezing.At issue is whether the proposed surgery is medically necessary for treatment of the patients medical condition.The clinical evidence does not demonstrate the proposed surgery is medically necessary. A 1.5cm intramural fibroid is insignificant and it is unlikely to be causing pain. With a normal endometrial complex, it is also unlikely that the fibroid impinges on the endometrium and therefore should not be the cause of heavy menses. In addition, the patients pain is not well documented and it is presumptuous to assume that a TAH-BSO will alleviate all of the pain, as is the patients expectation. Furthermore, there is no documentation either by physical exam or laboratory evaluation of urethral hypermobility or intrinsic sphincter deficiency that could be corrected surgically and result in resolution of the patients urinary stress incontinence. Moreover, there is no documentation of an attempt to treat the patients bleeding and pain medically with either NSAIDs or oral contraceptives. ACOG criteria for a hysterectomy performed for either pain or bleeding require that there be a failure of medical therapy prior to surgery. It should also be noted that the patient has been on HRT for more than one year and it is possible that this is contributing to the pain and/or bleeding, as it is not at a sufficient dose to suppress her intrinsic hormonal production. In summary, the submitted clinical information does not document any trial of medical therapy and sufficient preoperative evaluation to support the proposed surgery in this case. Accordingly, I have determined the requested surgery 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

This patient is a 72-year-old male who requires symptom control for osteoarthritis and spinal stenosis. He had aortic valve replacement 12 years ago, and as a result will require life-long anticoagulation with Coumadin. The patient was hospitalized nine years ago for a severe hemarthrosis of the left knee accompanied by a severe hematoma of the left thigh. His physician notes that a trial of acetaminophen failed to control his arthritis-related symptoms, and for the past five years that patient has used Celebrex successfully without further bleeding episodes or difficulty managing his anticoagulation. The Health Plan has denied the patients request for continued authorization of Celebrex citing a lack of medical necessity.I find that the use of Celebrex is medically appropriate for this patient.  He has documented osteoarthritis and spinal stenosis and requires an anti-inflammatory medication for control of his symptoms. Additionally, the patient will require life-long anticoagulation therapy because of an aortic valve replacement and previously experienced severe bleeding complications with no obvious abnormalities in his coagulation studies. Acetaminophen did not control his arthritic symptoms and the patient should not use medications with platelet-inhibiting effects due to the increased his risk of bleeding spontaneously or with trauma. Celebrex is the only available anti-inflammatory agent that the patient can use safely in combination with Coumadin therapy. He has been using Celebrex for the past five years with apparent benefit and without bleeding-related problems; treatment with Celebrex should be continued.Based upon the information set forth above, 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 14-year-old female with an extensive history of mental illness who has received mental health treatment since the age of eight years. She has had suicidal thoughts in the past and was admitted to an inpatient psychiatric unit on two previous occasions. It does not appear from the record there has been an actual suicide attempt. The patient was admitted to the residential treatment facility in June 2006 for mood swings and depression. She was evaluated by a psychiatrist and diagnosed with major depressive disorder. The patient was started on the antidepressant medication doxepin, with titration of her dosage during her stay. She showed some improvement in her symptoms and behavior and as of July 2006, according to the notes of her mental health providers, she was not having suicidal/homicidal thoughts and was not actively psychotic. The patient has been compliant with the milieu/group treatment environment to a limited extent.The patients parent has requested authorization for residential treatment services provided in July 2006 and continuing to the present time.  The Health Plan denied the request based upon a determination that these services are not medically necessary.After a detailed and intensive review of the clinical records and correspondence provided for review, it does not appear that the patient is actively psychotic or that she is actively suicidal or homicidal. The progress notes from two different days in July 2006 indicate that she was improving and there was no indication of an imminent risk of harm to self or to others or of active psychosis. There was no documentation of any medical or psychological complications that would require 24-hour observation and/or intervention.  The treatment that the patient received in the residential treatment facility after July 2006 could have been effectively provided at a lower level of care such as a partial hospital program or an intensive outpatient program. The clinical record does not support the patients need for continued stay at the residential treatment level of care from July 2006 onward.  Therefore, I have determined 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: Overturned Decision of Health Plan

The patient is a 53-year-old female who has chronic hepatitis C, genotype 1, stage III. She was treated with Peg-Intron and ribavarin for 48 weeks in 2004 but relapsed at the completion of the therapy. She was then treated with Pegasys and ribavarin for 12 weeks followed by Infergen and ribavirin for 48 weeks. Three months after completion of her therapy she relapsed again and her HCN viral load in June 2006 was 101,960 IU/ml. The patient wishes to be retreated with high dose daily Infergen and ribavirin for 48 weeks.Daily consensus-interferon (Infergen) and ribavirin is being used in patients who have failed to respond to previous combination therapy. Therapeutic options for hepatitis C treatment failures include retreatment with pegylated interferon, Infergen plus ribavirin, maintenance interferon therapy, and watch and wait for the development of new agents.  Infergen induction therapy together with subsequent ribavirin combination therapy showed promising results in two clinical trials conducted by Kaiser et. al. Two more recent trials have corroborated the Kaiser findings and there is significant interest in the use of Infergen for the treatment of nonresponders and relapsers.  Although the proposed therapy is not yet FDA approved, it is being used extensively by hepatologists nationally and internationally to treat relapsers and nonresponders to previous combination therapy. Based upon the studies citied above, the patient is an appropriate candidate for Infergen and ribavirin combination therapy.  Therefore, 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: Overturned Decision of Health Plan

The patient is a 58-year-old man with chronic back pain with a significant radicular component and neuropathic pain elements. He is on chronic narcotics and has undergone several epidural blocks. He has tried and failed amitriptyline and nortriptyline, and finds Neurontin helpful for sleep but not pain control. He also does Pilates and tai chi for pain control. He was started on Lyrica in January 2006 when he had a significant increase in pain, and has been maintained on Lyrica 125mg/day for six months. The submitted records indicate the patient has had sustained improvement and improved quality of life on Lyrica with reduction in other medications.At issue is whether Lyrica is medically necessary for treatment of the patients medical condition.Lyrica has been used successfully by this patient to control his neuropathic and radicular pain. He has been tried on multiple chronic pain medications, undergone a variety of invasive procedures, and participated in a number of non-pharmacologic therapies to control his pain with only modest success. While the Lyrica indication is for neuropathic pain due to postherpetic neuralgia and diabetic neuropathy, the drug is being used successfully by neurologists, pain specialists, and other practitioners to treat a variety of neuropathic pain conditions. Thus, the use of Lyrica by this patient is medically appropriate and is likely to result in continued benefit. As such, 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 57-year-old female with a history of right total knee replacement in 2005, kyphoscoliosis of the thoracolumbar spine and severe left hip dysplasia.  She has extensive degenerative joint disease with pain in the lower back, hips and legs.  The Health Plan recently authorized left total hip replacement.  The patient has requested authorization for a POV to assist with her mobility.  The Health Plan denied her request citing a lack of medical necessity.The records provided are not supportive of the patients need for a POV. Although the patient indicates she cannot operate a standard wheelchair, there is no documentation of weakness or impairment in the upper extremities. The providers note mentioned a walker but there is no assessment of the sufficiency of the assistive device. The record does not include a specific evaluation of the patients mobility and there is no indication of a need for a POV within the home. The patent has been authorized for hip replacement surgery and the Health Plan appropriately stated that physical therapy would evaluate her need for a POV postoperatively.Based upon the information set forth above, I have determined the requested equipment 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 an 11-year-old male with idiopathic short stature and an apparent diagnosis of neurofibromatosis. As of February 2006, growth in height had been along the third percentile, IGF-1 and IGFBP-3 levels did not suggest GH deficiency, and GH testing with glucagon revealed normal GH responses. There was a normal MRI of the brain in 2003. In November 2005 at 10.5 years there was a normal bone age of 11 years. The projected adult height given was 52 versus a mid-parental height of 57. The current growth velocity was poor at 2.4 cm/year.At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.The patient meets the July 2003 Food and Drug Administration criteria for growth hormone therapy for idiopathic short stature. The submitted literature is appropriately supportive of the efficacy of growth hormone therapy for idiopathic short stature. However, although the patient meets criteria for growth hormone therapy, there is concern in treating patients with neurofibromatosis with growth hormone therapy. The clinical evidence submitted does not provide significant information regarding the patient's neurofibromatosis. Therefore, the patient's providers should confirm the patient's neurofibromatosis is not a contraindication to growth hormone therapy prior to instituting such therapy. If and when no contraindication is confirmed, growth hormone therapy should be authorized. Therefore, the Health Plan's denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 12-year-old male who has been followed conservatively for short stature for some years. He has a diagnosis of constitutional delayed adolescence. However, in February 2006 he was noted to have a bone age which was not delayed, being reported at 11 years but read by his endocrinologist at 10-11 years. He has had a modest growth rate of 3.6 cm/year at the time of the office visit.  Using his height and a bone age of 11 years, his adult height prediction from the Greulich and Pyle tables would approximate 54.7 inches. If the patients endocrinologist is correct in her bone age reading, the patient might grow to 56.3 (at a bone age of 10 years). The work-up has excluded several endocrine causes of short stature including GH deficiency. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.This patient with idiopathic short stature has an adult height prediction that is in the low normal range and would not strictly fit all of the FDA criteria of July 2003 for GH therapy for idiopathic short stature. Although GH therapy for idiopathic short stature is considered a medically approved application, in this instance the patients degree of short stature and his adult height prediction do not rise to the level of medical necessity. 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 39-year-old woman with chondromalacia. She has had pain for several years. After a series of Hyalgan injections she had 18 months of relief. A request has been made for a repeat series of Hyalgan injections. The Health Plan has denied this request on the basis that another series of injections is not medically necessary for treatment of the patients condition.The patient has chondromalacia, a thinning and wearing of the cartilage. She has attempted medication, exercises and heat therapy to the knee without improvement. Her only relief came with Hyalgan injections. A second series of injections is a reasonable treatment option and there is no contraindication to repeating the injections. Given the beneficial results of the first series of Hyalgan injections, another series is appropriate to alleviate the patients pain. Therefore, I have determined the requested injections are 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 29-year-old female who underwent arthroscopic surgery on her left knee in July 2005. A cold therapy unit was utilized postoperatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary.Cold therapy units are extremely useful postoperatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, she clearly experienced a benefit from use of the device following her surgery. Therefore, I have determined the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 28-year-old woman with long-standing lumbar pain. She had surgery at a young age. She has spondylosis and probable arthritis secondary to surgical fusion at an early age. The patient reports methylprednisolone and Celebrex 200mg once daily has provided significant pain relief. She has requested authorization and coverage for Celebrex, which has been denied by the Health Plan. The submitted clinical information demonstrates the patient has taken Celebrex with documented clinical benefit. Celebrex is an anti-inflammatory and is indicated for patients with back pain, lumbar stress, lumbar arthritis, and other conditions such as spondylosis and spondylolisthesis when inflammation has developed. The patient has benefited from Celebrex in the past and is likely to experience continued benefit. As such, its continued use is medically appropriate in this clinical setting and should be authorized. 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: Overturned Decision of Health Plan

The patient is a 52-year-old female who was referred to a neurologist because of many intermittent symptoms including incontinence (urinary and fecal), myoclonus, paresthesias, fatigue and shortness of breath. Pertinent lab results included a normal chest x-ray and an elevated serum ACE level. The neurologist indicated the patients symptoms were typical for multiple sclerosis, but there was also clinical concern of sarcoidosis as a cause of her symptoms. A spiral CT of the chest was performed in October 2004 for which the patient is seeking reimbursement. At issue is whether the spiral CT was medically necessary for evaluation of the patients medical condition.A spiral CT of the chest was ordered to determine if the patient had sarcoidosis, which can affect both the central nervous system and the pulmonary system. An elevated serum ACE can indicate that the patient has sarcoidosis. In order to appropriately treat this patient, it was important to determine if the patient had sarcoidosis with or without the diagnosis of multiple sclerosis. Chest x-rays are not always sensitive in the evaluation of hilar and/or mediastinal adenopathy. CT (spiral) of the chest is the diagnostic exam of choice to evaluate for hilar and mediastinal adenopathy. The NIA criteria allow authorization of a chest CT for known or suspected inflammatory disease including sarcoidosis. In conclusion, the spiral CT of the chest performed in October 2004 was medically appropriate and necessary for the diagnosis and treatment of this patients condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old man with some elevation of his LDL and chest pain. He has already had two non-invasive tests, which indicate possible coronary artery disease (CAD). The patients provider has recommended the patient receive a CT angiography. The Health Plan has determined the requested CT angiography is not medically necessary for evaluation of the patients coronary arteries.Based on the current and existing American College of Cardiology (ACC) guidelines, the next step for a definitive diagnosis in cases such as this is a traditional cardiac angiography, if the clinical conditions warrant. The current medical alternatives would be medical observation and treatment of risk factors, medical therapy for presumed CAD or further workup of other causes of chest pain. Despite increasing clinical demands for CT angiography, it is only variably accepted as a useful diagnostic tool. It is the prevailing opinion in the cardiac community that there is insufficient evidence demonstrating CT angiography is as accurate as conventional invasive coronary angiography for screening or detection of CAD indications. According to available evidence-based guidelines, conventional invasive coronary angiography is the standard for assessment of coronary arteries and is superior to CT angiography. As such, the use of CT angiography in this clinical setting is not medically warranted.Based upon the information set forth above, I have determined the requested diagnostic procedure is not medically necessary for evaluation 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 25-year-old woman who has severe inflammatory acne with cysts, keloids and postinflammatory hyperpigmentation. She was previously treated by a dermatologist who prescribed topicals, oral antibiotics and interlesional steroid injections. She subsequently changed health plans and is now under the care of a family practice  physician. The patient requested a referral to a dermatologist, which her Health Plan denied on the basis that it is not medically necessary.It is medically essential that this patient be treated for her severe inflammatory acne by a dermatologist. It is not within the scope of practice of a family physician to treat severe acne with cysts and scarring. Without the specialized care of a dermatologist the patient may develop more disfiguring scars, cysts and/or postinflammatory pigment changes. Given the severity of the patients condition, referral to a dermatologist is medically indicated and should be authorized. Therefore, I have determined the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.