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

The patient is a 12-year-old male who in December 2003 had a height standard deviation of 2.95 and a significantly delayed bone age. Provocative stimulation testing was performed in January 2004, which ruled out growth hormone (GH) deficiency. It was noted the patients serum IGF-1 and IGFBP-3 markers for growth hormone action were in the lower quartiles for age and sex. The patient was started on growth hormone therapy and grew two inches in a three-month period. A request has been made for continued growth hormone therapy. The Health Plan has determined the requested therapy is not medically necessary for treatment of the patients diagnosis.Though the patient is short for his age at 3 standard deviations (SD) below mean for age, his stature is not inconsistent with mid-parental and target heights (within 1 SD). His projected final height at age 11+4 with a height of 126cm and a bone age of 9 years is 63.6 inches. Prior growth measurement has not been included so the patients baseline growth rate is not known.The patients mid-parental height is actually less than -2.5 SD at 64.5 inches. In the absence of evidence of a preceding abnormal growth velocity, it appears the patients present and predicted short stature is more consistent with a genetic etiology and thus, is not idiopathic. As such, growth hormone therapy is not medically indicated for treatment of the patients condition.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the 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 46-year-old male who was diagnosed with HIV in 1995. The patient has been taking antiretroviral medications since he was diagnosed. As a result the patient has developed lipodystrophy of the face, chest, neck, and back. The patient underwent liposuction of the chest, back, and neck areas in January 2004. A second procedure was performed in April 2004. The patient has requested authorization and coverage for a revisional procedure of the axillary and chest areas. The Health Plan has denied the patients request indicating that the requested procedure is cosmetic in nature and therefore, is not medically necessary.Lipodystrophy is well-known sequelae of antiretroviral therapy. The patient has undergone two suction-assisted liposuction procedures to address extensive fat accumulation in the neck, shoulder, back, and axilla. At the present time there are no functional deficits. Suction-assisted lipectomy of the body is a sculpting procedure with the stated goal of improving ones appearance. Irregularities may, and often do, result and are more common in conditions with extensive underlying pathologic change. In the case of this patient, he is disturbed by the results of the procedure in the axillary region. This represents a cosmetic deficit with no functional component. A functional result has been achieved. The previous procedures have resulted in a normal appearance to the extent possible. Further surgery would offer only limited improvement in the patients appearance.Cosmetically acceptable results cannot be guaranteed following reconstructive or cosmetic procedures. There will always be a less than perfect result following any surgical procedure. Scarring, unnatural feeling, and irregularities following liposuction are all examples of the downside of surgical intervention. Furthermore, the more pathologic the preexisting condition, the less likely a complete resolution will be achieved. In the present case, liposuction of significant fat accumulation resulted in residual fullness and skin excess following two procedures. Further surgery would only offer limited improvement and would require the excision of skin, which will result in axillary and thoracic scars. 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. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old female who is a highly active person status post surgical knee repair. She reports she continues to exhibit weakness in the affected knee. A custom knee brace has been prescribed by the patients physician. The Health Plan has denied coverage for the requested brace on the basis that it is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. There is no Class I literature/evidence to support the need for the requested knee brace for this patient. Furthermore, the patient underwent surgery over a year ago and her knee is now stable. The patient wishes to have the brace so that she may participate in sporting activities. There is no evidence establishing that a custom brace is necessary for the patient to return to athletic activities.  Therefore, I have determined that 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 a 58-year-old male with a long-standing history of migraine headaches and cardiac problems. He has been treated with a number of triptans, but continues to experience at least one headache per week. Most recently, the patient has been taking Zomig for acute relief. He has requested authorization and coverage for 18 Zomig tablets per month. The Health Plan has denied the patients request on the basis that the number of Zomig tablets requested is excessive and not medically indicated.Zomig is appropriate for patients who occasionally suffer an acute migraine headache. For patients who experience one migraine headache per week, a prophylactic medication such as Depakote or timolol is medically indicated. Given the frequency of the patients migraines, prophylactic treatment is medically appropriate and should be initiated. Furthermore, the number of Zomig tablets requested appears excessive and there is no clinical or scientific evidence demonstrating the requested prescription is medically indicated. Therefore, I have determined that the requested prescription is not medically necessary for the 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 54-year-old male who has been diagnosed with atrial fibrillation, paroxysmal ventricular fibrillation, and heart attack. The patient has requested authorization for a referral to a cardiologist for follow-up care and monitoring of his pacemaker. The Health Plan indicates the patients condition can be monitored by his primary care physician with referral to a cardiologist as needed.Standard of care for patients such as this is to have periodic pacemaker checks performed by a cardiologist as recommended by the pacemakers manufacturer and as needed. In this case, it is medically appropriate for the patient to be evaluated by a cardiologist on a periodic basis for the performance of pacemaker checks and for monitoring the patients ongoing cardiac risk factors. Such evaluations are medically indicated and should occur at the frequency recommended by the manufacturer of the patients pacemaker. Therefore, I have determined that the requested referral is medically necessary for the patients pacemaker monitoring. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 42-year-old female with relapsing remitting multiple sclerosis since 1998. Because of gait difficulties affecting her right leg (hemiparesis, weakness, and decreased tone), the patient has requested body weight support treadmill therapy. The Health Plan has denied authorization for body weight support treadmill therapy on the basis that it is not medically necessary for treatment of the patients multiple sclerosis.Body weight support treadmill therapy is essential for patients such as this patient. The therapy avoids major stress on the affected limb and prevents fatigue of the limb. Fatigue during therapy is to be avoided since it may aggravate the condition. Body weight support therapy is medically indicated for this patient until muscle power and tone improve in the right leg allowing the patient to ambulate more normally and with less stress. 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 41-year-old female with an apparent past history of Graves disease. The submitted notes state the patient has moderate skin excess and mild second-degree ptosis. The patient reports her lashes point downward obstructing her vision. The patients provider has recommended a bilateral upper blepharoplasty. The Health Plan has denied coverage for the requested procedure on the basis that it is not medically necessary.In general Graves disease (if it is in fact present here) causes problems with exposure. The need in such cases is not to open the eyes more but to be able to close them to protect the cornea and avoid the problems of keratitis and possible corneal ulcers, etc. The submitted photographs show the patients pupils are not covered and her eyelids do not obscure her vision. As such, there is no medical indication for the requested procedure. 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: Overturned Decision of Health Plan

The patient is a 56-year-old female with varices that she treats with compression stockings. The patient reports that a pair of compression stockings only lasts for three months. She has requested authorization for four pairs of compression stockings per year. The Health Plan indicates more than two pairs of compression stockings per year are not medically necessary for treatment of the patients medical condition.The standard recommendation for compression stocking use is to replace the stockings every three to six months, depending on wear and tear. The stockings are used to apply gradual pressure. Once the stockings lose their compressive properties they are no longer effective. Therefore, it is medically necessary to replace the stockings when they become loose. The use of up to four pairs of compression stockings per year is within the manufacturers recommendations. Since the patient reports less compression after three months of constant use, four pairs of stockings per year are medically reasonable and should be authorized. Therefore, I have determined that the requested supplies are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1The patient is a 58-year-old physically active female with severe osteoarthritis of the right hip dating back to 2002. The patients symptoms and disability have become progressively worse. She has had diagnostic hip injection and a scan, which have confirmed the diagnosis. The patient has consulted a provider who has recommended hip resurfacing as opposed to total hip replacement. The Health Plan indicates hip resurfacing is considered investigational.Review of current medical literature suggests that hip resurfacing is likely to provide a favorable long-term outcome compared to standard treatment. Given the patients relatively young age and continued high level of activity, hip resurfacing is more appropriate than traditional total hip replacement. Hip resurfacing is a medically reasonable procedure and is medically indicated for the patients condition. 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.Physician 2The patient is a 58-year-old female with a history of degenerative joint disease of the hip. She is requesting metal-on-metal hip resurfacing. The Health Plan has denied the request on the basis that the requested procedure is considered investigational.The patient is a 58-year-old female who is in excellent health. She is a candidate for conventional total hip replacement and is likely to benefit from the procedure. There is ample long-term follow-up showing that conventional hip replacement is an appropriate procedure at the age of 58. The long-term results of hip resurfacing are not known. There is no evidence that hip resurfacing is a more appropriate procedure for patients such as this patient. Therefore, I have determined that 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.Physician 3The patient is a 58-year-old female. She is involved in a high level of activity. The description of her pain and limitations is consistent with the examination showing a limited range of motion. The patient wishes to undergo hip resurfacing. The Health Plan has denied authorization and coverage for hip resurfacing on the basis that it is considered investigational.Hip resurfacing is valid for treatment of symptomatic hip degenerative joint disease. There is greater ease of revision (should it be necessary) than with standard hip arthroplasty. Furthermore, given the increased demands of highly active patients such as this patient, there is less risk of dislocation with hip resurfacing. The patient is likely to have a better overall outcome both short- and long-term with the requested procedure. 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 54-year-old male who is unable to obtain a penile erection without the use of medication. He has medical evidence of hyperlipidemia with a triglyceride level of 165 (normal is up to 150) in January 2004. He is seeking authorization for Viagra for treatment of his erectile dysfunction.Hyperlipidemia is a recognized and documented cause of organic erectile dysfunction. Treatment with PDE-5 inhibitor medications is accepted primary therapy for treatment of erectile dysfunction and is often successful. If not contraindicated by concomitant use of organic nitrates or drug intolerance to the medication, the patient should be treated with Viagra. 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

This is a 53-year-old female who has requested authorization and coverage for breast reduction surgery. Her weight on 7/2/04 was 269 pounds. She was seen in January 2003 and her weight was 219 pounds. In 1990 her weight was 285 pounds. At that time, she was wearing a 46DD bra. Her current reported bra size is 48DD. She complains of chronic neck, shoulder and interscapular back pain, tension headaches, inframammary rashes and significant hand paresthesias with the right being worse than the left in the ulnar nerve distribution. She has had a mammogram within the last year and has no nipple discharge or lumps. The patient relates she gained weight from 2003 to 2004 secondary to depression for which she is being treated. She was not on a weight loss program at the time of her 7/2/04 visit but does exercise by walking, swimming and going to the gym 3 to 4 times per week. Her physical exam on her 7/2/04 visit states, morbidly obese woman with massively enlarged, ptotic breasts, striae shoulder grooving is severe, and the shoulder posture is rounded. There is a very mild inframammary rash on the right and severe subaxillary rolls. The patient is seeking breast reduction surgery. Based upon the information provided, over the past 14 years the patients weight has fluctuated from a high of 285 pounds to a low of 219 pounds. Currently the patient is listed as 55 weighing 269 pounds with a body mass index of 44. The patient is morbidly obese. There is potential that through weight loss the patients bra size will decrease and issues related to her breasts will dissipate. If the patient is able to lose weight and sustain the weight loss and she continues to have issues related to her breasts surgery may be indicated; however, surgery is not indicated at this time.In addition to the above, there is neither documentation nor mention of intertrigo and its treatment in the patients records. Furthermore, there is no evidence of etiology of her ulnar nerve distribution arm numbness even though the patient has been seen by the neurology service on numerous occasions. 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: Overturned Decision of Health Plan

The patient is a 46-year-old female with a body mass index (BMI) of 49. She has comorbid conditions of hypothyroidism and hypertension. She has requested authorization for bariatric surgery. She has not undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. The Health Plan has denied the patients request.With a BMI of 49 and comorbid conditions such as hypertension, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 44-year-old female who has a history of recurrent low back pain with radiation down to the bilateral posterior calves. An MRI revealed degenerative disc disease and lumbar facet disease. Upon examination, the patients provider noted straight leg raising was negative and deep tendon reflexes were normal and equal throughout. In addition, sensation and strength were grossly normal. The patient has requested authorization for a wheelchair. The Health Plan has denied the request on the basis that a wheelchair is not medically necessary for the patients mobility.Review of the submitted medical records does not demonstrate that a wheelchair is medically necessary for this patient. The patient has been noted to be ambulatory without assistive devices. Additionally, the documented evidence indicates her gait is nonantalgic and strength is intact. In fact, upon examination by the patients provider, it was noted the patient was able to heel-toe walk without any difficulty. Thus, there is no evidence that the patient is unable to ambulate requiring a wheelchair for mobility. Therefore, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 41-year-old morbidly obese female with a history of arthritis of the lower spine and left hip. She indicates walking is painful and is seeking a power-operated vehicle (POV) for assistance with ambulation outside the home. The patient is awaiting authorization for weight loss surgery. The Health Plan has authorized a heavy-duty walker for the patient.Review of the submitted medical records does not demonstrate a POV is medically necessary for this patient. The patient has been noted to be ambulatory within her home. She is seeking a POV for community mobility. There is no evidence that she cannot utilize a walker or other mobility assistance equipment. Further she is awaiting approval for gastric bypass surgery, which, if successful, should assist in preventing the need for any mobility assistance. Moreover, the patient does not meet nationally accepted medical necessity criteria for authorization of a POV. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient presented to a pediatric endocrinologist at 13 years, 3 months of age with a height of 135.2 cm, which is greater than 2.5 standard deviations below the mean for the patients age and gender. His height velocity is listed as 4.1 cm per year, which is below the 10th percentile for age and gender. His height is also greater than two standard deviations below his target height predicted by the heights of the patients parents. A request has been made for growth hormone therapy.Although growth hormone provocative tests were greater than 10mg/ml the patients baseline IGF1 was below the reference range for his age and gender (165 vs. 202-953). The patients growth response increased after growth hormone treatment. Although the patients growth was likely aided by the onset of puberty, when combined with the above data the patients presentation is consistent with a diagnosis of functional growth hormone deficiency and as such treatment with growth hormone is medically indicated and necessary. 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.