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

This patient is morbidly obese and has back pain. Although the surgeons consultation describes neck and shoulder pain, these symptoms are not evident in the primary care physicians (PCP) notes. The PCP note dated February 2006 only describes low back pain that could be secondary to obesity.  The patient has requested authorization and coverage for bilateral reduction mammaplasty with the anticipated removal of 350 grams of tissue from each breast. The Health Plan has denied this request on the basis that the proposed procedure is not medically necessary.A breast reduction is not established to be medically necessary for this patient because her symptoms are not completely consistent with a diagnosis of symptomatic macromastia. The medical literature indicates that symptom presentation is the most important factor in diagnosing symptomatic macromastia. According to an article by Gonzalez, et. al., symptomatic macromastia is best defined as a pain complex in three or more anatomic areas. The incidence and severity of headache, neck pain, shoulder pain, back pain, breast pain and painful bra strap grooves in this group of patients are greater by 3 standard deviations than in a control population matched for age. The PCP notes only describe symptoms in one area (back pain), and obesity is a common cause of back pain.Furthermore, studies indicate that patients with symptomatic macromastia have a typical constellation of musculoskeletal symptoms involving the upper torso, neck, arms and head.  The only musculoskeletal complaint documented in the PCP notes for this patient is back pain.  It is unclear why the surgeons consultation note describes neck and shoulder pain, as these symptoms are not documented in any of the PCP notes. Her symptoms as described in the PCP notes do not meet medical necessity criteria. In addition, due to the small volume to be resected, medical necessity for the breast reduction cannot be established.  This patient has atypical symptoms for symptomatic macromastia, and attempts at conservative care are not well documented.  Moreover, photographs show breast enlargement that is consistent with her obesity. The patient does not meet the guidelines for a diagnosis of symptomatic macromastia.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 63-year-old man who had a rise in his annual PSA from 4.2 to 5.3 in January 2006. Sextant biopsies were performed and the patient was diagnosed with adenocarcinoma in January 2006. Pathology revealed a Gleason score of 6 (3+3) in 30% of the core. The patient was offered 3D-CRT, IMRT and brachytherapy but prefers to undergo proton beam radiation therapy. He believes proton beam therapy has better cure rates and fewer side effects than conventional photons. The Health Plan denied coverage for proton beam radiation therapy on the basis that it is not medically necessary.Proton beam is a precise and conformal beam that can deliver 7800cGy to the prostate without significant radiation to the adjoining structures. IMRT is also a precise and conformal radiation beam that can deliver the same dose of 7800cGy with equally fewer side effects. 3D-CRT can deliver 7400-7600cGy to the prostate with almost equal precision. Temporary brachytherapy plus conventional or 3D-CRT radiation can deliver 12,000cGy to 16,000cGy with no more side effects or complications than IMRT.  Given the small size of the patients tumor, any of the above choices will offer him a 95% cure. There is no convincing evidence that proton beam radiation therapy is superior to other currently used forms of external beam therapy or brachytherapy.Based upon the information set forth above, 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

This patient is a 53-year-old woman with arthritis involving the right knee. She had a series of Synvisc injections in December 2004, which provided pain relief for almost one year. The patient cannot take oral anti-inflammatory medications according to her orthopedist. In early 2006 her pain returned and she received one injection of Synvisc.  She has requested reimbursement and authorization for the complete series of injections.  The Health Plan denied this request on the basis that Synvisc is not medically necessary for treatment of her arthritis.The patient is relatively young and has severe arthritis in her right knee.  Although she will eventually require knee replacement, a second series of injections is a reasonable alternative at this time. The first series was performed more than one year ago and resulted in significant relief. The patient cannot take non-steroidal anti-inflammatory medications, and the repeat Synvisc series is appropriate to alleviate her pain and postpone surgical intervention. Therefore, I have determined the therapy at issue was/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 five-year-old male born with profound bilateral sensorineural hearing loss. He underwent cochlear implantation to his right ear at the age of 24 months. Testing at this time reveals that he receives no benefit from wearing a hearing aid on the non-implanted ear and the parents wish to have an cochlear implant placed for the right ear. Their request for authorization of the sequential cochlear implant was denied by the Health Plan as not medically necessary.The science of cochlear implantation is changing rapidly with time. The criteria for implantation has progressed so that children are benefiting from implantation at a younger age than was initially thought appropriate. There have been several studies exploring the benefit of wearing hearing amplification (external aid) on the unimplanted ear for patients with unilateral implants. These studies support this method of binaural hearing enhancement only in patients whose unimplanted ear still has some measurable hearing that can be enhanced for improvement of speech reception. It is also quite apparent from these studies that binaural hearing ability is far superior to having only one hearing ear and binaural hearing ability is the functional standard for interaction with the world. Bilateral implantation is now performed with increasing frequency based on this knowledge. More studies have been done with adults than with children, but studies on children have also been favorable. Although it is true that bilateral implantation is somewhat new, it has shown clear benefit for many people.  This patient would benefit greatly from receiving a second cochlear implant and, as such, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 38-year-old female who is several years post gastric bypass with a reported weight loss of 100 pounds. She sought consultation with a plastic surgeon that noted prior abdominal panniculectomy for excess skin. The patient is seeking a reduction of the redundant skin and fat of her upper arms and thighs. Two plastic surgeons and her primary care provider have examined her and all suggested that no matter what procedures are proposed, the patient would need to lose additional weight first. The patients BMI at the reported weight of 220 pounds is 40.3.  The patient submitted a request for authorization of bilateral thigh lifts to her Health Plan.  The request was denied based upon a determination that the requested procedures are not medically necessary.The record provided for review includes photographs of the patient dated January 2006, a letter from the patient and medical records. There is no evidence presented in the above material that supports the medical necessity of the proposed procedures. The patients provider noted excess skin and fat deposition in the medial and lateral thigh areas and some skin maceration.  He did not document any skin problems of the degree described by the patient. The patients stated height is 62 and her weight is 220 pounds with a BMI of 40.3. Her providers appropriately encouraged additional weight reduction prior to surgical intervention.  In summary, the evidence presented leads to the conclusion that the thigh lifts are cosmetic in nature. Therefore, I have determined the requested procedures 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 with a recent diagnosis of Churg-Strauss syndrome following a history of asthma. She presented in December 2005 with weight loss, leg weakness, pulmonary infiltrates on imaging studies, elevated p-anca, elevated IgE, elevated ESR, and nerve conduction/EMG studies documenting mononeuritis multiplex, producing a multifocal polyneuropathy.  She was treated appropriately with high-dose steroids and cyclophosphamide, but had an inadequate response.She was next treated with a course of IVIG with dramatic benefit, but when the effects wore off her leg pain again prevented her from walking. Her rheumatologist then recommended a course of five more treatments with IVIG, but the Health Plan has denied authorization for the treatment on the basis that IVIG has not been shown to be effective for the patients diagnosis.The patient has a history and findings most consistent with Churg-Strauss vasculitis, and is being managed by an experienced rheumatologist. This illness can be difficult to control, as many patients do not respond adequately to what was once the standard regimen of steroids and cyclophosphamide. As a result, the medical literature has noted reports of various other methods of primary or adjunctive treatment of this illness. As the submitted literature indicates, the most reliably effective intervention has involved repeated courses of IVIG.It is clear that the addition of IVIG to the regimen of steroids and cyclophosphamide for the treatment of Churg-Strauss vasculitis has produced more beneficial responses with greater durability, and the use of IVIG is now considered standard of care in patients failing to respond adequately to previous treatment with steroids and cyclophosphamide. In addition, this patients multifocal polyneuropathy is, in itself, a recognized indication for IVIG.In conclusion, the use of IVIG for the treatment of Churg-Strauss vasculitis in patients with inadequate response to steroids and cyclophosphamide is within the standard of care and is not considered investigational. 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 47-year-old woman who has a history of painful hammertoe and toenail fungus. A KOH preparation of her toenail was negative. The patient has elected not to take oral antifungals due to her concern about side effects, especially those involving the function of the liver. The patients provider recommended topical Penlac to treat the patients toenails and requested authorization from the Health Plan.  The Heath Plan determined the medication was not medically necessary, and denied the providers request.  Medically appropriate treatments for fungal nail infections include oral antifungals, fungoid solution, and Penlac solution. Oral antifungal medications are typically more effective than topical medications however, Penlac solution has shown some success and the risk of systemic side effects is less than minimal. The patient has expressed concern related to liver function with Lamisil, and she has asserted a preference for a topical medication.  As such, treatment with Penlac solution is medically appropriate. The patient should be monitored by her provider, and the therapy should be discontinued if it is not effective after a three-month trial.  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: Overturned Decision of Health Plan

The patient is a 64-year-old male who has extensive psoriasis affecting his scalp, trunk, arms, legs and feet. His provider has prescribed the application of Dovonex cream twice per day and by the providers assessment, 80% of the patients lesions are under control.  The patient has indicated that he needs to apply the medication three to four times per day. The patients provider has requested authorization for a three-month supply of Dovenox cream, which equals 1080 grams (three 120 gram tubes per month). The Health Plan denied the request based upon a determination that the requested medication dosage is not medically necessary.The patients provider has adequately documented the extensive nature of the psoriasis, and the need for treatment with Dovonex cream. The amount required for one months treatment is not entirely clear.  The current usage appears to be effective in treating the patients psoriasis, but the patient may be using the Dovonex three to four times per day. As prescribed, the cream should be applied twice per day.  Because the psoriasis is so extensive, it is medically necessary that the patient be provided the dosage requested by his primary care provider until he can be fully evaluated by a dermatologist.  The dermatologist can fully assess the condition of the patients skin and make a final determination as to the required dosage of Dovonex cream.Therefore, I have determined the requested medication dosage is medically necessary for treatment of the patients medical condition pending an evaluation by a dermatologist. The Health Plans denial should be overturned at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old male with depression and migraine headaches. He reports a recent weight gain of 30 pounds. The patients medical therapy includes, Cymbalta, Wellbutrin, lithium, Ritalin, Neurontin, Propecia, Provigil, Xenical, Ativan, Zyprexa and Ambien. He would like to lose the weight he has gained, and has reportedly had good results with Xenical in the past.  The patients request for authorization of Xenical was denied by the Health Plan based upon a determination that the medication is not medically necessary.There is no medical indication for Xenical therapy at this time. The record does not suggest that the patient has failed to lose weight with dietary management or a simple exercise program. He stated that he could not participate in an exercise program, but did not fully explain why or describe unsuccessful dietary changes he had made. The record does not provide the patients body mass index (BMI) or document co-morbidities such as medically treated hypertension, diabetes, coronary artery disease, dyslipidemia, cerebral vascular accident, sleep apnea required CPAP, or degenerative joint disease.  The patient is taking multiple medications that have weight gain as a side effect (primarily Zyprexa), but it does not appear from the record that his health status would preclude the more traditional methods of weight loss.  Based upon the information set forth above, 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 15-year-old female with a history of an ACL injury in September 2005. She is status post ACL reconstruction in December 2005. She received six visits of physical therapy from January through March 2006, which documented range of motion of 0-140 degrees with 5/5 strength. The therapist recommended discontinuance of physical therapy with a home program. Since that time the patient has been seen by a therapist at a competitive athletic training program who documented pain at terminal flexion and  4 degrees of knee extension in March 2006 with full range of motion in May 2006. The patient still has some asymmetry from side to side and the therapist documented difficulty with decelerating when running or hopping. A recent physician evaluation has not been provided.At issue is whether competitive athletic training physical therapy was/is medically necessary for treatment of the patients condition.The patient appears to have received a short course of physical therapy, which allowed her to get her range of motion back with some subsequent regression. She then received competitive athletic training physical therapy from March 2006 to May 2006. The patient did not require the specialized services of a competitive athletic training physical therapy program. Although it appears the patient experienced some regression following the authorized course of therapy, it was not necessary for the patient to receive rehabilitation services that were specifically geared to return to sports. The patient could have been appropriately treated with traditional physical therapy. Therefore, I find that the therapy at issue was/is not medically necessary. The Health Plans denial should be upheld. Since it does not appear the patient has recently been evaluated by a physician, she should be re-evaluated by an orthopedist to determine if additional physical therapy (traditional) is warranted based upon her current functional status.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 19-year-old male who was on probation for assault and was admitted to a 30-day residential treatment program for substance abuse.  He attended two previous treatment programs prior to becoming an adult and has been arrested three times.  The patient was adopted and never knew his biological parents.  He believes they were both  drug addicts. The notes from the residential treatment facility support a supposition that the patient was participating primarily because of the legal ramifications of not doing so.  He did not appear motivated or actively engaged in the treatment program.  The patient requested reimbursement for residential treatment services provided from February 2006 through March 2006.  The Health Plan denied his request based upon a determination that the services were not medically necessary.The patient had no signs of withdrawal and did not appear to be at risk for withdrawal when he was admitted to the residential treatment facility.  Although there were concerns that being with friends or in the school environment might make recovery more difficult, there were no serious medical, emotional or behavioral conditions that required 24-hour monitoring or supervision. The patients home environment was supportive and conducive to recovery.  A partial hospitalization program (PHP) for substance abuse rehabilitation would have been appropriate. In PHP the patient would have participated in a structured therapeutic program and his drug use would have been monitored with urine drug screens. The patients admission to residential treatment appears to have been motivated by his legal status to a significant extent.  At this age, the patients conduct and behavioral problems are not best approached by psychiatry and the strict behavioral controls set by outside agencies are likely to be more effective. Based upon the information set forth above, I have determined the services at issue were 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 48-year-old female with degenerative disc disease and myofascial neck pain. She has been receiving physical therapy (PT) and it has apparently been helpful.  The patients provider prescribed continued physical therapy and aquatic evaluation and therapy.  The patients request for authorization of continued physical therapy and aquatic evaluation and therapy was denied by the Health Plan based on a determination that the therapies are not medically necessary.A review of the record shows that the patient was receiving physical therapy and that it was beneficial.  Some instruction in a home exercise program was provided, but the PT progress notes indicate the patient had not been fully instructed. Since land-based physical therapy was helpful to the patient, aquatic therapy would not be medically necessary at this time.  The patient should continue with the land-based physical therapy in order to complete all of the instruction necessary for a home-based exercise program. Three times per week for three weeks would be a reasonable time frame.  Based upon the information set forth above, I have determined one of the requested therapies is medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old female who had chronic breathing problems due to a nasal septal deviation. She underwent septoplasty in August 2005, which was done entirely through an internal nasal incision. Following surgery, her provider noted nasal breathing good.  Also interested in cosmetic nasal tip surgery. The patient was advised to wait at least six months prior to any rhinoplasty. The patient now contends there is a nose bump located on the right side of her nose that was not present prior to surgery. She would like this bump surgically corrected.  In March 2006 her provider noted slightly prominent right nasal bone but no external deviation and no saddle deformity. The enrollees request for reconstructive surgery was denied by the Health Plan based upon a determination that a corrective procedure is not medically necessary.A nasal bump is not distinguishable in the provided photographs.  The medical record indicates there were no complications from the surgery and that no external incisions were made. Assuming there is a bump, it is not causing any functional deficits. As such, removing the bump or reshaping that area would only change the patients appearance and would not alter the function of her breathing. The American Medical Association defines cosmetic surgery as surgery that is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem.  The ASPRS position paper agrees, stating that when nasal surgery is performed solely to improve a patients appearance in the absence of any signs and/or symptoms of functional abnormalities, the procedures should be considered cosmetic in nature.  There is no medical indication for surgical reconstruction and the procedure requested by the patient is cosmetic.  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.