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

The patient is a 49-year-old male who is paraplegic with a history of polio quadriplegia who is requesting authorization for a manual wheelchair. He indicates he has a power-operated vehicle (POV) and a manual wheelchair and is seeking a replacement for his manual wheelchair. The patient states he only utilizes the POV for work and cannot use the POV at home. The Health Plan indicates that because the patient already has a POV, a manual wheelchair is not medically necessary. A review of the information provided indicates the patient has requested a manual wheelchair because his current manual wheelchair needs to be replaced and he cannot utilize his POV in his home secondary to access issues. Generally, two wheelchairs are not considered medically necessary. In this instance it is unclear why this patient has a POV for work only and why the POV was authorized if there were access problems in the patients home. Further, the information provided does not demonstrate why a new manual wheelchair is necessary. Therefore, this patient requires an updated physical therapy and access evaluation to determine what equipment this patient requires. As such, I have determined the requested equipment is not medically necessary at this time. The Health Plans denial should be upheld at this time. However, the patient should be provided an updated physical therapy and access evaluation to appropriately determine the patients equipment needs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is an eight-year-old male with a developmental delay with poor speech, and poor fine and gross motor skills affecting dressing skills, oral motor/feeding skills, toileting/bathing, grooming and hygiene. In addition, the patient has poor social skills with difficulties in school including difficulty with multistage instruction inattentiveness or distractibility. The submitted speech evaluation also documents that the patient has fleeting eye contact and abnormal pragmatic and social communication. A history of cranial birth injury is discussed in multiple places but no documentation has been provided. The patient also has a history of chronic otitis media, but no documented hearing loss. A request has been made for coverage for occupational therapy. The Health Plan has denied this request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition. While the issues of speech abnormality and auditory processing have been well documented in this case, the causes for the developmental delays in fine motor and gross motor skills including age appropriate activities of daily living are less well defined. The literature regarding auditory processing disorder is sparse and it is in question as an individual diagnosis. Rather, it is likely that it is on a spectrum of disorders. This is especially true in cases such as this in which pragmatic speech and communication delays coexist. Based upon the information provided, a neurologic reason has not been demonstrated as the cause of the patients delays. In the absence of a more specific diagnosis the requested therapy is not medically necessary. Neuropsychological developmental testing by a pediatric neuropsychologist and developmental pediatrician would be appropriate to fully evaluate the patients developmental disorders. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old female with rheumatoid arthritis, apparently being managed by both her internist and her rheumatologist. She is receiving a regimen of Enbrel, methotrexate, Plaquenil, Celebrex, and folic acid supplements for control of her arthritis. The records imply that the patient is doing well enough that she is able to continue working as a physical therapist. The patient has hypercholesterolemia. The patients provider has recommended Zetia over statin drugs because Zetia has a better probability of less liver toxicity than statin drugs. It is stated that the patient is following appropriate dietary measures, but her activity limitations prevent better non-pharmacologic control of her lipids; the degree of activity limitation is unclear from the records provided. The Health Plan has denied authorization for Zetia on the basis it is not medically necessary for treatment of the patients hypercholesterolemia. The patients rheumatoid disease appears to be under appropriate management. Patients who do well with TNF inhibitors are typically able to lower their other medications, and methotrexate doses usually drop to 7.5mg or less each week. The submitted information provides no clear statement of this patients doses. The original concerns regarding liver toxicity due to methotrexate given in modest doses for rheumatoid arthritis have not generally been proven to be valid. The incidence of actual liver inflammation at doses of 7.5-20mg weekly remains very small. Statins for control of elevated lipids have proven to be strikingly effective, both in terms of lowering the levels, and more importantly in terms of improved outcomes. While statins carry a small risk of liver or muscle inflammation, this has not provided cause to avoid statins; rather, statin use needs to be monitored.  The use of statins in patients taking methotrexate for rheumatoid arthritis is common, as both agents are effective for their intended purposes and the toxicity (liver or other) of each is modest, allowing ongoing treatment with regular lab monitoring of LFTs. However, if a patient requires higher doses of weekly methotrexate or has any prior liver problems or risks, concern over statin use might reasonably arise. While Zetia for control of lipid elevations appears to be effective, it is not yet clear whether it will prove to be as effective as statins, for which longer-term data is already available. Based upon the information provided, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if it is established that the patient requires methotrexate in doses above 10mg each week or if lab monitoring reveals any increase in LFTs after addition of a statin, then use of Zetia in place of a statin would be medically appropriate and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 40-year-old male with documented hypogonadism based on low serum testosterone on laboratory testing performed in March 2004. The patient was symptomatic as he experienced fatigue more easily and had early erectile dysfunction. Early topical treatment with patches and gel was not effective. The patient received subsequent treatment with intramuscular testosterone injections every two weeks between April 2004 and October 2004, which was effective. The Health Plan has denied this request indicating the requested injections are not medically necessary for treatment of the patients hypogonadism. The patient has been diagnosed with hypogonadism by his urologist. Laboratory testing was performed. The patients hypogonadism was symptomatic and deemed to require treatment. Review of the records provided indicates topical treatment with patches and gel was tried first. The patches were especially troublesome in that the patient experienced problems with extensive hair requiring shaving and difficulty in maintaining the patches in place. The patients treating urologist notes the topical agents tried were not efficacious. Only after trying the external treatments and finding them ineffective did the patient undergo treatment with the intramuscular injection form of testosterone. This was given every two weeks for a six-month period and proved to be an effective treatment for his medical condition. Testosterone injections are medically appropriate and indicated for the patients diagnosed condition. Based upon the information set forth above, I have determined that 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 32-year-old female who is 52 and 221 pounds with a body mass index (BMI) of 40.4. She has engaged in multiple attempts over the years to lose weight, all of which have failed. It does not appear the patient has obtained psychiatric clearance. The patient has requested authorization for gastric bypass surgery. The Health Plan has denied the request indicating gastric bypass surgery is not medically necessary. With a BMI of 40 and comorbid conditions, 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 scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. 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. 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 56-year-old male with quadriplegia who is requesting authorization for a fully electric hospital bed. He indicates he previously had a fully electric hospital bed under his old insurance and now his new insurance has authorized a semi-electric hospital bed. A review of the information provided indicates the patient has requested a fully electric hospital bed because he uses the height adjustment feature to help stretch his legs. However, a fully electric hospital bed is not required for this purpose because there are other means for the patient to accomplish this task and this is not the purpose of a fully electric hospital bed. The Health Plan has authorized a semi-electric hospital bed, which allows for elevation of the head of the bed to prevent choking. In addition, a semi-electric bed can address other areas of the patients needs. Therefore, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 36-year-old male who has a long history of degenerative disc disease with chronic low back pain. The patient states he has tried epidural injections, massage, chiropractic care, VAX-D treatments, and anti-inflammatories without long-term relief. His physician has recommended artificial disc replacement surgery using the Charite artificial disc. The Health Plan has denied this request indicating the requested procedure is investigational and therefore, not a covered procedure. The patient is a male with L5-S1 degenerative disc disease with chronic low back pain. He has not had improvement with conservative measures and is a candidate for surgery. Unfortunately, artificial disc replacement is of unproven efficacy for the treatment of chronic low back pain. The long-term results of this procedure are not yet known. Further studies are needed to determine outcomes beyond two years. 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 2: This patient is a 36-year-old man with a diagnosis of degenerative disc disease. He has requested coverage for artificial disc replacement surgery. The Health Plan has denied coverage for the requested procedure on the basis it is considered investigational. There is little data supporting the long-term efficacy of artificial disc replacement. There is presently at least a 35% failure rate associated with this procedure. Additionally, revision remains a potentially life threatening proposition. At present, the efficacy of disc replacement remains unproven. 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 3: The patient is a 36-year-old male who has a long history of back pain caused by degenerative disc disease. He has undergone several conservative management therapies, which have not produced relief for his pain. The patient has requested authorization and coverage for 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: Upheld Decision of Health Plan

The patient is a 42-year-old female who lost 100 pounds following gastric bypass in 2000. She previously underwent a medial thigh lift and abdominoplasty. She and her plastic surgeon are now seeking authorization for excision of excess skin and soft tissue of the arms and liposuction of the trunk and lower extremities. The patient has had scar revisions of these areas for hypertrophic scar. The Health Plan has denied the proposed brachioplasties and liposuction of the trunk and lower extremities on the basis the requested procedures are not medically necessary. There is no documented objective evidence that the patient meets accepted criteria for consideration of brachioplasties and liposuction of the trunk and lower extremities. There is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. As such, I have determined the requested procedures are cosmetic in nature and therefore, 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 44-year-old man who has had extensive psoriasis for at least 25 years. His psoriasis responded to PUVA photochemotherapy. Unfortunately, this treatment resulted in disfiguring hyperpigmentation. The patient does not want to be treated with methotrexate because of concern over side effects particularly, the risk of pulmonary fibrosis and liver damage. The patients dermatologist recommended Enbrel based on its efficacy as well as its significantly better safety profile. The Health Plan denied coverage for the requested medication on the basis it is not medically necessary. While there is significant anecdotal evidence from the dermatologic community of successful treatment of psoriasis with Enbrel, use of Enbrel is not indicated until all reasonable alternative treatments have been exhausted. Though the patient is concerned about use of methotrexate it does not appear the patient has been tried on acitretin (Soriatane). Soriatane is a frequently effective psoriasis treatment with the same side effects as Accutane, though the side effects tend to persist longer because Soriatane is long acting. It appears a trial of Soriatane is medically appropriate and should be undertaken before Enbrel is authorized. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, the patient should undergo a trial of Soriatane with appropriate monitoring. If the patients psoriasis does not improve after three months of Soriatane treatment, use of Enbrel would be medically appropriate and should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old female who is status post removal of a left-sided acoustic sarcoma in 1989 resulting in total hearing loss in the left ear. Her physician has recommended an implanted bone-anchored hearing attachment (BAHA). The Health Plan has denied this request indicating the patient does not meet criteria for authorization of the requested device. The patient has residual total loss of hearing in the left ear and normal hearing in the right ear. Optimal hearing rehabilitation would involve being able to hear from the left side. The BAHA device is designed to accomplish this. Though as the Health Plan indicates the patient has an anacoustic ear and no functional neurologic or bone conduction mechanism for hearing on the left, the neurologic and bone conductive mechanism for hearing in the right ear is normal. The BAHA device works by stimulating the entire skull, i.e., both inner ears at the same time. The purpose of the BAHA device is to rehabilitate the anacoustic left ear by transmitting sound across the skull to the hearing right ear. Based upon the information provided, the patient is an appropriate candidate for the BAHA device and is likely to benefit from implantation of the device. Therefore, I have determined that 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 48-year-old male with multiple medical problems. He desires gastric bypass surgery. The patient has a history of deep vein thrombosis/pulmonary embolism (DVT/PE) in June 2004 following a fracture in his leg. He was treated with six months of anticoagulation therapy. The patient has no prior or family history of hypercoagulable problems. He now desires a prophylactic IVC filter placement prior to bariatric surgery. The Health Plan has denied coverage for the requested procedure on the basis that it is not medically necessary. The patient has undergone standard treatment of DVT/PE. It appears he no longer requires Coumadin therapy. There are no indications for prophylactic IVC placement at the present time. The patient has no prior history or family history of a hypercoagulable state. Placement of an IVC filter will not have any impact on DVT formation. The only potential benefit is to decrease occurrence of pulmonary embolism. Given the patients obesity, prior DVT, and sedentary lifestyle, he is at an increased risk for DVT in the perioperative period. The standard of care for patients such as this patient is low dose Heparin or low molecular weight Heparin perioperatively, pneumatic compression stockings perioperatively, and a screening duplex scan of the legs for DVT formation. There is no evidence that prophylactic IVC placement prior to gastric bypass surgery will be beneficial for this patient. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 19-year-old male with a congenital condition with components of cerebral palsy-type neuromuscular disorder. He is wheelchair bound, and a request has been made for a custom, lightweight power-assisted vehicle (POV). He has a lightweight wheelchair that is approximately four years old and is in need of frequent repairs. The patients mother indicates the patient has right wrist chronic tendonitis, which is exacerbated by propelling the wheelchair. The physical therapist confirms this overuse history. The patients mother feels the patient needs some type of powered wheelchair because he is in college and has to negotiate terrain that is uneven and hilly. She states that the college makes power scooters available, but that is not a viable option for the patient because he is prone to tip out a power scooter and is unable to transfer to desk or toilet.The patients primary care physician has supported the patients request stating that a POV will allow the patient to manually propel and will provide assistance when needed to push long distances and up ramps and inclines, etc. The patients physical therapist indicated the patients power was 4/5 in the upper extremities and he had pain at end of range of motion. An evaluation in April 2004 indicated the patient was able to stand with maximum support. Another evaluation performed in June 2004 did not give any description of power, ability to transfer, etc. The Health Plan has denied coverage for the requested equipment on the basis that it is not medically necessary for the patients mobility. The Health Plan has authorized a repair evaluation of the patients current wheelchair along with any necessary repairs. In addition, a mobility evaluation has been authorized. The Health Plan utilizes criteria similar to Centers for Medicare and Medicaid (CMS) for determining appropriateness of a POV. It is considered DME to be used for purposes within the home. The Health Plan requires that the patient be unable to operate a manual wheelchair, demonstrate ability to operate POV controls, and be able to safely transfer in and out of the POV. It has not been demonstrated that the patient meets these criteria. He appears capable of operating a manual wheelchair, and has not shown his ability to transfer from a POV. There is no objective evidence that the patient would be able to transfer from chair to desk and toilet in the requested device. Also, the POV has been requested for use in the community and medical necessity criteria requires use in the home. The Health Plans recommendation that a mobility evaluation be performed to assist in better determining whether the patient meets criteria for a POV is medically reasonable and appropriate. As such, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.