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

The patient is a 17-year-old male with a complicated medical history of intractable epilepsy and intractable myasthenia gravis, which has been moderately responsive to frequent plasma exchange. He has bulbar weakness and chronic secretion problems. A request has been made for coverage for the Vest System, an oscillatory device to treat the patients ongoing breathing problem. The Vest System is medically indicated given the patients prior response to therapy and the high-risk of life threatening aspiration. Standard treatment modalities are not available to this patient in light of his myasthenia gravis and previous sternotomy. As such, use of the Vest System is medically reasonable and appropriate and should be continued. Therefore, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1The patient is a 62-year old man who is requesting percutaneous lysis of epidural adhesions. He has chronic lumbar pain and is status post lumbar laminectomy. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is considered investigational.The requested procedure has no long-term proven benefit. There are no long-term, prospective studies demonstrating that the requested procedure is effective. The submitted operative reports reveal epidural injections were performed; it is unclear from the reports exactly what is considered the percutaneous lysis portion of the procedure. While epidural injection may be effective for patients such as this patient, the lysis of adhesions is not necessary or recommended. 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 2This patient is a 62-year-old man who has been experiencing back pain secondary to laminectomy syndrome. He is requesting percutaneous lysis of epidural adhesions. The patient indicates this procedure has been performed approximately twice a year for the past several years. The Health Plan has denied authorization and coverage for this request on the basis that lysis of adhesions is considered experimental.The requested procedure is not the standard of care and is of unproven efficacy. There are no class I data to support lysis of adhesions at this time. The patient is likely to receive greater benefit from standard therapies. 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 62-year-old man with a history of post-laminectomy syndrome. He is requesting percutaneous lysis of epidural adhesions. The Health Plan has denied authorization and coverage for the requested procedure on the basis that lysis of adhesions is considered experimental.Review of the medical literature reveals the requested procedure is without established efficacy. There are no prospective criteria indicating that lysis of adhesions has long-term clinical benefit. Thus, it has not been established that the requested procedure results in a superior outcome to standard therapies. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 50-year-old male who has a long-standing history of cocaine addiction and bipolar disorder. The patient was admitted to a residential treatment program on 3/10/04. A request has been made for reimbursement for patients stay in the residential treatment program. The Health Plan indicates the services at issue were not medically necessary for treatment of the patients behavioral health problems. Review of the submitted documentation indicates the patient could have been managed in an intensive outpatient setting. The emergency room initial conduct assessment form states the patient was experiencing auditory and visual hallucinations though the content of hallucination was not described. The patient has denied suicidal ideation. It appears the hallucinations were related to intravenous use of cocaine and were self-limited. A medical/chemical dependency consultation performed on 3/11/04 does not reference hallucinations. At that time it was noted the patient was angry and disturbed, but showed only a slight behavior change. It was further noted that no active therapy was needed at that time. A rehabilitation program on either an inpatient or outpatient basis was recommended. The submitted treatment notes indicate the patient demonstrated clear insight into his dependency issues, though he maintained ambivalence. It appears the patient also has had the support of his wife. As such, according to the American Society of Addiction Medicine Criteria Dimensions the patient was an appropriate candidate for intensive outpatient treatment. Thus, treatment at the residential level of care was not medically warranted.Based upon the information set forth above, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, 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 with head posterior fossa development with Chiari malformation. In June 2002, the patient underwent suboccipital craniectomy, C1 laminectomy, and duraplasty. The patient has now been diagnosed with cerebellar ptosis. It has been recommended the patient undergo re-exploration of her posterior fossa decompression with possible replacement of her dural graft and partial posterior fossa cranioplasty.  The Health Plan indicates the recommended procedure is not medically necessary for treatment of the patients medical condition.The patient has a history of post fossa decompression and duraplasty. A cranioplasty and repeat duraplasty has now been proposed. The patients providers have not made a definitive diagnosis. As such, the proposed surgery is not medically indicated at this time. The Health Plan has offered to provide further workup and evaluation of the patients condition. The services offered by the Health Plan are medically reasonable and appropriate. 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

This patient is a 38-year-old male who has hepatitis C, genotype 4C. He began combination therapy with Peg-Intron and Rebetol five months ago. The patients pre-treatment viral load was 246,000; his most recent viral load was reported as 34,940. It has been recommended that Peg-Intron therapy be continued. The Health Plan has denied authorization and coverage for continued Peg-Intron therapy on the basis it is not medically necessary for treatment of the patients medical condition.Review of the submitted records reveals that continuation of Peg-Intron therapy is not medically indicated for treatment of this patients hepatitis C. Peg-Intron therapy that does not result in a two-log drop in viral count after 12 weeks of therapy is not likely to result in clinical benefit. A study by Fried, et al. showed that only 3% of patients who did not experience a two-log drop by the end of 12 weeks had sustained viral response by the end of the treatment course. In light of these findings, there is no medical justification for continuation of Peg-Intron therapy for treatment of the patients hepatitis C virus. Therefore, 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: Overturned Decision of Health Plan

The patient is a 53-year-old female with recurrent diverticulitis. She is currently a candidate for sigmoid colectomy due to her recurring symptoms. The patients provider has recommended a laparoscopic sigmoid colectomy rather than an open colectomy. The Health Plan indicates a laparoscopic sigmoid colectomy is not medically necessary for treatment of the patients medical condition.Analysis and Findings:Current literature documents the safety and efficacy of laparoscopic surgery for a variety of colorectal disorders. The laparoscopic approach is the standard of care for patients such as this patient. There is substantial data showing laparoscopic colectomy results in shorter hospital stays and decreased complications. Thus, a laparoscopic colectomy is an acceptable and preferred alternative to a standard open colectomy. Therefore, I have determined that the requested procedure is medically necessary for the 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 45-year-old female who has a history of cervical and lumbar discogenic disc disease. She has demonstrated continued low back pain and radiculopathy despite medical therapy. It has been recommended she undergo a series of lumbar epidural steroid injections. The patient has requested authorization and coverage for a referral to an anesthesiologist for epidural steroid injections. The Health Plan has denied this request indicating that the requested referral is not medically necessary for treatment of the patients medical condition.The patient has been referred to a neurosurgeon for epidural steroid injections. There is no documentation demonstrating the medical necessity for the epidurals to be administered by an anesthesiologist. Epidural steroid injections can be safely and appropriately administered by a neurosurgeon. The submitted information indicates the neurosurgeon has performed the procedure in the past. The request for the epidural injections to be performed by an anesthesiologist is not medically warranted. Therefore, I have determined the requested referral 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 51-year-old female with chronic low lumbar pain from degenerative disc disease. The patients medical history indicates mixed physical and psychological features such as sleep disturbance, appetite disturbance, weight changes, energy disturbance, loss of lipids, and depression. The patient has also undergone two inpatient detoxification programs in 2003 for dependence to high doses of OxyContin. The patients current medication regimen includes: Duragesic 50mg every 48 hours; Ambien; phenobarbital; Lorazepam; propoxyphene; clonazepam; Baclofen; Wellbutrin XL; Seroquel; and Protonix.The patients physician notes increased drowsiness with increased Duragesic, grand mal seizures related to Methadone, and agitation for oxycodone. The patients physician is requesting authorization for Actiq for breakthrough pain on the basis that Actiq is the only narcotic the patient is able to tolerate.The patients complicated medical history with physical and psychological problems makes adding a short-acting narcotic medication to her current regimen a potential for more complications such as narcotic dependence and recurrent seizures. The patient is currently on an overlapping regimen of medications including narcotics, benzodiazepines, barbiturate, anti-psychotic medication, sleep agent, and anti-depressant. Adding Actiq to the above regimen will most likely lead to further complications with potentially negative consequences.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a 48-year-old male with chronic viral liver disease and cirrhosis. He has been twice treated with PEG interferon and ribavirin without success. The patient is requesting a third trial of therapy with Infergen and ribavirin.There are few data indicating substantive success with re-treatment with Infergen and ribavirin after failing what is generally considered the current gold standard therapy, PEG interferon plus ribavirin, in the setting of two previous treatment courses. There are also little high quality data suggesting that Infergen and ribavirin in this clinical setting (or as maintenance for those failing viral clearance), retards progression or increases time to transplant. Until supporting data become available, treatment with Infergen and ribavirin cannot be supported outside of clinical research trials. Therefore, 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 52-year-old female with common variable immunodeficiency. Because of her immunodeficiency, she requires monthly infusions of gamma globulin. This is correct medical practice and is well documented to control the frequency of infections in patients with this syndrome. The patient wishes to obtain her therapy at home as opposed to an outpatient center.The issue in this case is the need for home administration of the gamma globulin. The patient has changed health plans and is now required to receive her therapy at an outpatient center. According to the patient, this has caused long delays for her and has required up to 6-8 hours of time.It is not medically necessary for the patient to receive the requested therapy in her home. The patient is not homebound and is employed and apparently on a full-time basis. There is no medical justification for the therapy to be provided in the patients home. The Health Plan is offering appropriate medically indicated care for this patient. Therefore, I have determined that the requested services are 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 17-year-old female who has been using methamphetamine since January 2003.  The submitted records indicate the patient has been experiencing mood swings, low academic performance, and low appetite in addition to behavioral and personality changes. The patient and her family started seeking help and treatment for the patients condition in approximately June 2003. It was recommended the patient complete an outpatient chemical dependency program. The submitted records indicate the patient was not motivated to participate in the outpatient program and was uninterested and inconsistent in her treatment. The patient was admitted to a transitional residential recovery services program on 9/8/04. A request has been made for coverage for the patients participation in the transitional residential recovery services program. The Health Plan indicates the services at issue were not medically necessary for treatment of the patients chemical dependency.Review of the submitted medical records and correspondence, reveals the patient is a 17-year-old female who has been using methamphetamine since January 2003. As a result of her drug use she has had academic problems, mood swings, decreased appetite, and personality changes.  The patient was evaluated on 5/4/04, at which time it was recommended she participate in an intensive outpatient program. Based upon the medical records provided, the patient was not engaged, motivated or committed to this program. Her attendance and participation were erratic and inconsistent. Since the patient has not actively participated in outpatient treatment, there is no evidence the services at issue were likely to benefit the patient. Therefore, I have determined that 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: Upheld Decision of Health Plan

The patient is a 46-year-old female with painful varicosities. In July 2004, the patient consulted a vascular surgeon who noted chronic venous insufficiency and symptomatic varicose veins on the right with chronic venous stasis. The vascular surgeon recommended sclerotherapy for treatment of the patients varicosities; however, the patient prefers to undergo surgical intervention. The Health Plan has denied authorization for vascular surgery on the basis that it is not medically necessary for treatment of the patients varicosities.Review of the submitted documentation does not demonstrate the patients condition warrants surgical intervention at this time. A limited ultrasound revealed no evidence of reflux; however, only the superficial veins (greater saphenous vein and lesser saphenous vein) were imaged. It appears further work-up may be in order. Additionally, there is no evidence the patient has undergone an adequate trial of conservative treatment. Although the submitted notes indicate the patient underwent a trial of compression stockings, there is no documentation regarding the results of the trial. Therefore, I have determined that the requested surgery 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 56-year-old female with a 44-year history of migraine headaches, which affect her almost 15 days per month. The patient reports being bedridden for at least two days per month. The patient was also involved in a motor vehicle accident in 1996 with resultant cognitive deficits prohibiting the use of preventative treatments such as Topamax, Depakote, and Inderal. She is using Imitrex as an abortive treatment with some benefit, as well as Effexor for depression.The patient underwent Botox injections on 6/2/04 with significant relief from her migraines for approximately a three-month period. The injections were repeated on 9/7/04. The patient has reduced her usage of her daily pain medications secondary to relief from Botox injections. She is seeking authorization and coverage for further Botox injections.The patients severe migraine headaches and organic brain syndrome warrants the use of Botox injections for treatment of her migraines. She is unable to tolerate preventative treatment medications because of her organic brain syndrome. Her abortive treatment regimen only provides some relief, leaving her bedridden at least two days per month. In addition, a review of the submitted documentation reveals that the patient has reduced her usage of butalbital, which was previously prescribed almost monthly. In light of these results, additional Botox injections are medically appropriate and indicated for treatment of the patients migraine headaches.  Based upon the information set forth above, 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 36-year-old female who has a history of morbid obesity. She underwent gastric bypass in April 2002. She has reportedly lost 100 pounds since the procedure. In addition, the patient underwent an abdominoplasty in April 2003. The patient reports she has an excess amount of fat in her mid to lower back, which causes her pain and interferes with her ability to sit and sleep. She has requested a consultation with a plastic surgeon for possible removal of the excess skin.Review of the submitted materials does not demonstrate the requested consultation is medically indicated. The patient is seeking liposuction or another surgical procedure to remedy pain and discomfort that she attributes to excessive fat accumulated in her back. It is unlikely the fat itself is the cause of this discomfort, and highly unlikely that liposuction alone will remedy the problems the patient is experiencing. There is no evidence in the relevant medical literature that localized non-inflamed fat accumulations are a cause of pain. Furthermore, there is no evidence that liposuction is a modality for treatment of pain from any cause. Therefore, I have determined that the requested consultation is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old female who was formerly morbidly obese. The patient reports she lost over 100 pounds by diet and exercise. The patients plastic surgeon indicates the patient weighs 180 pounds at a height of 68 inches. He has recommended bilateral brachioplasty and bilateral thighplasty. The Health Plan has denied authorization for the requested procedures on the basis they are cosmetic in nature and therefore, not medically necessary. Review of the submitted photographs and medical records from the patients primary care provider and plastic surgeon does not demonstrate the requested procedures are medically necessary. There is no evidence of any skin rash or infection on the patients arms or thigh area. Thus, there is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. In the absence of documented evidence of a functional impairment, such as a skin condition, which has failed to respond to conservative treatment, the requested procedures are not medically indicated and are cosmetic in nature. Therefore, I have determined that 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 who was morbidly obese prior to a 100-pound weight loss. She underwent body sculpturing procedures and an augmentation mammaplasty in the past with correction of a left tubular breast deformity. The patients plastic surgeon has requested authorization for repositioning and possible exchange of the patients breast implants and a mastopexy. The Health Plan has determined the requested services are not medically necessary for treatment of the patients condition.Examination of the submitted medical records and photographs reveals the appearance of spherical contracture of the left breast. This constitutes medical necessity for left breast implant removal and capsulectomy or capsulotomy, whichever is indicated at the time of the operation. At the time of the procedure it may be determined a new implant is required; if so, new implant placement should be authorized. However, there is no evidence of a functional impairment involving the right breast. As such, repositioning/exchange of the right breast implant is cosmetic in nature and not medically necessary. Furthermore, the submitted photographs and clinical information do not demonstrate a mastopexy is medically necessary. Based upon the information set forth above, I have determined that repositioning of the left breast implant with possible exchange of the implant is medically necessary for treatment of the patients medical condition. However, repositioning and exchange of the right breast implant and a mastopexy are cosmetic in nature and not medically necessary for treatment of the patients medical condition. Therefore, the Health Plan denial should be partially overturned.