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

The patient is a 34-year-old female with a long-term history of migraine headaches. She has now developed chronic migraine with daily mild to moderate headache and one to two severe, intractable migraines a month, which have required urgent care or an emergency room visit for parenteral medication. She has been evaluated by experienced headache specialists and has apparently had her rebound headaches addressed by her current provider. She has reportedly failed numerous medications including Depakote, Topamax, Neurontin, Inderal, and Pamelor. She responds poorly to triptans. She remains partially disabled because of her headaches. She is seeking authorization for Botox, which the Health Plan has denied.The patient has severe refractory and intractable chronic migraine. She has had full evaluations for other treatable causes with no findings. She has failed all standard preventive treatments. She does not appear to have rebound headaches. A trial of Botox is reasonable and likely to be more beneficial than any other available therapy. For this patient standard treatment would be two cycles of Botox with re-evaluation thereafter. If the patient has a significant response to Botox, consideration should be given to long-term treatment.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 15-year-old male with apparent hypersomnolence and alleged marked decrease in intellectual functioning as a result of a toxic injury secondary to carbon monoxide. Multiple stimulants, antidepressants, and mood stabilizers have been used without significant positive effect on the patients condition. Provigil apparently has been tried and appears to have been somewhat beneficial. The patient also apparently has a history of substance abuse and head injuries prior to his alleged exposure to carbon monoxide.Review of the current medical literature reveals no case-controlled, peer-reviewed literature demonstrating the efficacy of Provigil for improving intellectual performance. Furthermore, the information provided does not provide sufficient documentation of the patients apparent hypersomnolence, depressive symptoms, or attention-deficit hyperactivity disorder. There is no clinical indication for Provigil based upon the provided documentation. Therefore, I have determined that 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 59-year-old male with risk factors for coronary artery disease. The records indicate the patient is normotensive on captopril 50 mgm three times a day. He has a normal lipid profile on Crestor and niacin. He has been diagnosed with borderline diabetes; however, the HbA1c is 5.5%. He has a family history of coronary artery disease. He is overweight with a body mass index of 30. An EBCT score was 250. He is asymptomatic. A stress echocardiogram in 2002 was nonischemic. He is seeking authorization for continued regular cardiology services.The Health Plans denial is correct. The patient has risk factors for coronary artery disease. However, he is asymptomatic and has no evidence of significant coronary artery obstruction. He has been successfully treated with risk factor modification within the NECB and AMA guidelines. Based upon this information and the submitted medical records there is no evidence that continued care with a cardiologist is medically indicated. Therefore, I have determined the requested services are not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 20-year-old male who was rendered a paraplegic as a result of a pool dive. He is involved in appropriate rehabilitation. The patients physician has recommended a standing frame for the purpose of attaining weight bearing on his lower extremities. The Health Plan has denied this request indicating the requested equipment is not medically necessary for treatment of the patients medical condition.The standing wheelchair was developed for patients such at this patient to improve their quality of life and maintain reasonable health. Considering the patients young age, every strategy and modality has to be applied to ensure that he can survive without major medical complications and lead a reasonably productive life. The standing frame is essential to the welfare of this patient and should be authorized. Therefore, I have determined that the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old male with a history of depression. His condition has been managed on Celexa 20mg and outpatient psychotherapy. In addition, the patient is being followed by a psychiatrist. The patient has requested authorization and coverage for additional outpatient psychotherapy. The Health Plan has denied the request on the basis that the clinical evidence does not demonstrate additional psychotherapy is medically necessary.The Health Plans denial should be upheld. Based upon the information provided, it appears the patient has been responding to pharmacotherapy as managed by his psychiatrist. There is no indication of the focus of psychotherapy (i.e., cognitive behavior therapy, psychodynamic, etc.). All indications from the patients provider indicate the patient has improved without exacerbation of his depression. No evidence of new target symptoms has been provided. Furthermore, there is no plan to manage any specific symptoms or attain any specific goals. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 43-year-old male with a history of chronic low back pain who is undergoing treatment trials of numerous medication combinations including opiates. The patient experiences sedation secondary to his opioid use for which he was prescribed Provigil. Provigil has improved the patients side effect of sedation from the narcotic pain medications. The Health Plan has denied authorization and coverage for continued use of Provigil on the basis that it is not medically indicated for treatment of the patients condition.Though Provigil has been approved by the FDA only for narcolepsy, obstructive sleep apnea, and shift work sleep disorder, it has been used successfully to treat sedation secondary to medications such as opioids. Provigil is also a safe drug with a low risk of abuse. Furthermore, there is documented evidence the patient has benefited from use of Provigil without experiencing undesirable side effects. As such, continued use of Provigil to reverse or reduce opioid-induced sedation is medically reasonable and appropriate and should be authorized. Accordingly, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old male with left-sided prostate nodule on digital rectal examination of 9/9/04 and an elevated PSA of 4.9. Prostate biopsy on 9/14/04 showed benign tissue on the right side. However, on the left side a Gleason score of 3+4 adenocarcinoma was present in 40% of the tissue biopsied. A bone scan performed on 10/8/04 was negative for metabolic disease. Clinically this represents a T2a stage prostate adenocarcinoma, which is potentially curable by surgery. In January 2005, a second urologist reported that in addition to the adenocarcinoma in the left side of the prostate, there was also a Gleason 4+3 adenocarcinoma on the right side of the prostate. The patients urologist has recommended an open radical retropubic prostatectomy. The patient wishes to undergo robotic-assisted laparoscopic radical retropubic prostatectomy. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition. Based on Partins Tables, there is a 44% chance of the patients cancer being organ confined. The open surgical approach is a well-established treatment with good long-term results regarding survival and complications. The robotic-assisted laparoscopic procedure is relatively new, and while short-term results are comparable, long-term data especially with regard to survival is not yet available. The procedure offered by the Health Plan is considered standard of care for potentially localized and curable prostate adenocarcinoma, and is 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: Overturned Decision of Health Plan

The patient is a 54-year-old male with a history of hepatitis C who is status post liver transplant. Post transplant he has experienced complications of recurrent hepatitis C and bridging fibrosis. His providers have recommended initiating therapy with interferon and ribavirin. He has had the same transplant team for over two years. The Health Plan is denying coverage for services with the patients current transplant providers and has recommended the patient transfer care to other specialist. This patient has a significant and complicated history during which he has been under the care of the same team of providers. In addition, it appears he is beginning or has begun significant therapy with interferon and ribavirin. Given the patients history, current condition and treatment plan, for reasons of continuity of care it is medically necessary for the patient to remain under the care of his current providers. The patient should remain with his current providers for at least another six months. During that time period an appropriate transition plan to new providers can be developed. Currently, it is reasonable and appropriate for the patient to remain with his current providers. Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The patient should remain with his current providers for at least another six months. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has a significant Class III congenital/developmental skeletal deformity. The mandible is 70.1 mm in length, which is considerably longer than the normal mean length of 51.2 mm (3 standard deviations from the mean). The maxilla is in the normal anterior posterior position relative to the cranial base. However, there is a transverse deficiency -the upper jaw is not wide enough for the lower jaw. As a consequence of the discrepancy in the size of the jaws, the patient has a severe Class III malocclusion. Dental compensations (primarily, maxillary protrusion of the upper incisors and buccal inclination of other upper molars) have occurred to partially correct the Class III malocclusion so as to meet functional demands. However, despite this the patient still has a complete anterior crossbite where the lower incisors are in front of the upper incisors. This has resulted in lip incompetence and has placed increased functional demands on the muscles of mastication. Although at present there is no evidence of the presence of degenerative temporomandibular joint disease based on radiographs of the joints, the presence of myofascial pain suggests that this is likely to occur in the future. The patients oral-maxillofacial surgeon has recommended a modified high Lefort 1 maxillary osteotomy, bilateral sagittal split ramus osteotomy of the mandible, and autogenous iliac bone crest interpositional bone graft. The Health Plan has denied coverage for the requested procedure on the basis it is cosmetic in nature and not medically necessary. I agree with the diagnosis and surgical treatment plan of the patients oral-maxillofacial surgeon. The proposed surgery meets the definition of reconstructive surgery. The patient has a congenital/developmental defect, which impairs function. The surgery will improve function and create a more normal appearance. In addition, the surgery is likely to prevent future abnormalities associated with the dentition, muscles of mastication, and temporomandibular joint. Alternative treatments such as orthodontic treatment alone or combined with prosthetic treatment will not correct the malocclusion and functional impairment. Furthermore, the structures being altered are not normal structures of the body. The patients mandible is larger than normal and her maxilla is smaller than normal. Moreover, the requested procedure will improve function. As such, the requested procedure is reconstructive rather than cosmetic in nature and is medically necessary.Based upon the information set forth above, I have determined the requested procedure 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 26-year-old female with a long-term history of psoriasis involving 60-75% of her body. Her psoriasis has not improved with standard topical medications and UVB light therapy. In 2003, her psoriasis cleared almost completely after a trial of Enbrel. The patient had no side effects from the Enbrel. The patients provider is requesting authorization for Enbrel. The Health Plan has denied this request. In women of childbearing age, methotrexate and Soriatane are contraindicated. They are pregnancy category X medications. Methotrexate may cause bone marrow depression and liver damage and pretreatment usually requires a liver biopsy. Neither methotrexate nor Soriatane are widely used in women of childbearing age in the treatment of psoriasis. Cyclosporine is indicated for severe acute psoriasis  it is used for 6 to 12 months. There is a significant risk of kidney damage and hypertension with cyclosporine. Enbrel is a pregnancy category B drug. It can be safely stopped when a patient becomes pregnant. It is effective in the treatment of extensive psoriasis, including long-standing psoriasis. Enbrels safety profile is much better than the three medications described above. Additionally, a liver biopsy is not required. For these reasons, and the fact it has previously been effective, Enbrel is medically indicated and necessary for this patient. Therefore, I have determined 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 with a history of recurrent endometrial polyps that cause her to have menorrhagia. The patient and her physician wish to have a Mirena IUD placed to prevent the endometrial polyps from returning. The Health Plan indicates the Mirena IUD is only FDA approved for contraception, and has not been approved for treatment of endometrial polyps. Therefore, the Health Plan has denied coverage for the requested device. The Mirena IUD is only FDA approved for contraception and is not FDA approved for treatment of menorrhagia or endometrial polyps. Though there are several published articles showing that the Mirena IUD can be an effective treatment for menorrhagia, there are no articles demonstrating that the device is effective for the prevention of endometrial polyps. In fact, several articles studying menorrhagia excluded patients with endometrial polyps. In one study of 14 patients there were two failures, one because of an endometrial polyp and one because of a submucosal myoma. Another study showed that the Mirena IUD was less effective for the treatment of menorrhagia when the patient had uterine myomas. Off-label use of an approved device requires clear evidence of the effectiveness of the proposed use. To date, there are no studies showing the Mirena IUD is effective for treatment of endometrial polyps. Therefore, I have determined that the requested device 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 47-year-old male with a history of hepatitis B. He was initially treated with lamivudine until he started to develop resistance. He is currently being treated with Hepsera. The information provided indicates his liver enzymes have responded favorably to Hepsera. The Health Plan has denied coverage for Hepsera. The current standard of care for this patients hepatitis B is to continue treatment with Hepsera. Stopping Hepsera would increase the potential for the patient to have a hepatitis flare-up. A search of relevant literature reveals support for treatment with Hepsera with no end point in the treatment. Literature indicates that treatment is for at least one year with most patients requiring longer treatment and, importantly, the criteria for stopping treatment have not been established. Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 59-year-old male with idiopathic pulmonary fibrosis (IPF). According to an initial consultation with his pulmonologist, the patient has a medical history of diabetes mellitus, coronary artery disease, and is status post coronary artery bypass graft. At this consultation, the patient presented with progressive shortness of breath, non-productive cough and abnormal chest radiograph. The patient was previously hospitalized twice for pneumonia. Spirometry showed FVC 71%, FEV1 82%, and FEV1/FVC 92%. On 2/4/04, a CT scan of the chest revealed bilateral interstitial fibrosis primarily at the bases and periphery. Results of bronchial washings and transbronchial biopsy performed on 2/13/04 were non-diagnostic. On 3/1/04, an open lung biopsy revealed unusual interstitial pneumonitis. Based upon negative workup looking for infectious and malignant etiologies, the patient was diagnosed with IPF. Thereafter, additional pulmonary function tests revealed a decline with an FVC of 59% and an FEV1 of 59%. Clinically the patient had worsening shortness of breath and was placed on supplemental oxygen. The patient has been treated with varying doses of prednisone with limited efficacy. The patient did not tolerate azathioprine. The patients provider has requested authorization for Actimmune (interferon gamma-1b). The Health Plan has denied this request. The study by Ziesche, et al. enrolled 18 patients and studied the effects on Actimmune in the treatment of IPF. The results showed statistically significant improvement in total lung capacity, forced vital capacity and paO2 in patients treated with thrice weekly Actimmune. The results were promising and have led to a phase III trial using Actimmune versus placebo in the treatment of IPF. Kalra, et al. concluded Actimmune did not benefit IPF patients. Davies, et al. found little evidence to support the use of Actimmune in the treatment of IPF. Honore, et al. found that Actimmune can cause respiratory failure in IPF patients. Raghu, et al. reported in a prospective, double-blind study of 330 patients with IPF that treatment with Actimmune did not affect progression-free survival, pulmonary function or quality of life. The Raghu study appears to be the most comprehensive and clinically relevant study of the role of Actimmune in the treatment of IPF. Because a number of studies have found no benefit and some evidence of harm, Actimmune cannot be recommended for this patient. Therefore, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 37-year-old female with degenerative disc disease. She has had a positive discogram at L4-5 and L5-S1. Her provider is recommending a two-level ProDisc disc replacement at these levels. The Health Plan considers this procedure experimental. The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery at two levels. There is no data to support such a procedure. There are no known outcomes at two years or more. ProDisc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is no evidence supporting the safety and efficacy of a two-level disc replacement, 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. Therefore, the Health Plans denial should be upheld. Physician 2: The patient is a 37-year-old female with degenerative disc disease. She is seeking authorization for two-level disc replacement utilizing the ProDisc. The Health Plan has denied this request because it considers the ProDisc experimental.The current clinical evidence regarding ProDisc is based upon short-term follow-up in one study. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. There is no evidence for reduced long-term adjacent level disease progression compared to fusion. There are no studies that indicate long-term superiority over fusion. ProDisc is considered experimental and there is no evidence it is superior to available standard treatment. 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. Physician 3: The patient is a 37-year-old female with two-level degenerative disc disease at L4-5 and L5-S1. A two-level disc replacement has been recommended. The patient is status post posterior discectomy with continued back pain. The Health Plan has denied authorization for the requested procedure. The proposed procedure is experimental with no established efficacy. There are no studies supporting a two-level disc replacement. The safety profile is unknown. There is no clinical indication for the proposed procedure. There are other treatments available. For these reasons, 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. Therefore, the Health Plans denial should be upheld.