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

The patient is a 53-year-old female with diagnoses of asthma, allergic rhinitis, gastroesophageal reflux disease (GERD), prolactinoma, and hypercholesterolemia. An upper GI study in 2002 revealed a hiatal hernia and esophageal reflux. The patient was first diagnosed with asthma three years ago by her treating provider who is a pulmonologist and allergist. A spirometry performed on 3/8/04 was interpreted as normal A chest radiograph dated 1/24/05 was interpreted as normal. Her current medical regimen includes Advair, Singulair, albuterol, Nasonex, and Prevacid. The patient also receives weekly injections for her immunotherapy. The Health Plan has determined it is not medically necessary for the patient to receive her weekly injections from a pulmonologist and has referred the patient to an allergist. The patient was evaluated by an allergist who agreed with the above treatment plan and noted the patients asthma was well under control. The purpose of this review is to determine whether a referral to a pulmonologist is necessary for management of the patients asthma.Based upon current NAEPP guidelines, the patients asthma appears to be well controlled. The patients immunotherapy injections were previously managed by a pulmonologist and are now managed by an allergist. Based upon the patients most recent chest x-ray and spirometry, the Health Plan does not believe the patient requires a pulmonologist. The information submitted does not demonstrate any radiographic abnormalities such as lung obstruction, hypoxemia, etc., which would require the management of a pulmonologist. Furthermore, the patients immunotherapy can be safely and effectively managed by an allergist.Based upon the information set forth above, I have determined the requested referral is not medically necessary for treatment of the patients medical condition. Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old male who is status post gastric bypass in February 2004 followed by massive weight loss of approximately 150 pounds. He is now seeking authorization for panniculectomy, which has been denied by the Health Plan.The information submitted does not demonstrate the patient meets accepted criteria for authorization of a panniculectomy. Although the patient has undergone massive weight loss there is no evidence he has experienced chronic skin infections that have not been amenable to conservative treatment. In addition, there is a lack of evidence demonstrating significant functional impairment. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is an eight-year-old female who was adopted from Russia. While in Russia, she received speech therapy for a language delay in her primary language. The patient moved to the United States and began learning a new language. She was subsequently diagnosed with a receptive and expressive language delay. She was also noted to be bright, cooperative and interested in learning. The patient began receiving speech therapy services. The Health Plan denied coverage for speech therapy services as of 5/3/04 on the basis the services at issue were not medically necessary for treatment of the patients condition.The patient has a complicated history with language delays in both her primary (Russian) and secondary (English) languages. Services to improve speech were not covered from 5/3/04 through 12/13/04. Multiple evaluations and treatment plans indicate speech therapy was indicated. The patient required the skills of a qualified speech therapist. Furthermore, there was a reasonable expectation of achieving measurable significant functional improvement with continued therapy. Given the patients history and the findings of her therapist, I have determined the therapy at issue was 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 32-year-old male who was diagnosed with adenocarcinoma of the esophagus, arising from Barretts esophagus in May 2004. At that time he was noted to have hilar adenopathy. The patient was started on neoadjuvant chemoradiation, receiving 5040 cGy of radiation and two cycles of cisplatin-5FU. An attempt at surgical resection was performed in October 2004, but the patient was found to have military spread of tumor throughout his lungs; therefore, no resection could be performed.The patient was seen at USC and started on chemotherapy consisting of CPT-11 with Taxotere on 11/18/04. After six cycles of this treatment a CT scan revealed progressive disease. At this time, USC has recommended continuing the patients chemotherapy with a new combination to include Gemzar, Xeloda and C225 (Erbitux). Authorization for this treatment has been denied as it is out-of-network and the Health Plan indicates appropriate services can be provided by in-network oncologists.In cases such as this case, there are different opinions as to which chemotherapy drugs should be tried. Many oncologists would favor the choice of Xeloda with Gemzar as both drugs have activity in GI adenocarcinoma. These drugs are readily available in the community setting.The regimen proposed by USC includes the addition of Erbitux. This is a drug approved for use in metastatic colon cancer, either when used along with CPT-11 or as a single agent in those patients who are intolerant of CPT-11. Its use with Gemzar and Xeloda in this patient with esophageal cancer is considered investigational and unproven. There is no medical necessity for treatment with the protocol proposed by USC. The patient can be treated equally effectively by an in-network oncologist. 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: Upheld Decision of Health Plan

The patient is a 62-year-old male who had a rise in his PSA of 6 in 2002 to 10.7 in 2004. He had a total of five needle cores biopsied. On examination, his prostate was described as small and free of any nodules. He has had 3D conformal radiation therapy recommended but he would like to proceed with intensity modulated radiation therapy (IMRT).Based upon the information provided it appears the patient has a Gleason score of 6 in minute quantity of the right lobe of the prostate with a PSA of 10.7 and a tumor stage of T1c. The patient has a low volume of tumor. Based upon Partins Tables there is a 62% chance of cancer being limited to the prostate, a 33% chance of capsular penetration, a 4% chance of seminal vesicle involvement, and a 2% chance of pelvic lymph node involvement. Furthermore, based upon the patients relatively high PSA and low volume of tumor there is potential the tumor is outside of the prostate. As such the patient may require treatment of the pelvis as well as the prostate.Given this patients condition, 3D conformal radiation therapy is the appropriate radiation therapy for this patient. There is no evidence IMRT would be superior for this patient. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 63-year-old male who experienced head trauma as well as other injuries as the result of a fall from a ladder. The patient subsequently received acute inpatient care. The Health Plan has recommended transfer to a skilled nursing facility. The patients family has requested the patient be placed in a different facility for rehabilitation. The patient has made rapid improvement with physical therapy. He had continued need for speech therapy and may benefit from cognitive rehabilitation.The patient has made dramatic gains in the hospital without benefit of the acute rehabilitation structure. His medical and nursing needs can be addressed in a skilled nursing facility. Physical therapy, occupational therapy, and speech therapy can all be provided in a skilled nursing facility. The patient does not require extensive physical therapy, occupational therapy and speech therapy, but should have access to cognitive rehabilitation while receiving skilled nursing care. Therefore, I have determined that the requested services 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 left breast cancer diagnosed in February 2005. The patient has had a left maxillary sentinel node biopsy, which was negative. The patient is scheduled to have a left mastectomy and tram-flap reconstruction. Mammogram of the right breast performed in March 2005 showed a few benign calcifications. Ultrasound of the right breast performed in March 2005 was negative. The patients surgeon has requested a MRI of the right breast indicating the patients breast tissue is dense and nodular, and if the patient does have cancer in the right breast it will change the surgical management. The Health Plan has denied authorization for the requested MRI on the basis it is not medically necessary.Review of the current medical literature reveals there is no disagreement that MRI is more sensitive than mammography or ultrasound in detecting breast cancer. In high-risk patients, MRI has been shown to find breast cancers when mammography has been negative. Patients who have had a prior breast cancer are in a higher risk group for another breast cancer than the general population. The data shows 7% of women who had a prior breast cancer were found to have an occult cancer by MRI (Morris, et al.). Many of the cancers detected by MRI were ductal carcinoma in situ (DCIS). Though the submitted literature indicates the clinical value of a finding of DCIS is unproven, a significant percentage of DCIS progresses to invasive cancer. The detection of DCIS is not insignificant since patients with DCIS are treated with surgical resection and often radiation.The patient in this case is considered to be in a higher risk group than the general population. The patients surgeon has ordered the MRI on the basis the results of the test may possibly alter the patients treatment plan. The proposed screening MRI of the patients right breast is medically appropriate and indicated. Therefore, I have determined that the requested MRI is medically necessary for evaluation 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 20-year-old female with a history of protein C deficiency who presently has extensive deep vein thrombophlebitis extending through all the veins of the lower extremities, pelvis and inferior vena cava. She has an inferior vena cava filter, which was placed on 2/17/05. She has failed a variety of conventional treatments for deep vein thrombosis including Lovenox, Heparin, tissue plasminogen activator and Coumadin. She was admitted on 3/5/05 for evaluation of abdominal pain. A CT scan demonstrated inferior vena cava thrombosis with thrombus extending into the renal vein unilaterally with some perinephric edema. She was evaluated by hematology and placed on Refludan. She has received IV Refludan therapy, but will require therapy with this agent for a period of 12 months. She has been recommended to receive the Refludan via subcuticular injections administered twice daily.The documentation provided indicates the patient has responded to Refludan therapy. She has evidence of Heparin induced thrombocytopenia (positive antibody test) in addition to protein C deficiency and Refludan is the treatment of choice. She will require therapy for a period of 12 months. The literature has demonstrated the ability of the Refludan to be administered via the subcuticular route providing the desired prolongation of the partial thromboplastin time necessary for effective therapy for a period of 12 months. Continuing treatment via IV infusion would not be a feasible option for self-management. Refludan therapy is medically indicated for treatment of the patients thrombotic condition and should be administered in a manageable and effective way. Therefore, I have determined that subcuticular administration of Refludan 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 with hepatitis encephalopathy resulting in a seven-day hospital admission. The patient had an onset of his condition approximately two to three days prior to hospitalization. During the hospitalization records indicate the patient experienced deconditioning. Records further indicate the patients spouse was not able to care for the patient. After hospitalization the patient began receiving skilled therapy. The Health Plan provided coverage for the skilled nursing facility (SNF) services the patient received until 3/25/05  at which time the Health Plan determined further SNF services were not medically necessary. The patient is requesting coverage for continued SNF services.The patient received physical and occupational therapy from 3/16/05 to 3/25/05. During this time period the patients cognitive status had improved. On 3/22/05, he was minimum assist for transfers and minimum assist for ambulation. Although he could ambulate 30 feet, having progressed from 10 feet, his only progress was in distance. At the time of the Health Plans denial the patient was not independent and required at least minimum assistance for his activities of daily living and transfers. Furthermore, there is no evidence the patient could have been safely discharged home at the time of the Health Plans denial. Although the patients rehabilitation capacity may be limited, the extent of his ability to recover was not established. A 10-day course of rehabilitation therapy is not expected to be sufficient given the patients hospital length of stay and his pre-morbid status. The records reveal the patient remained a candidate for SNF services as of 3/25/05 as there is no evidence the patient had reached his maximum level of function and there is evidence that he would continue to progress with continued therapy.Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Based upon the information provided the patient should be evaluated on 4/14/05 to determine whether continued SNF services are necessary or whether the patient can be safely and effectively discharged from skilled care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 31-year-old female who reports that she has high blood pressure and panic disorder. These issues are not documented in the submitted medical records. The patient wishes to have in-office general anesthesia for routine restorative dental treatment. The Health Plan has determined the use of general anesthesia is not medically necessary.The Health Plans denial should be upheld. Review of the submitted clinical documentation reveals no evidence of medical problems that would necessitate general anesthesia for dental treatment. Furthermore, there is no documentation that other options for treatment such as conscious sedation have been used without success. Therefore, I have determined the requested general anesthesia is not medically necessary to assist with the patients planned dental procedure. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A forty-one year-old male with a right submandibular adenoid cystic carcinoma is requesting authorization for neutron beam therapy.Reviewers Findings:  Two of the reviewing physicians found that neutron beam therapy in this clinical setting is medically appropriate and indicated and is likely to result in a better outcome for this patient.  The third reviewing physician found that there is no evidence neutron beam therapy is more efficacious than external beam irradiation with photons and electron beam irradiation boost.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 58-year-old male with a history of back pain. His history is significant for a motor vehicle accident in October 2003. He has been receiving physical therapy since at least 2002 and now is requesting authorization for continued therapy. The Health Plan has denied this request.The physical therapy records submitted demonstrate the patient has on-going complaints of neck, mid-back, and lower back pain. While documentation shows the patients pain and range of motion are sometimes better and sometimes worse, overall the patient had no improvement through 2003-2004. The physical therapy notes submitted provide no specific details regarding the treatments provided of why a home exercise program would not be appropriate for the patient. Furthermore, there is no overall plan of care or endpoint/specific goals for the patient. Nor does it appear there is a focus on discharge to a home program.Given the patients lack of progress and lack of evidence demonstrating why continued therapy is necessary, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denials should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old female with chronic pain in the neck, shoulders and back, and chronic headaches. She has requested an MRI and MRA of the shoulders and upper extremities. The patient has previously undergone an MRI and MRA with moderate abnormal findings. The patient is on high-dose narcotics. The Health Plan has denied the requested MRI and MRA and recommended an MRI of the upper chest.The patient has an intractable chronic pain syndrome arising from a work related injury in 1991. The patient has been disabled because of this pain since 1991. The information provided does not demonstrate a significant change in the patients chronic pain indicating the need for a repeat MRI and MRA. The MRI of the upper chest including vascular structures is appropriate and indicated. Therefore, I have determined the requested services are not medically necessary for evaluation 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 58-year-old male with a history of daytime somnolence resulting from non-REM narcolepsy/idiopathic hypersomnolence. The patients history includes a polysomnography that ruled out obstructive sleep apnea, periodic leg movement and/or narcolepsy. The patient indicates he is employed as an attorney and excessive sleepiness is affecting his employment and is creating a driving hazard. The patient consulted a sleep specialist who prescribed Provigil. The submitted documentation indicates the patients symptoms have improved with use of Provigil.The apparent diagnosis in this case is idiopathic hypersomnolence. The patient was quite symptomatic because of daytime sleepiness. Clinically, the patient has improved with Provigil. Idiopathic hypersomnolence is recognized as a sleep disorder. Given the patients therapeutic response, continued treatment with Provigil is medically appropriate and indicated. Therefore, 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 49-year-old female who has had intermittent low back pain and was first evaluated on 12/20/04. She has tried various medications and has received a cortisone injection without significant relief. She also complains of a soft tissue lump on her right lower back. Other than her pain, the patient has no radiculopathy or other neurological findings described. Radiographs of the lumbar spine showed degenerative disc disease at L5-S1. The patients provider has referred the patient to physical therapy. If physical therapy is not successful the providers plan is to then obtain an MRI. The patient would like to proceed with an MRI without first attempting physical therapy. The Health Plan has denied authorization for the MRI.Most low back pain is relieved with medication and physical therapy and an MRI is not indicated. An MRI may be helpful in evaluating a patients persistent pain despite conservative treatment of if the patient has radiculopathy or other neurological signs or symptoms. The patients providers treatment plan is appropriate and consistent with standard of care. Therefore, I have determined the requested MRI is not medically necessary for evaluation of the patients back pain. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 16-year-old male who has been diagnosed as having mental retardation, severe developmental delay, and posterior inferior cerebellar artery (PICA). The patient also has microcephaly, congenital encephalopathy, and some features suggestive of Bloom syndrome. The patient has undergone substantial psychiatric, psychological, neurological and educational testing, and all the testing and evaluation have confirmed the patients diagnosis as mental retardation--mild, and severe developmental delay with PICA. The patient has received behavior modification and psychotherapy including individual and family sessions. The therapy focused on the patients social skills, expression, self-esteem, individualization and separation. Play therapy, talk therapy and cognitive behavior therapy were utilized.A request has been made for authorization and coverage for additional psychotherapy visits. The Health Plan indicates the requested therapy is not medically necessary.Review of the submitted clinical records reveals the patient has mental retardation, mild, severe developmental delay including expressive and receptive language delay, cerebral palsy and PICA. There is no reliable medical literature to suggest that play therapy, talk therapy, and cognitive behavioral therapy are effective in the treatment of an individual with mental retardation, cerebral palsy, and severe developmental delay. This modality of treatment is not considered standard of clinical care and therefore, is not medically indicated. As such, 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

A forty-nine year-old female with stage T1, Nx, Mx rectal cancer and is status post colonoscopic removal is requesting an out-of-network formal proctectomy with reconstruction  low anterior resection.Reviewers Findings:  The reviewing physician found that it appears the patient has received authorization to have the proposed procedure performed by an in-network colon and rectal surgeon, the requested services performed out-of-network are not medically necessary.  The Health Plan denial was upheld.