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

The patient is a 19-year-old male who has keloids and/or hypertrophic scars of the face, possibly secondary to pseudofolliculitis barbae. Intralesional Kenalog injections and silastic gel sheeting treatment resulted in a flatter appearance of the lesions. The patient does not wish to receive additional intralesional Kenalog injections. Instead, he has requested authorization for laser hair removal. The Health Plan has denied this request on the basis that the requested procedure is not medically necessary.The Health Plans denial should be upheld. According to the submitted clinical records there are no hairs growing within the scars. If there is no hair to remove, there is no value in performing laser hair removal and as such, there is no medical justification for the procedure. Additional treatment should be focused on the scars themselves rather than on hair removal. 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: Upheld Decision of Health Plan

The patient is a 54-year-old male with a history of degenerative disc disease from L2 to S1.  He is status post laminectomy at L5-S1 and he has hypercholesterolemia. The patient has been treated with medical therapy, which includes Tylenol #3, Ativan, Neurontin, and ibuprofen. He continues to have low back pain. Upon examination sensory, motor, strength, coordination, reflexes and gait were within normal limits. The patients provider has requested authorization for epidural injection therapy. The Health Plan denied the request citing a lack of medical necessity.The patient has not undergone a recent trial of conservative therapy such as physical therapy, massage therapy or chiropractic care. He has a long-standing history of back pain. The MRI from May 2006 demonstrated multilevel degenerative disc disease and post-operative changes at L5-S1. A trial of physical therapy in combination with the current medical management might potentially provide more long-term pain relief than would be achieved with epidural injection therapy. The patient should undergo a trial of conservative therapy prior to consideration of epidural injections. 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 48-year-old female with a BMI of 43. She has a number of comorbid conditions including asthma, diabetes mellitus type 2, and depression. She has requested authorization for gastric bypass surgery. There is no evidence that the patient has undergone a psychological evaluation to determine whether she is considered an appropriate candidate for weight loss surgery.With a BMI of 43 and comorbid conditions such as diabetes 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 clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not yet obtained psychological clearance for weight loss surgery. Based upon the information set forth above, I have determined that the requested surgery 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 requested procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the requested procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 64-year-old female who was found to have a right parietal cystic lesion with multiple septae. She underwent an endoscopic biopsy and decompression in May 2005, which was complicated by a deep white matter infarct leaving her with left hemiparesis.  Her neurological problems are most significant in the left upper extremity. Despite inpatient rehabilitation and outpatient therapy the patient continues to have severe left arm and hand weakness. She is requesting authorization for hyperbaric oxygen therapy for treatment of this condition.  The Health Plan denied her request based upon a determination that the therapy is not medically necessary.Several meta-analyses including a Cochrane Report, have shown there is no clinically significant advantage to hyperbaric oxygen therapy over standard rehabilitative care following a stroke. The efficacy of hyperbaric oxygen therapy has not been established and it is not considered the standard of care within the neurological community.   Hyperbaric oxygen therapy has no role in later-stage rehabilitation of hemiparesis. 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: Upheld Decision of Health Plan

The patient is a 24-year-old male who was admitted to residential treatment in November 2005. The November 2005 admission note indicated an absence of any acute medical issues and the presence of normal vital signs. The patients last use of opiates was one week prior to admission. The note indicated the patient had a seizure (of unknown etiology) late in October 2005. A clinical assessment form dated in November 2005 indicated the patient was transferred from another facility where he had been admitted in October 2005 and was detoxified from methadone for the prior three days secondary to prescription pain medication dependence. This same form indicated the patient was without any suicidal or homicidal ideation and had a supportive wife with whom he was living. The patient did describe a history of depression, anger, anxiety and severe cravings. At issue is whether the residential treatment services provided from November 2005 through December 2005 were medically necessary for treatment of the patients medical condition.Review of the clinical evidence indicates the patient had already been detoxified medically at the time of his admission to residential treatment and there were no symptoms of significant withdrawal documented upon admission or during his stay. There is no evidence of medications being administered for withdrawal during the patients stay and there is no evidence of any medical monitoring during the placement. In addition, the records demonstrate the patient was motivated for treatment and although he had a history of depression, there were no suicidal or self-harm ideations noted. Furthermore, the patient had a prior history of sobriety and there is no documentation of treatment failure associated with his prescription medication dependence in the submitted records. Moreover, the patient had a supportive system available to him. For these reasons, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 53-year-old female with right lower extremity weakness and numbness. The patient reports that she requires help from her husband to get to her medical appointments. Prior to her illness she was independent in her daily living activities, and had complete mobility with shopping, driving, etc. A home physical therapy evaluation was performed in June 2006. The patient has requested authorization and coverage for home health physical therapy, which has been denied by the Health Plan on the basis that it is not medically necessary.The submitted documentation indicates the patient has gait disturbance. She had an evaluation for physical therapy in her home in June 2006. She was noted to be independent with mobility but had impaired balance, impaired right lower extremity sensation, decreased right lower extremity (1-3 of 5), and was also noted to walk with a front-wheeled walker. Based upon the evidence provided, the patient requires home physical therapy as she remains homebound at this time. She is unable to leave her home without assistance from another person. She has experienced a decline in her level of function as a result of illness and therefore requires physical therapy to improve her right lower extremity strength and balance and regain her prior level of ambulation without requiring assistance. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old male with a diagnosis of ADHD.  He has been treated with stimulants for this condition and reports a positive but limited clinical response.  He has started Focalin XR and finds that his best response is at 40mg, double the dosage approved by the FDA. The patient states that he notes an increase in his blood pressure with the combination of 20mg Focalin XR and additional dexedrine spansules. This is not unexpected since the combination of the Focalin XR with other types of dexedrine is not recommended due to side effects that include elevation in blood pressure.At issue is whether Focalin XR at a dosage of 40mg per day is medically necessary for treatment of the patients medical condition.Focalin XR is compounded so it will be safe and effective when used one time per day.  Additional stimulant medication is not recommended with Focalin XR. The FDA approved Focalin XR at a maximum dosage of 20mg per day. The request for twice the dosage based upon a subjective finding of the patient is not an appropriate clinical rationale to exceed the recommended dosage.  It is also of concern that the patient is reporting side effects with an increase in blood pressure.  Furthermore, Focalin XR can be addictive and has abuse potential.  In light of these safety concerns, the patient should not exceed 20mg of Focalin XR per day and should not use any additional type of dexedrine compound with the mediciation. For the reasons stated above, I have determined the requested dosage 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 male with a history of head and neck pain.  He had two standard physical therapy sessions and was then prescribed an exercise program. The patients symptoms were not relieved, and his provider prescribed daily PT for approximately two weeks, without manipulation. The patient indicated he was required to go out-of-plan in order to find a provider for the prescribed therapy. He is now requesting reimbursement for therapy provided from early February 2006 through late February 2006.  The Health Plan determined the therapy was not medically necessary and denied his request.The purpose of skilled physical therapy is to provide a short-term therapeutic intervention and to devise and teach a home exercise program.  The patient participated in the therapy, received appropriate instruction and had a home program to assist in the management of his neck pain due to osteoarthritis. The additional physical therapy was maintenance in nature, and not likely to improve the patients condition/function in a more reasonable or predictable time period than with continued compliance with a home exercise program taught by a physical therapist.Based upon the information set forth above, I have determined the therapy at issue was 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 female and has severe left leg and left torso lymphedema as a consequence of a pelvic lymph node dissection for advanced ovarian cancer.  Lymphedema secondary to extensive lymph node dissections for cancer tend to be the most severe cases of lymphedema.  There is documentation that the patient has had an adequate trial of other standard therapies including include wraps, compression stockings and garments, and manual lymph drainage with overall poor response. At issue is whether the Flexitouch Lymphedema System is medically necessary for treatment of the patients condition.The submitted clinical information indicates the patient has failed an adequate trial of conservative therapies.  There is extensive documentation of her prior therapies.  It might be expected that these therapies would not be successful, given the proximal nature of her lymphedema onto her trunk.  It is very difficult to apply compression to these areas.  The Reid Sleeve suggested by the Health Plan is essentially another form of static compression, which would not have any significant advantage over the previously tried wraps and compression garments. The FlexiTouch Lymphedema System has the advantage of being a dynamic pumping system that provides pumping and compression to all areas affected by the lymphedema including the proximal thigh, groin, and trunk.  It is generally accepted that lymphedema pumps are indicated when other therapies have failed. Therefore, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 61-year-old male who is status post CVA with left hemiplegia, shoulder pain and disuse atrophy.  Conventional treatment such as medication and taping of the shoulder joint have not effectively eliminated his symptoms.  The patient has requested reimbursement and prospective authorization for continued use of the neuromuscular stimulator. The Health Plan denied his request based upon a determination that the device is not medically necessary.The safety and efficacy of the neuromuscular stimulator for the management of extremity and joint pain and disuse atrophy following CVA has not been established. No prospective study has been conducted to support its general use. There is no peer-reviewed evidence that the use of a neuromuscular electrical stimulator is likely to result in an improved clinical outcome for this patient. Therefore, I have determined the device at issue was/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 25-year-old man diagnosed in September 2005 with metastatic desmoplastic small round blue cell tumor. His disease was primarily intra-abdominal/pelvic, though a supraclavicular lymph node biopsy revealed metastatic disease. He was seen and evaluated by a medical oncologist and received six cycles of chemotherapy of alternating CAV and IE. Repeated radiologic imaging demonstrated a partial response, with residual pelvic disease encasing and obstructing the ureter causing hydronephrosis.The patient was seen by an in-plan surgical oncologist in April 2006 who did not recommend surgery, stating that it would only determine whether there was residual viable cancer and that surgical excision of residual disease would not improve survival or provide a cure. He recommended observation with repeat radiologic imaging, and resumption of chemotherapy if the tumor progressed. The patient was then seen in April 2006 by an in-plan urologist who felt that surgery was feasible, but without impact on survival. The urologist stated he would consult with the urological oncologist and get back to them.The patient sought non-plan consultation at a major cancer center in March 2006 and repeated radiologic imaging (CT and MRI) were obtained.  He consulted with the non-plan urological oncologist in May 2006. The urological oncologist proposed surgery based on similar treatment recommendations in diseases such as PNET and Ewings sarcoma, and the patient underwent pelvic surgery in May 2006 to remove all residual tumor.The patient has requested reimbursement for the surgery performed at the major cancer center, which has been denied by the Health Plan. The Health Plan indicates a surgical consultation was scheduled for the patient in May 2006.Desmoplastic small blue round tumors are an unusual malignancy. Because of the rarity, optimal treatment has not been determined. Treatment is often provided based on outcomes of similar types of tumors, such as PNET and Ewings sarcoma. Thus, the patient was treated with CAV alternating with IE.  On the issue of surgery, an expert opinion from a major cancer center would have been very valuable early in the course of the patients treatment, as neither the in-plan urologist or the in-plan urological oncologist were prepared to provide surgical intervention. As such, the patient independently sought consultation and treatment recommendations from a major cancer center. Surgical resection can provide local disease control and perhaps a survival benefit in selected patients who respond to the systemic therapy and demonstrate disease control, but still harbor minimal residual disease. The surgical services provided by the urological oncologist at the major cancer center were therefore medically appropriate given the status of the patients disease. Based upon the information set forth above, I have determined the services at issue were 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

This patient is a 60-year-old postmenopausal female with a diagnosis of osteoporosis confirmed by a bone density study. Past treatment and prevention has included estrogen, Miacalcin, Fosamax and IV pamidronate, which was first administered in August 2004.  The frequency of her pamidronate infusions is not specified in the record provided.  The patient has not tolerated oral bisphosphonate, Fosamax, which caused oral ulcers. The IV infusions of pamidronate have been well tolerated.  The patients request for continued authorization of IV pamidronate was denied based upon the Health Plans determination that the therapy is not medically necessary to treat her osteoporosis.Pamidronate is not FDA approved for the treatment of osteoporosis; its approval is limited to specific applications in the oncology setting or for the treatment of Pagets disease. This medication has been associated with renal toxicity, osteonecrosis and low white blood cell counts. The FDA recently approved IV Boniva (ibandronate) for the treatment of osteoporosis. Quarterly IV Boniva has been shown to be effective in the treatment of osteoporosis and the prevention of vertebral and non-vertebral fractures. There is currently an FDA approved intravenous alternative to pamidronate that has been shown to be safe, effective and generally well tolerated. 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 59-year-old female with a history of neck pain for many years. She had a C5-6 fusion and achieved 99% relief until August 2003 when she developed axial pain. The patient had an MRI at that time and was told, everything looks good. The patient was treated with bilateral shoulder trigger point injections and her shoulder pain improved, but her neck symptoms continued. The patient was also treated for lower back and right lower extremity pain in early 2006.The patient reportedly developed vertigo and headaches in February 2006, which persisted with radiation to the left scapula, and upper extremity.  The symptoms were reported to worsen and an MRI was apparently ordered by another of the patients long-term providers due to concern(ed) about possible complications in view of the abrupt onset of the patients symptoms.  The patients orthopedic provider reviewed the MRI of the cervical spine done in March 2006 and provided additional injection treatments.  The patients request for reimbursement for the cost of the MRI was denied by the Health Plan citing a lack of medical necessity.A review of the medical records provided indicates the patient had a relatively sudden onset of neurological symptoms, which worsened over the course of several weeks.  In light of her previous cervical fusion, an MRI was appropriate for a more complete evaluation of her symptoms before proceeding with additional treatment.  Therefore, I have determined the MRI at issue was 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

This patient is a 38-year-old female with active Crohns disease. She has been treated with 6-MP, Azulfidine and Remicade. Although she responded positively to Remicade, she apparently experienced a hypersensitivity reaction and continued treatment is contraindicated. The patients provider has requested authorization for treatment with Humira. The Health Plan denied the request citing a lack of medical necessity.The patient continues to have flares of her Crohns disease despite treatment with all of the commonly prescribed medications. Although Humira has not been approved by the FDA for the treatment of Crohns disease, it has been used in multiple clinical trials with good results. Treatment with Humira is a reasonable alternative to total colectomy, and the patients clinical history suggests that it will be effective.  Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.