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

The patient is a 15-year-old female with markedly short stature. She has been on growth hormone therapy since the age of 13. According to her physicians note of November 2003, the patient was 39.25 inches and had a bone age of 11 years. Her predicted adult height at that time was estimated at 54.1 inches. She had received Ritalin and Strattera in the past. Her endocrine workup excluded GH deficiency and primary ovarian failure of Turners syndrome. She was noted as having a goiter, but thyroid function tests results have not been provided. Growth hormone therapy was subsequently initiated at the age of 13. In March 2006 the patients height was noted as 55.75 inches, indicating a positive response to GH therapy. At issue is whether growth hormone therapy is medically necessary for treatment of the patients condition.The Food and Drug Administration has approved growth hormone for the treatment of idiopathic short stature as a medically indicated therapeutic intervention to promote growth velocity and final adult height. The submitted clinical information indicates the patient has had a significant growth response since GH therapy was initiated. While the patients presentation is consistent with idiopathic short stature, thyroid functions tests have not been provided to rule out other possible causes for her delayed growth. Therefore, I have determined that GH therapy is medically necessary depending upon the results of thyroid function testing. The Health Plans denial should be overturned. If there is evidence the patients thyroid function is normal, GH therapy should be authorized/covered. If there is not evidence the patients thyroid function is normal, the GH therapy should not be authorized/covered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a seven-year-old female with a diagnosis, by mothers report, of pervasive developmental disorder.  She has related speech deficits including pragmatic speech delay.  The patient scored two standard deviations below the mean (fifth percentile) in two subtests of the CLEF-4 (concepts and following directions and recalling sentences) and is eligible for speech therapy through the school system.  The patient has been receiving private speech therapy where the CLEF-4 was also administered. That testing report appears to be associated with an evaluation dated January 2006, but the report itself is not dated. The patient had lower scores for formulated sentences and word structure with the earlier test administration. The patients parent has requested authorization for continued speech therapy. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.In reviewing the patients private speech therapy progress notes and evaluations, I cannot discern functional gains or apparent improvement. Specifically, the Objectives as outlined in the progress summary and treatment plan dated January 2006, are identical to the objectives outlined in the November 2005 treatment plan.  Most of the objectives appear to have been achieved prior to January 2006 and the remaining goals show no incremental increase in the progress made. As such, the functional gain essential to a determination of medical necessity, cannot be established.Based on the evidence cited above, 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 10-year-old male who has a probable diagnosis of Aspergers syndrome with Learning Disability and ADD/ADHD.  He has been treated with stimulants for over two years and his parents report that weight loss and serious side effects occurred.  A trial of a non-stimulant medication resulted in paranoia. The parents state that the patient needs medication for the symptoms of ADD/ADHD and Provigil was tried in an off-label application and found to be effective. The parents have requested authorization for continued treatment with Provigil. The Health Plan denied their request based upon a determination that the medication is not medically necessary.It is not uncommon to find symptoms of ADD or ADHD in a child with a possible diagnosis of Aspergers syndrome. The majority of these children respond to stimulant medication or a combination of stimulant medication and other medications such as Tenex or Clonidine.  As with this patient, the use of Strattera is often complicated by side effects and is not recommended as the treatment of first choice.  Stimulant side effects can usually be controlled by modification of the drug dosage.  The off-label use of a medication such as Provigil that has not been found to be safe or efficacious in this setting, is not the standard of care in the community.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old man has multiple pigmented skin lesions, at least some of which are on his abdomen and right arm. The patient has requested that his moles be evaluated by a dermatologist. The Health Plan denied this request indicating that evaluation and treatment by a dermatologist is not medically necessary because the patient can be sufficiently treated by his primary care physician.Generally, dermatologists are better qualified and more knowledgeable and experienced in treating skin cancers and evaluating possible skin cancers. Though the Health Plan indicates that evaluation and treatment of dermatologic disorders, as well as skin surveillance for skin cancer, are within the scope of practice and clinical expectation of a primary care physician, there is no evidence of peer-reviewed studies supporting this contention. Consultation with a dermatologist for evaluation of the patients moles is medically reasonable and indicated. If the dermatologist determines excision/biopsy is appropriate, the Health Plan should provide authorization for these services to be performed by the dermatologist. Therefore, I have determined that the requested consultation 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 five-year nine-month old female with a history of developmental delays including expressive and receptive language delays. She has been receiving speech therapy since April 2005.  She has had various diagnoses including ADHD and autism.  Formal testing to demonstrate the diagnosis on the autism spectrum is not included in the information provided. Documentation from the therapist states the patient was evaluated at an autism clinic in January 2005, but she was not given a diagnosis of autism. The report goes on to state that a neurologist diagnosed the patient with a severe expressive language disorder and ordered an MRI and EEG.  No test results have been provided.  It is noted that the patients brothers also had speech and language delays.  At issue is whether continued speech therapy is medically necessary for the patients diagnosis.Based upon the documentation provided, the patients specific diagnosis is unclear (other than expressive and receptive language delay).  Three different therapists have provided reports for this patient. The goals are altered slightly with each evaluation, making it difficult to determine if the original goals have been achieved.  In any event, the goals listed are considered educational in nature. Given the absence of a clear diagnosis and the educational nature of the goals, 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 74-year-old male who was admitted to a skilled nursing facility (SNF) for rehabilitation and wound care after an acute hospital stay for congestive heart failure and COPD. In May 2006, his wound was documented as 1.1cm by 1.0cm in size and the wound care involved cleansing with normal saline and the application of a dry dressing and foam padding. The patient was functionally impaired, requiring caregiver assistance or stand-by assistance with bed mobility, transfers and ambulation. The patient has requested authorization for continued care at the SNF.  The Health Plan denied the request based upon a determination that continued SNF services are not medically necessary.By the end of May 2006, the patient had improved significantly.  He had progressed to the point that he was independent or moderately independent with bed mobility, transfers, ambulation and navigation of stairs (two) and was able to ambulate 250 with a front wheel walker.  His wound was described as 0.4cm by 0.5cm in size with a red wound bed and surrounding skin areas in May 2006.  The Panafil ointment for debridement was discontinued in May 2006. There is no depth measurement or wound staging documented and no wound assessment after May 2006.  The patient was taking oral nutrition and was described as having an increased energy level.  His wound was small and the relatively simple wound care could have been performed at home if continued care was needed.  The patient was appropriate for discharge home by the end of May 2006.Based upon the information set forth above, I have determined the requested services are 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 72-year-old male with a synovial cyst and foraminal stenosis. He has low back pain radiating to the lower extremities. He and his provider have requested authorization and coverage for X STOP decompression surgery. The Health Plan has denied this request on the basis that the requested procedure is considered experimental/investigational.Although X STOP decompression is a novel, minimally invasive approach to decompression surgery, it has not yet been proven to be as or more efficacious than traditional decompression surgery. Long-term safety studies and re-operation rates have not been confirmed. At this time, traditional decompression surgery is still the standard of care surgical option for the treatment of spinal stenosis. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2:  The patient is a 72-year-old male with degenerative spinal stenosis at L4-L5 and L5-S1. He has attempted multiple conservative therapies without sustained relief. The patient is requesting authorization for a two-level X STOP implantation procedure. The Health Plan indicates there is insufficient evidence demonstrating the efficacy of X STOP implantation at this time.The X STOP procedure is still experimental as long-term follow-up data is not yet available. Also, the short-term data does not demonstrate that the success rates are better than conventional lumbar laminectomy, which is the gold standard procedure in this setting and is safe and effective. Since no data exists to suggest that X STOP is superior to conventional laminectomy decompression surgery, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3:  The patient is a 72-year-old male with lower back pain with radiation to his buttocks and thighs bilaterally. Conservative treatment and a laminectomy in 2002 at L5-S1 have not relieved his symptoms. MRIs performed in December 2005 and February 2006 showed degenerative changes and a large facet synovial cyst at L4-5 on the right with neural foraminal stenosis at L5-S1 on the right. Bi-level X STOP implantation surgery has been recommended. The Health Plan considers this procedure investigational and therefore has denied coverage. A pre-market approval application for the X STOP device was filed in January 2004 and the outcome results are being collected as required. At this time the procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. As such, the procedure cannot be recommended at this time. Accordingly, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 46-year-old male with muscular dystrophy and respiratory failure after an episode of pneumonia. He is now on ventilation and can be off the ventilator for a few hours per day. He is tolerating a portable (home) ventilator. Family members have demonstrated the ability to suction and bag with the ventilator. The patients family has requested authorization for home health care services. The Health Plan has determined that discharge to home is not medically appropriate or safe and therefore has recommended placement in a sub-acute facility. There is no data in the records indicating the patient cannot be adequately cared for in an in-home setting. Sub-acute care is not inherently safer or superior to at-home care, especially if the family is appropriately trained. The submitted evidence demonstrates the patients family has received caregiver training and the patient is able to tolerate home ventilation. He is receiving tube feedings. The evidence provided does not identify specific safety concerns necessitating sub-acute care. As such, home health cares services are medically appropriate and should be authorized by the Health Plan. Based upon the information set forth above, I have determined the requested services are 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 53-year-old male with adenocarcinoma of the prostate, reported as clinical stage T1c. In March 2006 his PSA level was 4.9. An ultrasound guided biopsy was performed in April 2006 and one of the five cores from the left side of the prostate revealed a Gleason score of 3+3 (total 6) adenocarcinoma of the prostate; the five cores from the right side were benign.  Surgical treatment with radical prostatectomy was recommended. The Health Plan offered either open radical (retropubic) prostatectomy or laparoscopic radical (retropubic) prostatectomy.  The patient requested authorization for a laparoscopic radical (retropubic) prostatectomy with robotic assistance performed by a non-Plan provider.  The Health Plan determined the robotic assisted procedure was not medically necessary, and denied the request.Radical prostatectomy is the appropriate surgical treatment for a 53-year-old male with clinical state T1c prostate adenocarcinoma, a Gleason total of 6, and a PSA of 4.9.  This would typically represent a localized prostate cancer that can be cured with surgical removal. There are currently four acceptable and recognized surgical approaches for removal of a localized prostate cancer. They are:1.Open radical (retropubic) prostatectomy;2.Laparoscopic radical (retropubic) prostatectomy;3.Robotic assisted laparoscopic radical (retropubic) prostatectomy; and 4.Radical (perineal) prostatectomy.All of these techniques offer good results in terms of complication rates and survival statistics when capably performed by a qualified and experienced surgeon.  It should be noted however, that truly long-term outcome data for the laparoscopic surgeries, whether robotically assisted or not, are not yet available.  There is no medical basis for objection to any of these surgical approaches, and each has its advocates and relative advantages. In terms of complication rates and survival statistics, the two surgical alternatives offered by the Health Plan, open radical (retropubic) prostatectomy and laparoscopic radical (retropubic) prostatectomy (without robotic assistance), are fully acceptable alternatives to the laparoscopic radical (retropubic) prostatectomy with robotic assistance requested by the patient. Therefore, I have determined laparoscopic radical (retropubic) prostatectomy 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 52-year-old male with previously diagnosed bipolar disorder and cocaine dependence.  He was admitted for inpatient treatment in April 2005 after four days of heavy cocaine use and a subsequent escalation of dysphoria and mania.  The patient had previously been treated as an inpatient for approximately 10 days and was thought to be stabilized on a regimen of lithium, Lamictal, and Seroquel. At the time of this admission he presented as belligerent, agitated, and hyperactive.  He had poor concentration but was not delusional. The patient expressed feelings that life was not worth living and verbalized his regrets regarding the loss of personal and business relationships.  He was again treated with lithium, Lamictal, and Seroquel.  He required prompting to attend group therapies, and the progress notes indicate he was frequently absent from group participation.  The patients provider tried to obtain an LPS conservatorship for him but failed; the patient was discharged to a clean and sober living residence in May 2005.  His last measured lithium level was 1.0 in April 2005 and his discharge medications included lithium 450mg three time per day and 300mg at bedtime, Lamictal 25mg in the morning and 50mg at bedtime, and Seroquel 100mg at bedtime.  The patient has requested reimbursement for the inpatient hospitalization provided in May 2005. The Health Plan denied his request based on a determination that the services were not medically necessary.The patient clearly suffers from bipolar disorder and cocaine dependence. His demeanor was rather belligerent and entitled, but this does not equate to a need for extended hospitalization. There were no indications of suicidality after his first few days as an inpatient, and in general he avoided group therapies.  He appeared readily capable of arranging for a clean and sober residence in early May 2005.  By that time he was tolerating his medications well and his April 2005 lithium level was entirely therapeutic.  By early May 2005 the patient could have reasonably transitioned to a lower level of care.Based upon the information set forth above, 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 10-month-old male with documented deformational plagiocephaly and mild torticollis. He was evaluated by neurosurgery and treatment with cranial orthotic therapy was recommended. The patients parents have requested authorization for the cranial remolding orthosis. The Health Plan denied their request based upon a determination that the device is not medically necessary.Since it is now recommended that infants sleep exclusively on their backs, plagiocephaly is becoming more common. Although conservative positional treatment is effective in many cases, the use of a cranial remodeling orthosis is required with more severe problems. This patient has been properly evaluated by neurosurgery and given this his significant deformational plagiocephaly and torticollis, cranial remodeling therapy is medically reasonable and appropriate. Therefore, I have determined the device at issue 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 61-year-old female with profound congenital bilateral hearing loss.  She has undergone cochlear implantation to her right ear and gained benefit from the device.  Hearing from the left ear, which was initially the better hearing ear, has declined over time and there is now no useful hearing obtained through the use of a hearing aid. The patient has requested authorization for left-sided implantation with the goal of binaural hearing.  The Health Plan has denied her request based upon a determination that a second cochlear implant is not medically necessary.When a patient with hearing loss presents for evaluation, the standard of care is to fully evaluate and to derive options toward lessening this deficit.  When the hearing loss involves both ears and is so severe as to impair activities of daily living and communication, the accepted recommendation is to (hearing) aid both ears for optimum function.  This case is analogous except that the type and extent of the hearing loss is such that it cannot be improved with the use of hearing aids. There is increasing recognition in the current literature of the substantial benefit of bilateral cochlear implantation in helping to return and/or to allow a patient to lead a more productive and functional life.  Despite the right cochlear implant, the patient in this case is still limited in her ability to fully participate in functional communication and a second cochlear implant is likely to significantly improve her communication and listening skills.  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 48-year-old male with a leg length discrepancy and left lower extremity atrophy. He underwent a total hip replacement in February 2005, and following surgery had 73 sessions of physical therapy. The physical therapist outlined a treatment plan focused on increasing the range of motion, strengthening, and improving muscle imbalance, postural deficits, gait and pain control. Stretching, mobilization, exercises and other therapeutic modalities were used appropriately during the course of the patients therapy.   The patient has requested authorization for an additional course of physical therapy.  The Health Plan denied the request based upon a determination that additional therapy is not medically necessary.Although in February 2006 the patients provider did prescribe additional physical therapy for left leg muscle weakness, he did not indicate in what way the prior therapy had been inadequate or what new treatment modality should be employed with this additional therapy.  Appropriate back and leg exercises were incorporated into the previous course of physical therapy. It would appear that the patient has reached a plateau and there is no medical need for a repeat course of physical therapy.  At this point in time, the patient should be able to continue to work on the target muscle groups with a home exercise program. 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.