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

The patient is a 50-year-old female who has a body mass index (BMI) of 47. She has co-morbid conditions including diabetes type II, degenerative joint disease, obstructive sleep apnea, asthma, hypertension, hyperlipidemia, gastroesophageal reflux disease, depression and anxiety. The patient is status post gastric stapling approximately 20 to 27 years ago. The previous surgery resulted in significant weight loss, which was not sustained. She has also attempted multiple other weight loss modalities without long-term success. The patient now wishes to undergo Roux-en-Y gastric bypass.With a BMI of 47 and significant co-morbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. The failure of the patients prior stapling procedure does not preclude revisional bariatric surgery. It is highly likely the proposed Roux-en-Y procedure will be beneficial for this patient. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. Therefore, I have determined that 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: Upheld Decision of Health Plan

The patient is a 43-year-old with an eight-month history of Dupuytrens contracture in his left hand. The patient believes Kenalog injections are the most appropriate therapy for treatment of his condition. The patient has been evaluated by a number of providers who have not recommended Kenalog injections. The Health Plan has denied authorization for the requested therapy.The Health Plans denial should be upheld. There is no scientific evidence demonstrating Kenalog injections are beneficial for treatment of the patients condition. Kenalog injections are not considered standard of care for treatment of Dupuytrens contracture. Furthermore, there are standard available treatments that are known to be effective for treatment of the patients condition. 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 50-year-old man with a history of plantar fasciitis, Achilles tendonitis, and calcaneal bone spurs. He underwent extracorporeal shock wave therapy (ESWT) in May 2005.  He is requesting reimbursement for the procedure. The Health Plan has denied the patients request on the basis ESWT was not medically necessary for treatment of the patients condition.There have been no long-term, prospective studies published that support the benefits and effectiveness of ESWT, and the long-term risks of the procedure are unknown. There is no proven benefit for ESWT over standard care therapies. As such, there was no medical justification for ESWT for treatment of the patients plantar fasciitis and Achilles tendonitis. Accordingly, I have determined the procedure 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: Upheld Decision of Health Plan

The patient is a 68-year-old male enrollee with chronic obstructive pulmonary disease and asthma. He received symptomatic relief with the use of a nebulizer.  Primarily because of his travels, he requires a portable battery-powered nebulizer. He has requested reimbursement for a portable nebulizer from this Health Plan. The Health Plan provides coverage for standard portable nebulizers. The Health Plan has denied the reimbursement request for the battery-powered nebulizer. The patients available history affords no mention of his current condition or the overall severity of his asthma. There is no mention of the specific reason the patient uses a nebulizer in preference to the more standard metered dose inhaler (MDI). The standard of care for asthma is to use rescue therapy for management of acute symptoms. Generally, it is no longer advocated to use short acting bronchodilators for maintenance therapy. In terms of efficacy, the nebulizer affords no advantage over MDIs. Generally MDIs are preferred due to their portability and availability for acute symptoms. In this situation, the enrollee has overcome this obstacle by using a battery-powered portable nebulizer. Unfortunately, the clinical history makes no mention of why the patient is managed with a nebulizer in preference to an MDI. The Plan covers a portable nebulizer; it is not the battery-powered unit purchased by the patient. There is no dispute that rescue therapy is medically necessary and must be available when symptoms present. Therefore, portability is important and medically necessary. However, there is no evidence that the patient required a battery powered nebulizer or that he could not have been safely and effectively treated with appropriate alternatives. Because there is no evidence that alternative treatments were contraindicated, I have determined the equipment at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a three-year-old female with a history of recurrent otitis media. She is also status post ear tube placement with continued drainage and ear infections after the tubes fell out. The ear, nose and throat physician documented continued fluid behind the eardrum. Audiology has documented a decrease in hearing from the right ear. The patient has speech delays documented by a speech therapist.At issue is whether continued speech therapy is medically necessary for treatment of the patients condition.The Health Plans denial should overturned. Given the patients documented oral and hearing loss, speech therapy is medically necessary and indicated. In light of the documented delays, speech therapy is also restorative. Furthermore, based on the patients response to therapy to date, she is likely to benefit from continued therapy. As such, I have determined the patients condition is medical in nature and therefore, 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 54-year-old female with a family history including one aunt with breast cancer at age 40, a father with melanoma, and a mother with pancreatic cancer.  She had a mammogram and ultrasound of the breasts in December 2004. The results indicated slight breast tissue asymmetry and three small benign appearing nodules in the left breast.  A six-month follow-up exam was suggested. The patient recently underwent removal of breast implants and bilateral mammoplasty. The tissue removed during this procedure showed no evidence of malignancy.  Since the surgery, the patient has developed firmness around the left nipple areolar complex. A repeat mammogram and ultrasound showed no distinct mass.  The clinical assessment was probable fat necrosis. A fine needle aspiration biopsy showed cell atypia and suggested additional tissue would be helpful for a definitive diagnosis of atypical hyperplasia vs. low-grade CDIS.   The patients clinician indicated that a repeat biopsy for more tissue would be needed and ordered an MRI, which was denied by the Health Plan on the basis it was not medically necessary.There are several indications for an MRI of the breast with malignant disease including: the pre-operative extent of the cancer, identification of post-operative residual cancer, the extent of lobular cancer, identification of occult primary cancer with positive axillary lymph nodes, screening of high risk patients, or problem solving. The evaluation of breast implants is an indication for MRI with non-malignant disease. High-risk patients are those with a personal history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene. This patient does have a family history of cancer but no clear genetic predisposition.  She is not considered at high risk for breast cancer and therefore MRI breast screening is not indicated.  Additionally, if indeed the patients left breast abnormality is fat necrosis, an MRI could be misleading.  Fat necrosis can enhance and create a false positive result. As the patients provider has suggested, a repeat biopsy, preferably a core biopsy, for more tissue is warranted and will most likely provide a definitive diagnosis. There is no clinical indication for a breast MRI at this time. Therefore, I have determined the requested MRI is 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 15-year-old male with a diagnosis of cerebral palsy with spastic quadriplegia. He underwent a dorsal rhizotomy in 1997. He has also been receiving Botox injections to the lower extremities. He has been receiving physical therapy once a week because of a regression in ambulation skills. Most recently he has been using a Lite Gait and Gait Keeper as equipment to improve his skills. The patients provider has documented the gains the patient has achieved while utilizing this equipment. The Health Plan has denied coverage for the Lite Gait and Gait Keeper.A review of the literature regarding locomotor therapy and assisted training demonstrates there is evidence supporting such therapy for patients with cerebral palsy. There is also significant support for utilizing such therapy in the stroke population. Furthermore, the patients records demonstrate the equipment is designed for repeated use, is being used to treat and to improve functioning and to prevent further deterioration of the patients medical condition. Moreover, there is evidence that the equipment has benefited the patients condition. Therefore, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 60-year-old male with prostate adenocarcinoma. In September 2004, a prostate biopsy revealed Gleason 3+3=6 adenocarcinoma on the left side of the prostate gland. In October 2004, a bone scan was negative for metastatic disease. In May 2005, a repeat prostate biopsy revealed Gleason 3+3=6 adenocarcinoma of the left side of the prostate gland at the apex and mid-gland. In July 2005, a CT scan of the pelvis revealed prostatic enlargement with calcification. The patient elected to proceed with proton beam therapy. The Health Plan had recommended alternative treatment including external beam radiation therapy, brachytherapy, and radical prostatectomy. The Health Plan has denied reimbursement for the proton beam therapy.Based upon the patients relatively low PSA  ranging from 2.3 to 5.6  the cancer appears to be localized to the prostate gland itself representing a potentially curable cancer. The patient chose to proceed with proton beam therapy. The Health Plan offered the patient appropriate alternative treatments. Based upon current peer-reviewed literature, there are no randomized controlled trials demonstrating proton beam therapy is superior to other forms of conformal external beam radiation therapy. Therefore, because the Health Plan offered the patient appropriate treatment alternatives, there is no evidence that proton beam therapy was medically necessary for this patient. As such, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 57-year-old man with a lesion in the talus. A request has been made for an osteochondral allograft transfer system (OATS) procedure. The Health Plan has denied authorization for the proposed procedure on the basis it is considered investigational for repair of an ankle joint.The OATS procedure has been very successful in the knee and recently has been utilized in the ankle for situations such as these. There are no other options for the patient; the procedure is likely to provide pain relief and help to prevent the need for fusion. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: This patient is a 57-year-old male with an osteochondral lesion of the right medial talar dome, which is greater than 1 cm in size. The patients provider has recommended an osteochondral allograft transfer system (OATS) procedure. The Health Plan has denied authorization for an OATS procedure on the basis that it is considered experimental.There is sufficient data to support the OATS procedure in the talus for lesions greater than 1 cm such as the one involved in this case. There is also ample short-term ankle literature supporting the OATS procedure. Given the large size and advanced stage of the patients lesion, he is an excellent candidate for the OATS procedure. The requested procedure is likely to provide the best chance of a positive outcome for this patient. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 57-year-old male with a significant osteochondral lesion in the talus from which the patient is very symptomatic. It has been recommended the patient undergo an osteochondral allograft transfer system (OATS) procedure. The Health Plan has denied authorization for the requested procedure on the basis it is not likely to be effective in patients such as this patient.The talar lesion will most likely lead to significant arthrosis of the ankle from which the patient will likely experience pain, stiffness and disability. Drilling and bonegrafting are associated with unpredictable results that are usually far from satisfactory outcomes. Osteochondral bone grafting is the only procedure that has a reasonable chance of restoring articular integrity. Ankle fusion is a major operation with significant morbidity that does nothing to preserve or restore function. Since the OATS procedure has the greatest likelihood of restoring normal ankle function, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old female with multiple sclerosis and generalized muscle stiffness. She also has chronic neck pain and stiffness. She has failed physical therapy and is now seeking authorization for massage and aquatic therapy. The Health Plan has denied authorization for the requested therapies.The Health Plans denial should be upheld. Massage therapy is not medically indicated for this patient. Although it may provide short-term passive pain relief, it will not improve or benefit the patients condition in the long-term. Likewise, aquatic therapy is unlikely to provide improvement in the patients condition particularly in a patient such as this who underwent, tolerated, and failed traditional physical therapy. Because there is no evidence the requested therapies would provide sustained benefit for this patients condition, I have determined the requested therapies are not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This case concerns a 12-year-old girl with idiopathic short stature. Her mid parental height was 160 cm (63 inches). Her recent bone age was 10 years giving her an adult height prediction in the range of 5.05 to 51.5. Recent height velocity is 3 cm per year. The patient had a workup for other causes of short stature demonstrating normal TSH, IGFBP-3 and IGF-1 levels and a normal karyotype. She was said to be beginning pubertal development. A request has been made for authorization and coverage for growth hormone therapy. The Health Plan has denied this request on the basis it is not medically necessary for treatment of the patients condition.The literature cited documents the efficacy of growth hormone therapy for children with short stature. These findings led to the FDAs ruling in July of 2003 that growth hormone therapy was indicated when a childs height is 2.23 standard deviations below the mean and that child would be judged unable to achieve a normal adult height.  In this case, the patients height prediction places her in the low-normal adult range for women but shorter than her potential height. The studies cited supersede the Lawson-Wilkins guidelines of 2003 and document that adult height can be safely advanced in idiopathic short stature (ISS). A growth hormone trial is medically reasonable and appropriate in this instance.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old male with a body mass index (BMI) less than 50. The patient also had a number of comorbid conditions including depression, degenerative joint disease, hypertension, hyperlipidemia, gastroesophageal reflux disease and sleep apnea.  In December 2004, the patient underwent Lap-Band surgery. The Health Plan has denied reimbursement for this procedure.Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and was not indicated in this case. Therefore, I have determined that the procedure 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 62-year-old female who has had a compression fracture of L1 and a right wrist fracture. She was in a great deal of pain after the injury and was unable to sit or stand. She underwent a course of physical therapy before being discharged from the hospital. She has very limited mobility. However, limitation status at time of discharge is unclear. After being discharged, the patient obtained a hospital bed and bedside commode.  The Health Plan has denied reimbursement for this equipment on the basis it was not medically necessary for treatment of the patients condition.The patient did not require a bedside commode per the records provided. Ambulation is an essential part of recovery from a vertebral fracture. Ambulating to the toilet is an important element of recovery. Thus, use of a bedside commode was not medically indicated or in the best interest of the patient. However, patients such as this patient often benefit from use of a hospital bed as the bed aids in mobility and pain management. Vertebral fractures are very painful and patients often require skilled nursing facility care. In this case, use of a hospital bed likely helped avoid a stay in a skilled nursing facility. As such, I have determined that although the bedside commode was not medically necessary for this patient, the hospital bed was medically necessary and should be covered by the Health Plan.As set forth above, I have determined that a portion of the equipment at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 46-year-old female with a history of chronic pancreatitis and also constipation. An ERCP with sphincterotomy was performed, which showed evidence of sludge in the GB. The patients constipation has also been worked up with defecography and anal manometry. Apparently, the patients constipation has been worse since her ERCP. A request has been made for authorization for an endoscopic ultrasound, which was denied by the Health Plan on the basis it is not medically necessary for evaluation of the patients condition.Based upon the information provided, it is not clear whether an endoscopic ultrasound is being requested for workup of the pancreas or the anal canal. A detailed consultation by the patients provider regarding the patients constipation does not indicate an ultrasound was being considered for anorectal sphincter. If the endoscopic ultrasound has been ordered for evaluation of the patients pancreas, an ERCP has already been performed and no specific abnormalities were discussed regarding the pancreas. The typical presentations of chronic pancreatitis are also not present. The submitted evidence includes no report of pancreatic enzymes being tried. Furthermore, there is no evidence a MRCP has been performed or that there has been further evaluation of CBD and the pancreatic duct. Based on the clinical information provided, there is no objective evidence that an endoscopic ultrasound is medically necessary for this patient at this time. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 22-year-old female with chronic sinusitis and orbital headaches for six months with no improvement in her condition despite multiple courses of medications including Allegra, Biaxin, and Flonase. The patient is seeking a CT scan of the sinuses. The Health Plan has denied this request.The Health Plans denial should be overturned. The patient has a history of chronic symptoms despite repeated courses of antibiotics. Based upon the information provided, the treatment the patient has received to date was appropriate and indicated. Because the patient has not received relief from treatment, a CT scan of the sinuses is indicated to assist in evaluation and treatment of the patient. The results of the CT scan will impact the patients future treatment plan. Therefore, I have determined the requested CT scan is medically necessary for evaluation of the patients condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 20-year-old female with myofascial pain and trigger point syndrome. She has requested authorization and coverage for Botox injections to her trigger points. The Health Plan has denied the request indicating the requested therapy is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Botox is currently FDA-approved for treatment of dystonia, spasticity, and blepharospasm. There are no peer-reviewed reports demonstrating long-term efficacy or safety of Botox for treatment of trigger point injections in cervical dystonia or myofascial pain syndrome. As such, conservative treatment modalities are likely to be more effective than Botox for treatment of the patients chronic pain. 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.