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

The patient is a 32-month-old male born full term. At five weeks of age he was hospitalized for fever and bloody diarrhea. He had delayed motor development with hypotonia at two months. He was not fixing or tracking appropriately. At four months, the patient was seen by a neurologist who documented truncal hypotonia and hyperreflexia as well as visual impairment. An MRI showed diffuse mild atrophy or underdevelopment of the brain. A second opinion regarding the MRI described delayed myelination. The most recent neurological exam in December 2004 was normal.The developmental pediatrician notes on the December 2004 evaluation the difficulty in the area of social communication. She has also noted difficulties with attention shifting and awareness of other interests. Despite these issues the pediatrician does not place the patients diagnosis in the autistic spectrum disorders. She has recommended completion of the medical workup to rule out other causes for the communication skill deficiency. She has also recommended twice weekly occupational therapy.At issue is whether twice weekly occupational therapy is medically necessary.There is insufficient literature to support or refute occupational therapy for children with developmental delay. Review of the patients history reveals documentation of delayed myeliniation and a neurological exam, which has progressed from truncal hypotonia, vision disturbances, hyperreflexia and significantly delayed fine and gross motor skills at four months of age, to a normal neurologic exam at two years of age. Based on the developmental pediatrician evaluation and occupational therapy evaluation in December 2004, the patient now has primarily educational/developmental issues. The delays in age appropriate ADLs appear to be related to the delay in maturation of his central nervous system (though, this is not to say they will resolve spontaneously) and to his delay in social communication. These issues are not historically considered medical in nature; prior to the age of three such issues fall under the auspices of a regional center, and after age three they are considered educational in nature. 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: Overturned Decision of Health Plan

The patients parents indicate the patient has been followed for asthma since 1994. The patient was seen by her provider in January 2002 and treated with multiple medications. The patient was signed up for a research study and provided with Foradil samples. The study was discontinued. In addition to treatment for asthma, the patient is receiving allergy injections prescribed by another provider. The patients parent indicates the patient was still having trouble with asthma and was using albuterol puffs more often than recommended, especially when exercising. The patients physician has indicated that the formulary equivalent, Serevent, has possible dangerous side effects A request has been made for authorization and coverage for Foradil, which has been denied by the Health Plan.Review of the submitted information indicates the patient has a documented history of urticaria and asthma, including exercise-induced symptoms.  The patient is involved in competitive long distance running. Although studies have indicated the danger of side effects for Serevent without the concurrent use of inhaled corticosteroid, the drug Foradil has the same potential for risk without the concurrent use of inhaled corticosteroid. However, studies have demonstrated the long-acting bronchodilator, Foradil has a more rapid onset of action and longer duration of action in the treatment of asthma. In addition, studies have demonstrated a greater improvement in airway resistance as compared to Severent.Therefore, in light of the advantages of Foradil, I have determined it is medically necessary for control of the patients exercise-induced asthma. As such, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old female who had a body mass index (BMI) of 36. She has had exacerbation of obesity related comorbidities including traumatic arthritis of the knee, and biopsy-proven reflux esophagitis. The patient tried and failed conventional weight loss therapies. Her degenerative joint disease made escalated exercise problematic. For these reasons, it was recommended the patient undergo gastric bypass surgery. The Health Plan has denied coverage for the procedure at issue on the basis it was not medically necessary.The patient had a BMI of 36 and documented comorbidities including hypertension, venous stasis, degenerative arthritis and esophagitis despite PPIs. While her knee degenerative joint disease was initially traumatic in nature, her excess weight caused acceleration of the arthritis. Though the patient had a BMI of less than 40, her comorbidities were severe enough to warrant weight loss surgery. The patient met nationally accepted criteria for weight loss surgery. Gastric bypass surgery was medically indicated and necessary for this patient as it was not likely she would have been able to lose weight and maintain the weight loss through non-surgical means. Therefore, I have determined the procedure 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 female. She has a history of alcohol abuse since the age of 19. Until recently, she reportedly had been drinking four beers and four shots of whiskey each day.  She mixed alcohol with Soma, taking 90 pills in a two-week period. The patient also abused Vicodin and over-the-counter cough syrup. She entered inpatient hospitalization for detoxification in March 2004, and was safe for a lower level of care in April 2004. She then entered a partial hospitalization program, for which she is requesting reimbursement. The Health Plan authorized 1 day of inpatient detoxification, 5 days of inpatient rehabilitation, and 17 days of intensive outpatient therapy.At issue is whether the services at issue were medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The patient was not diagnosed with a comorbid psychiatric disorder, and was not suicidal or psychotic during the period at issue. The records provided fail to demonstrate that partial hospitalization services were warranted. The care authorized by the Health Plan was medically reasonable and appropriate for treatment of the patients behavioral health problems. Therefore, I have determined that 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 three-and-a-half-year-old male diagnosed with autism who has had a regression of speech since the age of 18 months. As a function of his autism the patient has significant maladaptive behavior including severe perseverations, tantrums, and sensory-seeking behaviors including pelvic stimulation, spinning in circles, tilting his head, screaming, and jumping up and down. He was admitted to an early childhood partial hospitalization program in November 2004.Upon review of the multi-disciplinary progress reports, the patient has made excellent gains in his behavior. The Health Plan has recommended discontinuing the partial hospitalization program and beginning more traditional services provided by the school and regional center when available.At issue is whether continued partial hospitalization services are medically necessary for treatment of the patients condition.Though there is little scientific literature either in support of or against hospital-based programs for the treatment of autism, such programs are available and considered appropriate in situations in which extreme behavior are present. Such is the case with this patient. The recommendations of the patients treating physician and psychologist are to maintain the program until they complete training and have formalized the outpatient applied behavioral analysis program. Allowing the patient to return to the community without proper services in place is potentially harmful to the patient and would possibly allow the patient to regress. Therefore, the patient should complete the program and should be appropriately transitioned to an applied behavioral analysis program and school setting. 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 60-year-old woman with chronic daily headaches and underlying migraine. She has failed Inderal, Topamax, Depakote, Zanaflex, nortriptyline, Neurontin and Keppra. She responds to triptans. The patient was tried on Botox three times with very good results. The Health Plan has denied coverage for Botox indicating it is experimental.The patient has chronic daily headaches most consistent with chronic migraine as documented by the patients diary and treating neurologists notes. The patient has tried and failed over eight preventive therapies. The submitted notes demonstrate the patient had significant improvement in her headaches with prior use of Botox. Therefore, I have determined that the requested therapy 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: The patient is a 60-year-old female with chronic migraine refractory to multiple abortive/prophylactic medications as noted in the submitted records. She has responded to trials of Botox injections and wishes to continue treatment with Botox. The Health Plan indicates the efficacy of Botox has not been established in peer-reviewed literature.The submitted information indicates the patient tried a number of medications, which apparently were ineffective. Review of the neurological literature reveals the use of Botox for headache is common and widespread in the practice of neurology as it is very effective and well tolerated. Furthermore, there is evidence the patient has benefited clinically from Botox. Therefore, I have determined that the requested therapy 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 60-year-old female who has a history of migraines, now with chronic daily headaches. Several preventive medications have been tried without success including nortriptyline, Bellamine, Neurontin, Topamax, and Keppra. She has since been treated with Botox and is reported to have had improvement in her headache pain. The Health Plan has denied coverage for Botox on the basis it is considered investigational for treatment of migraines.This patient has refractory migraines. She has tried and failed more than three preventive regimens and needs abortive treatment with triptans. Excessive acute medication overuse can lead to rebound headaches. Review of the scientific literature demonstrates evidence exists that Botox can be beneficial for treatment of chronic daily headache and refractory migraines. Additionally, the patient has benefited from Botox. The likelihood of similar benefit with further trials of more preventive medications is low. Therefore, I have determined that the requested therapy 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: Overturned Decision of Health Plan

The patient is a 32-year-old female who underwent bilateral mammaplasty in 2004, which she states has left her with asymmetry of a significant degree. Her board certified plastic surgeon has requested authorization for revision of her reconstructed breasts. The Health Plan has denied the request indicating the requested procedure is not medically necessary as the documentation indicates that the likely intervention is for cosmetic reasons.Records reviewed include a frontal view photograph revealing recently operated upon asymmetric breasts. The records submitted note significant scars distorting the right breast. The proposed procedure would correct the patients asymmetry and address her scars. This evidence and other information provided demonstrates the requested procedure would be to correct or repair abnormal structures of the body caused by trauma or disease to create a normal appearance to the extent possible. Therefore, I have determined the requested procedure is reconstructive in nature and medically necessary. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old male with hepatitis B who was initially treated with lamivudine in November 2000. His viral count became detectable in February 2004 and he was placed on adefovir. After starting treatment with adefovir his liver enzymes and DNA level are negative. The patients provider has recommended the patient continue taking adefovir. The Health Plan has denied this request.The patient should remain on adefovir until his hepatitis B surface Ag converts to negative. There are many reports regarding the use and safety of adefovir for treatment of this patients condition. A recent report concluded that administration of adefovir in patients with lamivudine-resistant hepatitis B results in significant suppression of viral replication; however, continuous therapy will probably be required in order to maintain submission. Furthermore, discontinuing adefovir therapy could predispose the patient to fulminant hepatic failure. Based upon this information, I have determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This 53-year-old woman with multiple medical problems requests growth hormone (GH) for presumed adult GH deficiency (AGHD) based on non-specific symptoms and the response to an arginine/GHRH stimulation test. She has obesity with progressive weight gain and depression treated with Lexapro. She complains of muscle pain and weakness, poor sleep, fatigue, poor concentration, and decreased libido. She is post-menopausal and on large doses of thyroxine for presumed hypothyroidism.The evaluation by her endocrinologist revealed a normal MRI of the pituitary. An arginine/GHRH stimulation test revealed a normal peak GH of 11 ng/ml. She has a suppressed TSH presumably due to the large dose of thyroxine and has an elevated LH and FSH, a normal pituitary response to inadequate estrogen replacement in menopausal patients.There is no evidence of AGHD in this patient. The diagnosis is usually made based on the clinical context, which is suggestive of some disorder of the hypothalamic-pituitary axis. Other causes for the patients symptoms could be her depression, the medication used to treat her obesity, inadequately treated menopausal symptoms or latrogenic hyperthyroidism. These must be considered and treated before undertaking a course of testing for AGHD. All tested pituitary hormones and the IGF-1 appear normal in this patient. Her MRI shows no structural lesion in the pituitary. The GH response is said to be subnormal based on a cutoff that is derived from the literature using an immunoradiometric assay. Different published assays do not completely agree on the cutoff between normal and subnormal responses. The patients response is normal. The diagnosis of AGHD is based on the clinical context, signs and symptoms, as well as the results of biochemical testing. The patients signs and symptoms are sufficiently non-specific, and GH stimulation tests sufficiently inaccurate, that it is possible to have a false positive diagnosis. As such, there is insufficient evidence growth hormone therapy is medically indicated for this patient. 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: Overturned Decision of Health Plan

The patient is a 41-year-old female with a body mass index (BMI) of 44 and multiple comorbid conditions. She has requested authorization and coverage for gastric bypass with duodenal switch. The Health Plan has denied the request on the basis it is not medically necessary for treatment of the patients morbid obesity.The patient is an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. The literature shows that duodenal switch is a safe and effective form of weight loss surgery. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a five-year-old female with an articulation difficulty involving F, L, and S sounds. She was evaluated by a speech and language therapist who also diagnosed her with an auditory processing disorder. The therapist recommended speech therapy once a week to improve language and phonemes structure. At issue is whether the recommended therapy is medically necessary for the patients condition.The National Institute on Deafness and Other Communication Disorders (NIDCD) describes auditory processing disorders in basic terms. The NIDCD reports little research has been performed on these diagnoses, especially in the realm of treatment. To date, there is insufficient evidence speech therapy has a beneficial role in treating the patients disorder. Given the lack of literature supporting the diagnosis and its treatment with speech therapy, medical necessity for the requested therapy has not been established. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 58-year-old woman with SLE and bronchiectasis. According to the initial consultation note dated October 1991, the patient was first diagnosed in 1963. The patient underwent a partial left lung resection. The bronchiectasis was thought to be caused by multiple childhood respiratory infections.Sputum culture on 10/16/04 revealed scant pseudomonas, which was sensitive to IV antibiotics only and resistant to ciprofloxacin. The patient was started on inhaled tobramycin. According to a letter from the patients provider dated January 2005, the patient had clinically improved and was to continue on inhaled tobramycin.The Health Plan denied coverage for inhaled tobramycin on the basis it is not medically necessary for treatment of the patients medical condition.The materials submitted for review include a study by Barker et al. The study was a prospective, randomized, controlled trial comparing use of inhaled tobramycin versus placebo in clearing pseudomonas from patients with bronchiectasis. The authors found a decrease in pseudomonas in the inhaled tobramycin group and eradication after 6 weeks in 35% of the experiment group.Upon review of the records provided, the patients bronchiectasis seems to be limited to an area in the left lung. As such, it appears her previous course of inhaled tobramycin was likely sufficient to eradicate the pseudomonas. Therefore, based upon the information provided, continuation of inhaled tobramycin is not medically necessary at this time. As such, the Health Plans denial should be upheld at this time. However, sputum cultures should be obtained. If the pseudomonas colonization/infection is persistent then the patients request for inhaled tobramycin should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 56-year-old female with a long history of depression and apparently other medical issues who was admitted to the hospital in March 2005. She was reported to be thinking of suicide without a plan. The patient has also been experiencing marital problems. It was noted the patient had occasional derogatory auditory hallucinations. She also has a long history of non-lethal self-mutilation. The patient has been treated with antipsychotic and antidepressant medications with positive results. She was admitted to a residential treatment program in March 2005 where it appears she remained until April 2005, except for a brief transfer to a hospital for medical attention. A request has been made for reimbursement for these inpatient psychiatric treatment services. The Health Plan has denied the request indicating the submitted documentation does not demonstrate inpatient psychiatric treatment services were medically necessary beyond April 2005.Based upon the information provided, there is no evidence to suggest the patient was actively suicidal or psychotic as of April 2005. The submitted documentation does not include any clinical records documenting the patients status as of April 2005. Thus, there is no evidence establishing the patient required continued inpatient psychiatric treatment as of that time. Therefore, I have determined that based upon the information provided, 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: Upheld Decision of Health Plan

This patient is a 15-year-old female who is status post a motorcycle accident with resultant medial collateral ligament, medial meniscus, and anterior cruciate ligament injury requiring arthroscopy and repair of the MCL in January 2005. Prior to surgery the patient was provided with an over-the-counter brace for protection. A custom molded brace has been requested postoperatively to allow normal ADLs, assist in rehabilitation, and shorten healing time. At issue is whether the requested equipment is medically necessary for the patients postoperative rehabilitation.The American Association of Orthopaedic Surgeons position statement indicates after ACL reconstruction there may be a role for rehabilitation braces used in the early post-surgical phase, but functional braces used later during recovery appear to provide no added protection. There is no documented evidence that knee bracing of any type prevents injury during high load activities or sports activities. Additionally, in the case of this patient, there is no documentation of loss of activities of daily living. In most cases of ACL and MCL surgery, the goal of rehabilitation is to strengthen the stabilizing muscle of the knee as well as to heal the ACL repair. The use of bracing generally tends to weaken rather than strengthen the affected muscles and therefore, is ineffective. Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.