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

The patient is a 45-year-old woman with a history of morbid obesity, hypertension, back pain, and diabetes. The patient currently utilizes an electric scooter to ambulate within her home and for community mobility. The patient states that she cannot access certain areas of her home while utilizing the electric scooter and therefore, is requesting authorization for an electric wheelchair. The Health Plan has authorized a manual wheelchair.The Health Plans denial should be upheld. The patients records do not demonstrate that the patient cannot operate a manual wheelchair. There is no documentation from the patients physical therapist or the patients physician demonstrating that the patient cannot operate a manual wheelchair. Therefore, an electric wheelchair is not considered medically necessary at this time. Furthermore, given the patients history and current condition, a manual wheelchair appears more clinically appropriate. For these reasons I have determined that the requested equipment is not medically necessary. 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 longstanding history of attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder. The patient was previously treated with Adderall XR, which was followed by a combination of Adderall XR and Strattera, and then only Strattera. A request has been made for continuation of combination therapy with Adderall XR and Strattera. The Health Plan has denied authorization and coverage for the requested therapy on the basis that it is not medically necessary.The notion of combining psychotropics for off-label treatment of a variety of conditions has support in the psychiatric community. Given the relative newness of Strattera, there perhaps has not been enough time for case reports or formal studies on combination therapy to surface. In the case of this patient there is documented evidence from the patients psychiatrist of a clear improvement with a combination of Adderall XR and Strattera, with no indication of untoward side effects. In October 2003, the patients provider indicated the patient appeared to be doing well on a combination of Adderall and Strattera as he had a decrease in lability, was not fighting, was smiling spontaneously and had improved energy. This is in contrast to the earlier documentation, which noted the patient was not doing well academically and was lethargic when receiving only Adderall XR. In addition, it was noted that the patient was extremely oppositional and not doing his schoolwork when receiving Adderall and imipramine. The submitted records demonstrate the patient experienced only minimal response to single agent therapies. However, it appears he responded extremely well to the combination of Adderall XR and Strattera, with much better attention in school, proportionately better grades, and less acting out. Subsequent treatment with regular short-acting Adderall and Strattera was not as successful. Given the documented evidence that combination Adderall XR and Strattera was successful in overriding the patients oppositional behavior, continuation of such therapy is medically appropriate and indicated.Based upon the information set forth above, I have determined that the requested combination therapy 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

The patient is a 29-year-old woman who has severe cystic acne of the back, thighs, buttocks, and face with scarring. Her acne has been minimally responsive or unresponsive to oral antibiotics, topical antibiotics, benzyl peroxide, Retin A, Ortho Tri-cyclen, and oral Aldactone. The patient has had consultations with dermatologists who use Smoothbeam laser for treatment of acne. She states that her primary care physician does not prescribe Accutane for women of childbearing age. The Health Plan has denied authorization and coverage for Smoothbeam laser therapy on the basis that it is not medically indicated.Accutane is the gold standard for treatment of severe cystic acne that is resistant to other forms of treatment. The submitted information documents that the patient has been tried on all of the other conventional forms of treatment. Though Accutane is contraindicated in pregnant women or women who plan to become pregnant while on Accutane, Accutane is not contraindicated in women of childbearing age. The manufacturer and the standard of care require a pregnancy test at the patients first visit and three days after the patients next menstrual period, prior to initiating Accutane. It is essential that a pregnancy test be performed monthly approximately one week prior to the office visit in order to reevaluate the patient and prescribe the next months prescription. The patient is required to use two effective forms of contraception from one month prior to one month after cessation of treatment. Adherence to the pregnancy prevention program should be explained to and required of patients who use Accutane. Although there are strict precautions associated with the use of Accutane, the effectiveness of Accutane may persist for years after Accutane cessation. While Smoothbeam laser therapy may be effective, the medical literature does not establish that it results in the same degree of efficacy that is associated with Accutane. As such, the medically necessity of Smoothbeam laser therapy for treatment of the patients acne has not been established.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 37-year-old man with a body mass index (BMI) of 50. The patients comorbidities include hypertension, gout, and asthma. The results of the patients psychological evaluation indicate the patient has a history of bulimic behavior. The patient wishes to undergo gastric bypass surgery. The Health Plan has denied authorization and coverage for the requested procedure based upon the results of the patients psychological evaluation.The patients eating disorder is a deterrent to successful weight loss surgery. The outcome of gastric bypass surgery is patient dependent. Over long periods of time 15% to 25% of patients will regain some or all of their lost weight. The success of gastric bypass is dependent upon the patients strict adherence to a limited food intake. Unless a patient is psychologically stable and ready for the lifelong dietary changes necessary for a successful outcome, it is highly likely the procedure will fail. The information provided does not demonstrate that this patient is an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for the 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 33-year-old female with a BMI of 52. She has comorbid conditions including hypertension and hydronephrosis with decreased renal function. She wishes to undergo gastric bypass. She has not undergone a formal psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.With a BMI of 52 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure 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 procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a nine-year-old male who had difficulty learning to read during first grade. He was diagnosed as having a central auditory processing delay by a speech therapist. The patient has received speech therapy since March 2002. The patients speech therapist documented delays in auditory memory, interpretation and processing. A request has been made for authorization and coverage for speech therapy. The Health Plan indicates that speech therapy is not medically necessary for treatment of the patients clinical condition.Though central auditory processing disorder has been described in the medical literature, the neuropsychologic nature of the disorder is still ill defined and the true nature of the disorder remains unclear. As a result, appropriate treatment has not been well established and no techniques have been validated. In the case of this patient, an initial evaluation was performed documenting deficits, but goals for improvement were poorly outlined and were not correlated to documented deficits. Thus, the degree or extent of the patients improvement is unclear. Additionally, the stated goals were educational in nature and not medically related. Given the uncertainty associated with this diagnosis and the difficulty with developing medically related goals, there is insufficient evidence that speech therapy is medically indicated for treatment of the patients condition.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 56-year-old male who was seen by a dermatologist in October 2003. Apparently the patient was referred to a dermatologist for treatment of a basal cell carcinoma of his right superior shoulder. The dermatologist then referred the patient to a plastic surgeon. The information submitted does not provide evidence of why the dermatologist referred the patient to a plastic surgeon. On 12/3/03, the plastic surgeon indicated the patient had a history of solar damage. The patients physical exam indicates multiple areas of sun damage with no areas suspicious for malignancy. The plastic surgeon recommended follow-up by the patients dermatologist. The patient has requested laser resurfacing for a spot on the side of his face, which frequently bleeds from shaving.The treatment of a bleeding telangiectasis is medically necessary. However, that treatment involves local destruction of the bleeding spot, not laser. Also, it is essential that the spot be evaluated for possible skin cancer. Neither the dermatologist nor the plastic surgeon describes a bleeding spot. Thus, there is no identifying history or physical exam. Furthermore, no information has been provided demonstrating the location of the bleeding spot. The patient describes that spot as being on the side of the face. This description does not provide enough specific information as to where the patients bleeding spot is located. Regardless, although the patient may require local destruction of the identified bleeding spot, laser resurfacing is not medically necessary or medically indicated 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 60-year-old female with a history of sporadic but persistent chest pain for 10-12 months. She also reports occasional shortness of breath at the same time but not always. In December 2003, physical examination by the patients provider revealed slight chest wall tenderness on the left and an occasional expiratory wheeze. Cardiac exam showed regular rate and rhythm. It was not noted whether a murmur or click was heard. The patients provider noted the patient had been previously seen by another provider who apparently heard a murmur and found an electrocardiogram to be normal. It appears the enrollees previous provider recommended an echocardiogram for assessment of a heart murmur. The Health Plan has denied authorization and coverage for an echocardiogram on the basis that it is not medically necessary.Based upon the submitted documentation, it appears a murmur was appreciated by one of the patients providers who then recommended an echocardiogram for the evaluation of this patient who also had complaints of shortness of breath and chest discomfort. Evaluation of a heart murmur in patients with cardiorespiratory symptoms is a widely accepted indication for an echocardiogram. Thus, an echocardiogram in this case is medically reasonable and appropriate and is indicated based upon American College of Cardiology guidelines. Therefore, I have determined that the requested echocardiogram is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1The patient is a 41-year-old woman with a history of chronic lateral epicondylitis. She wishes to undergo extracorporeal shockwave therapy. The Health Plan has denied authorization and coverage for extracorporeal shockwave therapy on the basis that it is considered investigational.The requested therapy is not the standard of care at this time. There have not been sufficient studies establishing the benefit, risks, and outcomes of extracorporeal shockwave therapy for treatment of lateral epicondylitis. Furthermore, there is no class I peer-reviewed data to demonstrate that extracorporeal shockwave therapy is better for long-term relief of chronic lateral epicondylitis than standard therapy. Therefore, I have determined that the requested therapy 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 2The patient has failed non-operative standard therapy. In addition, the patient has depigmentation and muscle atrophy contraindicating additional cortisone injections. The patients provider has recommended extracorporeal shockwave therapy (ESWT). The Health Plan has denied authorization and coverage for ESWT on the basis that it is considered investigational. The patient has failed prior therapy and is not likely to benefit from continued conservative therapy. ESWT is a known intervention and good outcomes have been reported. Furthermore, ESWT is less invasive than surgery. Since ESWT may obviate the need for surgical intervention, it is medically reasonable and appropriate for the patient to undergo ESWT. 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 3The patient is a 41-year-old woman with longstanding lateral epicondylitis. She has attempted treatment with injections of Xylocaine and Kenalog but has persistent pain. The patient wishes to undergo extracorporeal shockwave therapy for treatment of lateral epicondylitis. The Health Plan has denied her request on the basis that extracorporeal shockwave therapy is considered investigational.Extracorporeal shockwave therapy for treatment of lateral epicondylitis is not considered to be standard of care. A recent article in the Journal of Bone and Joint Surgery found that the procedure had little benefit and therefore, was not recommended. The current scientific literature does not demonstrate the efficacy of the requested therapy or the associated complications or risks. Therefore, the patient should be treated with standard of care modalities.Based upon the information set forth above, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 58-year-old female with irritable bowel syndrome and constipation. She is taking massive doses of Correctol and Milk of Magnesia. She is reportedly having up to 10 bowel movements a day. There is also the belief that she may have Hirschsprungs disease. Various motility studies and manometry studies have been recommended but it does not appear as though they have been performed. The patient has been taking Zelnorm and it is noted that her symptoms have improved. It is unclear whether the patient is continuing to take massive doses of laxatives. The Health Plan has denied further authorization of Zelnorm.The Health Plans denial should be overturned. The submitted evidence demonstrates that Zelnorm is helping the patients condition. This is further evidenced by the fact that the patient is gaining weight and is not becoming dehydrated. For these reasons, the patient should continue on Zelnorm for another three months. At the end of this three-month period the patient should be re-evaluated to determine whether Zelnorm is still benefiting her condition.Based upon the information set forth above, 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

The patient is a 36 year-old female who is 53 tall weighing 280 pounds. Review of the submitted clinical information does not demonstrate that the patient has any life threatening comorbidities. The patient does have obesity related comorbidities that will improve with surgery. The submitted information indicates the patient continues to smoke. Evidence of a psychiatric evaluation has not been provided. The patient has requested that she receive a timelier consultation for bariatric surgery. The patient also indicates that she wishes to undergo duodenal switch gastric bypass rather than the Roux-en-Y procedure.A wait of six months for an appointment and up to a year before surgery is not uncommon and is consistent with many bariatric surgical programs. There is no evidence that the patient has Pickwickian syndrome or severe insulin dependent diabetes mellitus that would necessitate immediate surgery. Based upon the information provided, the delay in surgery will not pose a threat to the patient. Furthermore, it will allow time for psychiatric evaluation and smoking cessation. If at the time of the patients bariatric surgery consultation the bariatric surgeon indicates the patient is an appropriate candidate for duodenal switch gastric bypass, then the duodenal switch procedure should be authorized. The duodenal switch procedure requires less postoperative dietary restrictions. Furthermore, the recent report by Anthone, et al. documents excellent weight loss and lower dumping symptoms. Thus, the duodenal switch procedure is a medically reasonable and appropriate alternative to Roux-en-Y gastric bypass.Based upon the information set forth above, I have determined that a timelier bariatric surgery consultation is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. If upon examination by a bariatric surgeon it is determined that the patient is an appropriate candidate for duodenal switch gastric bypass, then the duodenal switch procedure should be authorized depending upon psychiatric clearance and smoking cessation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 13-year-old female who has been diagnosed with dyslexia. The patient has been evaluated by a speech therapist as well as through a reading program. The patient was found to have deficits in reading including symbol imagery, passage decoding, and spelling. These difficulties are affecting the patients writing mechanics. The patients family has requested authorization and coverage for continued speech therapy. The Health Plan has denied the request on the basis that continued speech therapy is not medically necessary.While dyslexia has been well documented as a specific learning disorder, it has not been well established in the medical literature as a condition that can be treated medically. Although speech therapy programs and reading programs have been shown to be of some benefit in this situation the goals of the programs are educational in nature rather than medically based. Thus, there is insufficient evidence that speech therapy is medically indicated for treatment of the patients dyslexia.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a five-year-old male with a history of speech delay described as both expressive and receptive. The patient was evaluated by a speech therapist and subsequently treated for delayed speech for approximately two years. A formal speech evaluation including standardized tests or goals is unavailable. A neurologist examined the patient and documented the patients history of speech delay. No other neurologic abnormalities were documented. At issue is whether speech therapy is medically necessary for treatment of the patients condition.The information submitted provides insufficient documentation of specific deficits of speech. It does not appear that standardized testing was performed to document the severity of the patients speech delay. Furthermore, there is no evidence that the patients speech delay is related to a neurologic condition. It was well documented by the patients neurologist that no other neurologic findings were present upon exam. In cases of speech delay without neurologic findings, speech therapy is not medically indicated. 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.