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

The patient is a 49-year-old male with stage T1c Gleason grade 3+3 (total 6) adenocarcinoma of the prostate noted in 1 mm of 8 biopsy cores with pre-biopsy PSA of 3.3. The patient has requested treatment with a robotic-assisted laparoscopic radical prostatectomy. The Health Plan has authorized a radical retropubic prostatectomy, with bilateral pelvic lymphadenectomy. The Health Plans denial should be upheld. The robotic-assisted laparoscopic procedure is relatively new, and while short-term results are comparable, long-term data especially with regard to survival is not yet available. While there is no medical objection to the robotic-assisted laparoscopic approach, to date there is insufficient data to demonstrate its superiority to other procedures. The open surgical approach is a well-established treatment with good long-term results regarding survival and complications and is considered standard of care for treatment of the patients prostate adenocarcinoma. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old obese female who is 277 pounds and has bilateral varicose veins that are painful. On duplex, she has mild reflux of the saphenofemoral junction on the right, and no other reflux on the left side. Her varices seem to be equally distributed between both legs. The patient indicates she is symptomatic. Use of compression stockings has been recommended. The patient has requested authorization and coverage for vein stripping or injections (sclerotherapy). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients varicose veins.The duplex findings demonstrate only mild reflux on the right side. Performing vein stripping on the right side will not have any effect on the patients symptoms. Furthermore, with regard to the patients request for injections or sclerotherapy, the submitted documentation does not demonstrate the patient has undergone a three to six month trial of conservative management. Conservative management should involve compression stocking use and continued weight loss. Moreover, the submitted documentation does not indicate the size of the veins; treatment of veins less than 1-2 mm is generally considered cosmetic. Lastly, if GSV reflux is to be treated, the duration of reflux on duplex needs to be documented, as minimal reflux with the Valsalva maneuver is considered normal and does not require intervention. Based upon the information set forth above, I have determined that the requested services are 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 15-year-old male with a diagnosis of gynecomastia who was seen and referred to a plastic surgeon for male breast reduction after an endocrine evaluation was performed and the patient was placed on Tamoxifen therapy. Based upon the information provided, it appears that during the nine months the patient was followed by the endocrinologist, the patients weight increased from 168 pounds to 203 pounds. A request for authorization for bilateral male mastectomy has been made. The Health Plan has denied this request indicating the proposed procedure is not medically necessary.The enclosed photographs and the descriptive examination of the breast tissue by the patients endocrinologist are supportive of a diagnosis of adolescent gynecomastia. In cases such as this, it is medically appropriate for the patient to await spontaneous resolution, which is aided by diet and exercise. Thus, at this time there is insufficient documentation demonstrating bilateral mastectomy is medically warranted in this patient. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 42-year-old female with weakness and fatigue of undiagnosed origin. The patient is currently independent with an exercise program at the local pool. She is requesting authorization and coverage for aquatic therapy. The Health Plan has denied this request indicating the requested therapy is not medically necessary.The Health Plans denial should be upheld. The patient has weakness and fatigue and wishes to receive aqua therapy. Aqua therapy under the direct supervision of a therapist is not medically necessary for this patient.  The submitted evidence indicates the patient is currently independent with an exercise program at a local pool. Since the patient is able to participate in an independent pool program, the requested therapy would be for purposes of maintenance and therefore, is not medically warranted. 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: Upheld Decision of Health Plan

The patient is a four-year-old male who was diagnosed with autism in June 2003. He began receiving speech therapy in February 2003 and occupational therapy in November 2003. Currently the patients receptive and expressive speech is delayed with only one to two word combinations. The patient follows one-step commands and can respond to direction with context. He engages in parallel play, but has minimal interactive socialization. He continues to have significant concentration/distractibility issues and continues to have difficulty with fine motor skills and poor motor planning. He is imitating sounds in his environment and is able to respond to simple questions. The Health Plan has denied coverage for occupational and speech therapy services on the basis they are no longer medically necessary.I have reviewed all the information provided, including the DVDs. While the DVDs demonstrate some improvement with the patients ability to respond to his environment and simple use of language, the occupational and speech therapists do not document substantial gains over the two years of therapy the patient has received. The patients initial evaluations do not include objective testing to document the patients deficits. Although the patient made some progress towards his goals in speech therapy, he has not met any of his goals over two years of therapy. Furthermore, there is no evidence of follow-up, objective testing. Regarding occupational therapy there is no evidence of objective standardized testing or intermittent reports and the daily reports are not specific and do not relate to specific goals.Because of the lack of objective evidence regarding the patients deficits as well as the lack of evidence demonstrating substantial gains during the patients course of therapy, I have determined the requested services are not medically necessary. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a six-year-old male with a history of speech
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 59-year-old female with primary progressive multiple sclerosis diagnosed in December 2004. She is requesting authorization for a power-operated vehicle (POV). The patient walks with a cane, although the only documented exam from her primary neurologist indicates she had a normal gait in November 2004. The submitted documentation demonstrates the patient is ambulatory with a cane and independent in her home. The Health Plan has denied authorization and coverage for a POV on the basis it is not medically necessary.The Health Plans denial should be upheld. Review of the submitted documentation does not demonstrate a POV is medically necessary. The patient is ambulatory with a cane. In addition, the patient is independent in her home. Thus, the patient does not meet nationally accepted medical necessity criteria for authorization of a POV. Accordingly, I have determined a POV is not medically necessary to assist with the patients mobility problems. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old male who has been diagnosed with moderate obstructive sleep apnea (study performed in July 2004). The patient indicates he has undergone several surgeries in attempts to correct this problem. The most recent surgery was that of revision septoplasty and inferior turbinate reduction. This was performed in February 2005. The patient continues to be symptomatic in terms of obstructive sleep apnea. He has requested authorization for a follow-up sleep study. The patient wishes to have his repeat study performed at an out-of-network facility. The Health Plan has denied this request indicating appropriate services are available from an in-network provider.The Health Plans denial should be upheld. There is no evidence the patient requires the services of an out-of-network provider. The Health Plan indicates appropriate sleep study services are available from an in-network provider. Based upon the evidence provided, there is no justification for a referral for out-of-network sleep study services. The patient should be referred to an in-network provider whose practices are within standard of care. Accordingly, I have determined that the requested services are 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 44-year-old female with long-standing history of alcohol abuse, typically involving two to seven hard drinks per night and some very sporadic use of cocaine. The patient had a prior course of alcohol rehabilitation in October 2002. She estimated that she had been drinking heavily since June 2003, though had not been drinking as of May 2004. She was admitted to residential treatment in May 2004 where she remained until July 2004. The patient was also thought to be depressed. Symptoms of depression included sleeping poorly with sleep continuity disturbance, less interest in activities, poor concentration, and feeling guilty about her drinking. The patient had not felt suicidal at any time. The patients admission interview revealed she had slightly disheveled grooming, was cooperative with the interview, and had an anxious and depressed mood and congruent affect. She was goal-directed, and her thought content was focused on the events leading to her admission. Admission diagnoses included alcohol dependence, alcohol induced mood disorder, and major depression, single episode.  As of the time of admission, the patient had already been treated with Zoloft by her outpatient psychiatrist and this was added to with Wellbutrin after entrance to residential treatment.A request has been made for residential treatment services the patient received from May 2004 through July 2004. The Health Plan indicates the services at issue were not medically necessary.All told, while the patient warranted treatment for both her alcohol dependence as well as depression, the patient had essentially detoxified herself before admission and was motivated for treatment. Based upon the information provided, it appears the patient had not had a course of alcohol abuse-related treatment since 2002. As such, it appears a less intense level of treatment would have been appropriate. In addition, despite the initial assessment of severity of the patients level of depression, none of the submitted documentation demonstrates the patients depression was more than in a mild range. Given the patients motivation for treatment, lack of withdrawal symptoms, and level of depression, residential treatment was not medically indicated. 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: Upheld Decision of Health Plan

The patient is a 10-month-old male with plagiocephaly. His parents are seeking authorization for a cranial orthosis/band. The patient has been evaluated by appropriate specialists and neck physical therapy and a cranial band have been recommended. The Health Plan has denied authorization for the cranial band.The treatment of plagiocephaly with helmet molding is controversial. Studies regarding the efficacy of helmet therapy are limited with varying results. Helmet therapy is generally utilized for patients in early infancy with severe problems such as facial changes. This patient is not in early infancy and does not have severe problems. There is insufficient scientific and clinical evidence to support helmet therapy in this patient. Therefore, I have determined the requested equipment is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 47-year-old woman with multiple sclerosis (MS) and moderately spastic gait who currently requires no assistive devices to ambulate. She has requested authorization for a folding power operated vehicle (POV) to enhance her mobility. The submitted information includes no documentation of a trial of assistive devices such as a cane or walker. The Health Plan has denied the patients request on the basis the requested equipment is not medically necessary. Review of the submitted information does not demonstrate a POV is medically necessary for this patient. The patient has been noted to be ambulatory within her home. There is no evidence she requires mobility assistance equipment to ambulate. The patient does not meet nationally accepted medical necessity criteria for authorization of a POV. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 42-year-old male who underwent ACL reconstruction in January 2005. As part of his rehabilitation program a CPM machine was recommended and utilized. The Health Plan has denied reimbursement for the CPM machine.The use of a CPM machine following ACL reconstruction is very common in the orthopedic community. Although CPM machines are not utilized by all physicians or all patients, it is an effective rehabilitative device that is generally prescribed based upon the type of procedure and specific patient factors. This patient had extensive surgery and a CPM machine was recommended to improve the patients chances of regaining full range of motion. Because CPM machines are considered effective for rehabilitation following this patients surgery, I have determined the equipment at issue was medically necessary. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a young female who was seen by her primary care physician and was referred to a plastic surgeon with complaints of massive ptotic breasts, which have caused her to have shoulder grooving, back pain, and neck pain. A bilateral breast reduction was proposed and authorization was sought. The Health Plan has denied authorization and coverage for the requested procedure citing a lack of medical necessity.The patient meets medical necessity criteria for breast reduction surgery. The submitted photographs document massive mammary hypertrophy of a very significant degree. The patient is clearly symptomatic. The procedure proposed is likely to be the most effective method to relieve the patients symptoms. 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 55-year-old male who has osteopenia based upon a bone mass density scan performed in 2003. A L5 vertebral wedge fracture was reportedly found in approximately 1999. Preventive treatment with Fosamax and Actonel was attempted, but was discontinued due to gastrointestinal side effects. The patient was started on Miacalcin nasal spray (Miacalcin) without side effects, but with unknown response. He wishes to continue this treatment. The Health Plan has denied reimbursement for Miacalcin on the basis it was not medically necessary.The Health Plans denial should be upheld. There is no data indicating Miacalcin results in fracture prevention for men or women. If there is documented evidence the patient experienced a prior fracture, there are several alternative treatments available that would be appropriate for this patient. There is no evidence Miacalcin was likely to be beneficial in this case. Therefore, I have determined that the medication at issue was not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old woman weighing 125 pounds with large breasts. The submitted information indicates the patient has strap grooving secondary to macromastia. It has been recommended the patient undergo breast reduction surgery. The Health Plan indicates the patient does not meet criteria for authorization of breast reduction surgery. The submitted information does not demonstrate that the requested procedure is medically indicated. Based on the information provided, the extent of the patients pendulous breasts does not seem excessive. Although the patients symptoms may be associated with macromastia, there is not sufficient documentation to demonstrate that the requested procedure is medically justified. Based upon the information set forth above, I have determined that the requested procedure is 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 an 18-year-old female with a history of a severe eating disorder. There is documented evidence of long-term daily purging. The patient received partial hospitalization services from March 2005 to April 2005. The Health Plan has denied reimbursement for the services the patient received after March 2005. The patient has objective documented evidence of a severe eating disorder. Over a nine-month period there were apparently three days during which the patient did not purge. Upon her admission to partial hospitalization the patient was described as despondent. By March 2005 the patient was progressing with her program but was in need of further therapy at the same level of intensity. The records document that throughout the patients partial hospitalization program she was not appropriate for a less intense level of care until April 2005. The patients condition was such that she required partial hospitalization services from March 2005 to April 2005. There is no evidence that discharge prior to April 2005 was indicated or would have been appropriate.Based upon the information set forth above, I have determined the services at issue were 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 an 11-year-old female with type I diabetes who is on an insulin pump (Medtronic Minimed). She has been denied coverage for BD Logic blood glucose test strips for use in the attached Medtronic Minimed blood glucose monitor. The BD Logic strips are required for this glucose monitor, which records the blood glucose level electronically in the pump. The Health Plan indicates other test strips are available for monitoring of the patients medical condition.In terms of medical necessity, the patient must have the ability to measure blood glucose levels five to eight times daily when on an insulin pump. The reagents used to do this (monitor and strips) are required as a medical necessity. However, there are large numbers of medical glucose sensing systems that could accomplish this. Though BD Logic test strips may be more convenient, there is no evidence demonstrating the requested supplies are 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 38-year-old female who indicates her vision is significantly impaired because of excess skin. According to the Health Plan, the patient has been evaluated by three ophthalmologists who do not believe the patients visual field loss is related to excess skin. The Health Plan indicates the patients impaired vision is due to dry eyes. The patient has requested authorization and coverage for blepharoplasty. The Health Plan has denied this request on the basis the requested procedure is cosmetic in nature, and therefore, not medically necessary.The Health Plans denial should be upheld. The submitted visual field tests are not characteristic of visual field loss secondary to excess skin. There is no significant superior visual field expansion despite the patients eyelids being taped. It was also noted the patients eyelids do not rest on her eyelashes. Given the evidence provided, I have determined that the requested procedure 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 58-year-old female who felt a small nodule in the inferior medial left breast. Mammogram in August 2004 was negative. In August 2004, the patient was evaluated by her clinician who performed an ultrasound and a core biopsy of a 1 cm mass at 7oclock. The pathology was fibroadipose tissue. In September 2004, the patient then underwent an excisional biopsy. The pathology results were benign nonproliferative fibrocystic changes. There was no evidence of malignancy.In a follow-up appointment with her clinician in November 2004, three fatty nodules were palpated at 9 oclock in the left breast. An MRI was ordered for further evaluation, which was performed in mid-November 2004. The patient has no history of breast cancer and has been on estrogen for many years. The Health Plan has denied reimbursement for the MRI at issue on the basis it was not medically necessary for evaluation of the patients medical condition.There are several indications for MRI of the breast, which include pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high-risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants.Since this patient had a relatively recent mammogram, ultrasound, ultrasound-guided biopsy, and excisional biopsy of the left breast, a new malignancy in the breast would be very unlikely. A repeat left breast mammogram and ultrasound and follow-up clinical exam would have been appropriate before considering MRI and possibly another biopsy. Given the specifics of this case, an MRI was not medically warranted for this patient.Based upon the information set forth above, I have determined that the MRI at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.