Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1:  The patient is a 36-year-old female with cervical pain and swelling at the base of the neck. The etiology of her pain is not known. The patient reports that after two prolotherapy sessions she experienced improvement in her symptoms. She has requested authorization for six prolotherapy sessions, which the Health Plan has denied on the basis that the therapy is considered experimental.There are many different protocols of prolotherapy with no current obstructive data to define the dose, ingredients or frequency of injections to obtain tightening of ligaments. Additionally, the safety of prolotherapy is unknown. Furthermore, the patient has not exhausted standard therapies such as myofascial release, trigger point injections, electrical stimulation, etc. 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 2:  The patient is a 36-year old female with neck pain of unknown etiology. She reports that treatment with medications, physical therapy, massage and acupuncture did not provide long-term relief. The patient believes prolotherapy has been helpful and therefore requests authorization and coverage for the therapy. The Health Plan has denied this request. The peer-reviewed literature has not clearly demonstrated the safety or effectiveness of prolotherapy from a basic science or clinical outcomes standpoint when compared to placebo in randomized, controlled trials. Prolotherapy is not a generally accepted medical intervention and not among the standard of care interventions for chronic neck pain. Accordingly, 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 3:  This patient is a 36-year-old female with a history of chronic neck pain for over one year for which she has had various physical therapy and chiropractic treatments. The neurology evaluations, and MRI and other studies have not shown definite pathology. At issue is coverage of prolotherapy by the Health Plan.A critical review of prolotherapy in the treatment of osteoarthritis, neck pain and other musculoskeletal conditions reveals that the clinical efficacy of the therapy remains inconclusive.  Although the patient reported pain relief, the use of prolotherapy for pain control is still considered investigational and it is not consistent with the current standard of care. There is no reliable evidence demonstrating that prolotherapy is more effective than standard care. 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. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This case concerns a 48-year-old female who has requested reimbursement for epidural steroid injections and facet joint injections provided from June 2004 through August 2004. The Health Plan has denied this request indicating the therapy at issue was not medically necessary for treatment of the patients neck and low back pain.Review of the medical documentation indicates the patient has a past medical history of systemic lupus erythematosus (SLE) and fibromyalgia. She had ongoing neck and low back pain issues since a motor vehicle accident in April 2004. She underwent diagnostic studies including a brain CT, spinal x-rays, cervical MRI and lumbar MRI, which were all essentially normal. She underwent medical therapy with Duragesic patches, Lidocaine patches, Percocet, Ultracet, Vicodin, Flexeril, Klonopin, Effexor, and trigger point injections. She continued with significant pain and was referred to pain management. During the period of June 2004 through August 2004 she received cervical/lumbar epidural and facet injection therapy.Given the documentation provided, injection therapy was medically necessary and indicated for this patient. She had ongoing pain refractory to multiple medical therapies. Her PCP referred her to pain management for specific therapy. The pain management specialists felt that given her underlying medical conditions (i.e., SLE/fibromyalgia) and her poor response to multiple medical therapies, injection therapy was indicated and medically appropriate. The patient had not responded to medical therapy for a period of eight weeks following her motor vehicle accident and injection therapy was a viable option for pain control. The documentation indicates that the injection therapy provided prolonged pain relief. Based upon the information set forth above, I have determined the therapy 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 nine-year-old male with a history of speech delays including expressive and receptive language deficits and decreased auditory memory and processing skills.  He also has decreased intelligibility of his speech. By report, these deficits have affected his reading skills. No medical records are provided with details regarding other developmental milestones or medical history. The March 2005 evaluation noted that hearing is reported to be normal.  The patient initially received three sessions of speech therapy beginning in March 2005, then resumed therapy in August 2005 through February 2006. The parents request for reimbursement for therapy provided from August 2005 through January 2006 and prospective authorization and coverage was denied by the Health Plan citing a lack of medical necessity.Although the speech deficits appear to be developmental in nature as described by the provider, there is an attempt to apply standardized testing in establishing goals and measuring progress.  As a general rule, objective measurement of progress to goals requires consistent application of the same measurement tool.  In this case, although standardized testing is applied, the measurement criteria are not consistent from one evaluation to the next.  As an example, the August 2005 evaluation was said to utilize the TOLD-3, Goldman-Fristoe Test of Articulation and the Expressive Vocabulary Test. Complete results are not provided for the TOLD-3 and the Expressive Vocabulary Test and there is no data from the Goldman-Fristoe Test of Articulation included in the evaluation. The second problem is that on the follow-up evaluation for the period of August 2005 to January 2006, areas of the TOLD-3 are referenced in the January report that were not included in the August report and newly applied standardized testing tools are utilized for the remainder of the evaluation. As such, no valid, objective conclusions can be drawn from the reports to verify progress.  The record includes limited developmental and medical history and no medical evidence that the speech delays are related to an illness or injury; the patients hearing is reported as normal.  The standardized testing that is provided indicates that most of the scores fell well within two standard deviations of the mean, which is typically considered within the normal range. Therefore, I have determined the therapy at issue was/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 29-year-old female who has requested authorization for Provigil for the treatment of depression related fatigue. She has been diagnosed with manic-depressive disorder. Her excessive fatigue was attributed to psychiatric medications such as Abilify, Celexa and Topamax. She has failed alternatives such as Seroquel, Lamictal, and Wellbutrin. Based on a fatigue severity scale, a 20% decrease in fatigue was attributed to Provigil. At issue is whether Provigil is medically necessary for treatment of the patients medical condition.Provigil for excessive fatigue is not an FDA-indicated use. The use of Provigil as a part of polypharmacy to offset the sedating effects of the patients psychiatric medications is not medically necessary or indicated. Provigil in this clinical setting is not based on a peer-reviewed, controlled trial. This off-label use of Provigil encourages polypharmacy and is not recommended. Eliminating sedating antipsychotics or reducing the dosing may have the same effect on the patients fatigue as Provigil. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 66-year-old female who is status post vertical banded gastroplasty (VBG) with subsequent weight regain. At present, her BMI is 48 and she has obesity related comorbidities such as type 2 diabetes, hypertension, hypercholesterolemia, gastroesophageal reflux disease, and depression. She has had some transient weight loss with diet.  Upper GI series and endoscopy suggests that the VBG has broken down.  The patient has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The patients provider recommends gastric bypass surgery and has submitted a request for authorization.  The Health Plan denied the request citing a lack of medical necessity.With a BMI of 48 and comorbid conditions such as type 2 diabetes, hypertension, hypercholesterolemia, gastroesophageal reflux disease, and depression, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. Weight regain after VBG is not uncommon, especially given the lack of dumping. It is appropriate to convert a failed VBG to a Roux-en-Y gastric bypass under these circumstances.  It is highly likely that the gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly 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 morbidly obese.  The psychological evaluation indicates the patient is an appropriate candidate for the 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. Therefore, the Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1:  The patient is a 44-year-old active male with severe osteoarthritis of the right hip, which is painful and disabling. He has researched his treatment options and has requested authorization for hip resurfacing arthroplasty, which has been denied by the Health Plan on the basis that it is considered investigational.The patients orthopedic surgeon considers him an appropriate candidate for hip resurfacing. In view of the patients age and activity level and acknowledging the advantages of resurfacing, which include preservation and conservation of bone stock, more normal joint function and stability, and also ease of revision to a conventional stem type replacement if necessary, there is sufficient evidence the requested procedure is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Accordingly, the Health Plans denial should be overturned.Physician 2:  The patient is a 44-year-old male with degenerative joint disease of the hip. He has had worsening pain and wishes to undergo surgical intervention. The patient believes hip resurfacing arthroplasty is the most appropriate procedure for treatment of his condition. The Health Plan indicates there is insufficient data regarding the long-term safety and efficacy of the procedure.There is no Class I data establishing the superiority of hip resurfacing arthroplasty over conventional total hip replacement. To date, there is insufficient evidence that the requested procedure is more beneficial than standard interventions. Given the lack of data demonstrating that hip resurfacing arthroplasty results in a superior clinical outcome over conventional hip replacement, the requested procedure is not recommended. Based upon the information set forth above, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3:  The patient is a 44-year-old male with hip arthritis. A request has been made for hip resurfacing arthroplasty. The Health Plan has denied this request on the basis that the requested procedure is considered experimental for the treatment of the patients condition.Hip resurfacing arthroplasty remains an unproven procedure at this time. Previous attempts at resurfacing have been ineffective with high rates of failure and complication. While there has recently been renewed interest in hip resurfacing with the metal-on-metal prosthesis, the procedure has not been sufficiently studied in terms of risk, benefit and complications. Given the current lack of available data, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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 female who had a body mass index (BMI) of 53 when evaluated for bariatric surgery. Her comorbid conditions included dyspnea on exertion, degenerative joint disease, fatty liver and lower extremity edema. The patients provider indicates her BMI had decreased to 49.5 and she has completed psychological and nutritional evaluations and was deemed an appropriate candidate for weight loss surgery. The psychological evaluation was absent from the record. The patient has selected the Lap Band procedure because she believes it is less invasive than other alternatives for surgical weight loss.  The Health Plan has denied coverage for the Lap Band based upon their determination that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of approximately 50 and comorbid conditions such as dyspnea on exertion, degenerative joint disease, (DJD) fatty liver and lower extremity edema, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. However, the current scientific data clearly shows that the Lap Band is inferior to other surgical alternatives in terms of excess body weight loss. The weight loss with the Lap Band is typically 50% of excess, as compared to 60-70% with Roux-en-Y and greater than 60% with the duodenal switch. A patient who weighted 315 pounds would need to lose approximately 155 pounds to reach a BMI close to 25 for the surgery to be considered successful. If in fact the Lap Band procedure results in the loss of 50% of excess body weight, the patients BMI would remain at approximately 40, which is still considered morbidly obese.  Given the above information, the patient should investigate other surgical weight loss procedures to secure optimal weight loss. Additionally, the results of the psychological evaluation should be made available for review, to fully consider the patients appropriateness for bariatric surgery.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 a 52-year-old male who has a history of migraine headaches. He experiences two headaches per week, eight per month. He has been prescribed triptans (i.e., Imitrex nasal spray and Zomig) as abortives. He was previously seen by a neurologist. He reportedly has used Inderal and Pendil in the past as preventives without success. The patient is currently using Norvasc as a preventive for headache. No headache diary information is supplied. No information is given to indicate that headache frequency, severity or duration have been altered by this medication. Imitrex nasal spray gives the patient rapid relief and if he has headache recurrence the next day he uses Zomig. The patient has requested authorization for 12 sprays of Imitrex 20mg per month. The patient has reportedly had benefit with abortive use of a triptan, Imitrex NS for migraine. The patient experiences eight headache days a month at present and some of those may be due to recurrence or several headaches grouped together in a row. At this headache frequency, preventive medications are indicated. The patient has tried Inderal at an unstated dose and duration. It is therefore not known if the patient failed Inderal or was taking an inadequate dose. He has tried a calcium channel blocker, Norvasc, without significant improvement in headache pattern. In general, calcium channel blockers do not have good evidence of benefit as migraine preventives. Several agents including propranolol, timolol, amitriptyline, divalproex and topiramate have evidence as successful first-line agents for migraine prevention. Identification of an effective preventive may take several weeks or months on treatment. It is acceptable per package instructions to re-treat with a second dose of Imitrex nasal spray or Zomig two hours after a first dose, but no more than two doses in a 24-hour period. Thus, the use of 16 doses of a triptan in a month is within the package instructions. However, this does not constitute optimal treatment and should only be continued until the patient can be re-evaluated by a neurologist for development of a treatment plan including the use of preventives such as timolol, amitriptyline, divalproex or topiramate. Consequently, I have determined the patients request for 12 sprays of Imitrex 20mg per month is medically necessary for a period of three months from the date of this decision to allow the patient adequate time to start a new regimen that includes the use of preventives. Accordingly, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a nine-year-old female who demonstrates difficulty in producing /s/ sounds. Past medical history is significant for multiple sinus infections, although no medical documentation of the infections has been provided. The therapist documents a normal birth history and motor development. The patient has no history of feeding, chewing or swallowing difficulties. Oral motor skills were within normal limits. The therapist also reports a normal hearing screen. Language is within normal limits, but the patient has difficulty with lateralization of the /s/, /z/ and /s/ blends. Speech intelligibility is at the 80% level for the average listener. At issue is whether speech therapy provided from February 2004 through March 2005 was medically necessary.Review of the medical literature reveals no evidence to support the contention that sinus infection can be related to chronic articulation abnormalities. With no medical reports documenting the history of significant chronic sinusitis and no medical literature supporting the supposition that the sinusitis caused the misarticulation, there is no evidence the misarticulation has a medical cause. Since no disease or other medical cause has been established, I have determined the therapy 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 37-year-old female with a body mass index (BMI) of 40. She is requesting authorization for a Lap-Band procedure. She has also reported a number of comorbid conditions including depression and obstructive sleep apnea. At issue is whether Lap-Band is medically necessary for treatment of the patients condition.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 is not indicated in this case. The patient can be appropriately treated with standard laparoscopic bariatric surgery. 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: Overturned Decision of Health Plan

The patient is a 28-year-old male with severe asthma.  He previously participated in a clinical trial of Xolair, which was very effective in controlling his asthma and his FEV1 increased from 41% to 84%.  Since Xolair was discontinued his pulmonary function tests have declined significantly, despite maximal therapy. The patients IgE was 301 in October 2005 and he has tested positive for aeroallergens.  The patients provider has submitted a request for authorization of Xolair.  The request was denied by the Health Plan citing a lack of medical necessity.The Health Plan indicated the patient has not demonstrated a 12% reversibility following administration of short-acting beta agonists and has not been compliant with prescribed asthma medication. The patients provider has explained that performing pulmonary function tests is difficult because it would not be safe to discontinue current medications due to the severity of the patients asthma.  There is however spirometry from February 2006 which demonstrated 20% reversibility for FEF 25-75%, which clearly documents small airway disease. Additionally, the patients acceptance for participation in the Xolair clinical trials would suggest that he met the 12% reversibility requirement at that time.  A review of the pharmacy records and the patients medical history shows no indications of non-compliance with prescribed medication.  The patients provider has documented a history of severe steroid dependent asthma, which improved dramatically during treatment with Xolair.  The record also reflects a significant decline in vital capacity and FEV1 since Xolair was discontinued.  This data supports the medical necessity of treatment with Xolair. The patient meets all FDA requirements for treatment with Xolair. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.