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

The patient is a 54-year-old male who became dependent on Vicodin due to chronic back pain. His physician recommended utilization of Subutex for both withdrawal and maintenance therapy. The detoxification went fairly well, but the patient later filled prescriptions for Vicodin and hydrocodone tabs. The record does not provide a detailed account of his providers response to his breakthrough use of narcotics. His subsequent request for authorization of Suboxone was denied by the Health Plan based upon their determination that concurrent use of narcotic medications and Suboxone is not medically necessary.The National Institute of Health (NIH) has outlined a protocol for the use of Subutex/Suboxone for detoxification and maintenance of abstinence from narcotic medications. The patient met the criteria for the use of Subutex/Suboxone and appeared to follow the protocol during the detoxification phase of his treatment. He was however, unable to tolerate the maintenance phase and filled prescriptions for a substantial amount of narcotics. Although the NIH protocol allows for breakthrough use of narcotic medications, the protocol requires a clear plan of corrective action to regain the state of abstinence from all narcotics in order to continue on the Subutex/Suboxone protocol. A review of the progress notes from the patients provider did not reveal a clear corrective action plan following the patients relapse or explain how the large quantity of prescription medications would be collected from the patient. The circumstances surrounding the patients use of narcotics during the Subutex/Suboxone maintenance phase raise serious questions and concerns about his commitment and the efficacy of this course of treatment that did not appear to be adequately addressed by the attending physician. 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

The patient is a 12-year-old male with a diagnosis of Aspergers Syndrome and a co-morbid diagnosis of ADHD. Several medications have been tried such as Ritalin, Concerta, Adderall and Adderall XR. 40mg of Focalin XR daily was clinically effective in treating the patient. The FDA recommends a maximum dosage for Focalin XR of 20mg daily. The patients parent submitted a request for reimbursement and prospective authorization of Focalin, 40mg daily. The Health Plan denied the request based upon a determination that the medication dosage was/is not medically necessary.The literature does recognize the use of Focalin in dosages as high as 40mg per day for certain individuals who have ADHD and have not responded to lower dosages of stimulants. Focalin is a potent stimulant, and there are some potential health concerns with prescribing this medication at a higher dose. A cardiac assessment should be carried out to rule out any pre-existing cardiac abnormalities. This may be accomplished through the patients primary care provider in conjunction with a complete physical examination. Periodic monitoring of the patients physical health status is also recommended. Focalin XR, 40mg daily, has been shown to be effective for this patient. Assuming there are no medical contraindications for the use of Focalin XR at this dosage, the clinical indications support the use of Focalin at the prescribed dosage. Objective measures of on-going efficacy such as the Conner Teacher rating scale are generally helpful in this context. In summary, although the prescribed Focalin XR dosage of 40mg daily exceeds the FDA recommendation, the literature does support this dosage for selective patients with ADHD. As there are potential side effects of a cardiac nature, if the patients cardiac status has not been recently evaluated, such evaluation should occur as soon as possible. Therefore, I have determined the medication at issue was/is medically necessary for treatment of the patients medical condition pending cardiac evaluation. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 57-year-old male with long-standing back pain. He has attempted conservative treatment without success. It has been recommended that he proceed with laminectomy and fusion at L4-S1. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary.The patient has had extensive consultation with a spine surgeon and has been evaluated by two neurosurgeons; all of these physicians agree that surgical intervention is necessary. The patient has failed conservative treatment; thus, it is unlikely that further conservative therapy will be beneficial for the patient. Given the patients complaints, findings on examination and radiographic studies, and in light of the failure of conservative treatment, he is clearly a surgical candidate. The proposed procedure is clinically appropriate and indicated. Therefore, I have determined 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 52-year-old male with recurrent sigmoid diverticulitis. Surgical resection of the sigmoid colon has been recommended. The patient wishes to have the procedure performed laparoscopically by a colorectal surgeon. The Health Plan has referred the patient to a general surgeon for consultation regarding possible surgical intervention.Standard therapy for recurrent sigmoid diverticulitis is sigmoid colectomy. The most appropriate method of resection today is via a laparoscopic approach. This technically advanced, demanding operation requires the skills of surgeon specifically trained and experienced in laparoscopic colon resection. The inflammatory nature of this disease makes surgical resection technically more difficult and therefore requires someone well versed in the laparoscopic approach. Medical literature supports the laparoscopic approach in diverticulitis. There are fewer complications, shorter hospital stays, and a more rapid return to pre-hospital activities. Although it is not medically necessary for a board certified colon and rectal surgeon to perform the laparoscopic sigmoid colectomy, the patient should be referred to a surgeon with extensive experience in laparoscopic colon surgery. The literature documents a minimum number of cases between 15 and 40 to show proficiency in this procedure. This does not necessarily mean that a board certified colorectal surgeon must be chosen, as there are many with minimal to no laparoscopic colon surgery experience. The patient should be referred to a surgeon, whether general or colorectal, who has extensive experience in laparoscopic colon surgery. Therefore, I have determined the requested referral is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old female who has undergone anterior cervical corpectomy and fusion for cervical spondylosis. The patient reports persistent debilitating pain beginning in December 2005. MRI showed moderate foraminal stenosis at C3-4 and mild to moderate canal and foraminal stenosis at C4-5. The patients neurological examination and electrodiagnostic studies were normal. The patient has requested authorization for repeat cervical fusion to address the adjacent segment disease and eliminate her pain. The Health Plan denied her request indicating the requested procedure is not medically necessary.The patient has a normal neurological examination and electrodiagnostic studies showed no evidence of denervation, plexopathy, ulnar neuropathy or polyneuropathy of the upper extremities. Although there is evidence of adjacent segment deterioration at C3-4 and C4-5, there is no clear indication for surgery at this juncture. A second neurosurgical evaluation and surgical opinion is a reasonable approach prior to a second cervical surgery. Therefore, I have determined 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 man with a 20-year history of a trigeminal autonomic cephalgia most consistent with chronic cluster headache. The patient has nearly daily severe, incapacitating headaches with associated autonomic features that respond to Imitrex injections and partially to oral triptans. The patients neurologists have suggested reducing his use of triptans. He has tried and failed Topamax, Depakote, Neurontin, Verapamil, Lithium ES, Indocin, Lyrica, and Cymbalta. The submitted records do not include information about the dosing or duration of these medications.The patient is seeking coverage for reimbursement for his prior use of Imitrex as well as authorization for continued use of Imitrex at a frequency of two injections or two tablets per day. The Health Plan has denied this request on the basis that the quantity of medication at issue was/is not medically necessary.The patients headache disorder is most suggestive of chronic cluster headache. The chronic use of daily triptans such as Imitrex may lead to an element of medication overuse headache, and the patients neurologists have suggested reducing the frequency of the patients triptan use. It appears the patients primary care physician has been providing the patient with triptans.The submitted records document that the patient has been receiving Toprol and Crestor, which seems to indicate that he has hypertension and hyperlipidemia. In addition, it appears the patient is a smoker. In light of these potential cardiac risk factors, the use of Imitrex may be contraindicated and it appears a cardiac evaluation would be appropriate. Additionally, given the patients severe and complicated headache disorder he may benefit from a referral to a headache specialist center. In any event, daily use of Imitrex (injectables or tablets) is not medically appropriate or clinically indicated.For the reasons set forth above, I have determined the quantity of medication 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 two-year-old female who has a history of profound bilateral congenital sensorineural hearing loss diagnosed at 15 months of age by Auditory Brainstem Response testing. A three-month trial of power hearing aids was of little benefit. Audiologic testing revealed responses/threshold between 100dB and no response for the right ear and between 95dB and no response for the left ear. Binaural aided testing with the power hearing aids revealed thresholds between 50-70dB. CT scan imaging of the temporal bones revealed anatomy suitable for cochlear implantation. The recommendation of the cochlear implant team is for simultaneous bilateral implants. The Health Plan has denied coverage for the proposed procedure on the basis that it is not medically necessary for treatment of the patients condition.The patient is certainly a candidate who meets medical indications/necessity for unilateral cochlear implantation. At issue is whether bilateral cochlear implants are medically necessary. The submitted literature has been thoroughly reviewed. The peer-reviewed literature available on bilateral cochlear implantation in profoundly deafened children is small and inconclusive. Pertinent literature includes Litovskys study in 2004 (the Gantz study in 2002 included only adults) in which only 3 of the 20 subjects were prelingually deaf children. The rest were adults. The three children had sequential, not simultaneous, bilateral cochlear implants and the improvement in sound localization and speech perception was slight. Subsequently, Litovsky has looked at an additional 13 children, again all of whom received sequential not simultaneous bilateral cochlear implants (Ear & Hear 2006). The results suggest that many but not all of the children performed better on measures of sound localization on acuity. The authors concluded that these results must be interpreted with caution because benefits on any other task as well as the long-term benefits of bilateral cochlear implants are yet to be fully understood. Peters, et. al., presented a study at the American Otolaryngological Society in May 2006 demonstrating improved speech perception scores in noise in a cohort of 30 children. However, all children received sequential rather than simultaneous bilateral cochlear implants and the age range was 3-13 years. Thus, there is no significant peer-reviewed literature that supports the purported benefits of simultaneous bilateral cochlear implantation in a two-year-old patient. In fact, Dr. Litovsky admonishes that the factors that might contribute to such benefits must be carefully evaluated in large populations of children using a variety of measures. The number of children evaluated thus far has been small and the variety of measures are few. Given the lack of evidence supporting simultaneous bilateral cochlear implantation at this time, I have determined 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 six-year-old male with a history of delayed fine motor skills. No other developmental delays are documented in the submitted records. The patient has been receiving occupational therapy since December 2004. The Health Plan authorized a portion of the therapy but has denied coverage for occupational therapy the patient received from February 2005 through July 2005 (except for dates of service from March 2005). At issue is whether the occupational therapy at issue was medically necessary.Based upon the clinical evidence provided, the patient does not have a defined illness, injury or congenital anomaly requiring occupational therapy. Additionally, in reviewing the therapy notes the first goal is an educationally based goal. The second goal is a sensory based objective with no measurable goal. The third goal is age appropriate, but the patient has not shown significant progress over the six months of therapy based on the daily progress reports provided. Furthermore, there are no follow-up progress reports documenting gains. All told, I have determined 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 45-year-old female who has idiopathic hypersomnolence. She has undergone a sleep study and was found to have mild sleep apnea. The sleep study also showed decreased sleep onset latency, but the patient does not have narcolepsy. The patient is not receiving other therapy for sleep apnea. The patients request for authorization of Provigil was denied by the Health Plan citing a lack of medical necessity.FDA approved indications for prescription of Provigil include narcolepsy, shift work sleep disorder and adjunctive therapy for sleep apnea. The patient has only mild sleep apnea and there is no peer-reviewed data to support the use of Provigil for the treatment of idiopathic hypersomnolence. The record indicates the patient is taking several other medications; some known to have a sedating effect. A review of current prescriptions with her provider may help to identify the source of her excessive daytime sleepiness. For these reasons, 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

The patient is a 15-year-old male with attention deficit and obsessive-compulsive disorders who has idiopathic short stature. Work-up including MRI of the brain, IGF-1, IGFBP-3 and thyroid evaluation were unrevealing. The growth chart indicates a falling off in stature from 12 years of age despite relative increases in weight. When the patients endocrinologist initiated growth hormone (GH) therapy, the patient had a projected adult height as low as 52 despite his target height based upon his parents stature of 59.5. The notes supplied indicate that his twin sister was 54 tall at age 14 years. The growth response to GH has been reported to be good. The patients parent has requested reimbursement as well as prospective authorization for growth hormone therapy. The Health Plan has denied this request citing a lack of medical necessity for growth hormone treatment.The Food and Drug Administration has approved growth hormone for the treatment of idiopathic short stature as a medically indicated therapeutic intervention to promote growth velocity and final adult height. The patients presentation is consistent with idiopathic short stature. The submitted clinical information indicates the patient has had a significant growth response since GH therapy was initiated. As such, there is sufficient evidence supporting the medical necessity for the patients past and continued use of GH therapy.  Based upon the information set forth above, I have determined the therapy at issue was/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 59-year-old female with a prior history of Major Depression, Generalized Anxiety Disorder, and Dependent Personality Disorder. She was admitted to inpatient treatment in July 2005. Her depression was characterized by feeling compelled to spend, anxious feelings, some anhedonia and increased sleep latency.  However, she was not felt to endorse any symptoms of Bipolar Disorder. By the point of admission, the patient had been treated with Wellbutrin XL, Effexor XR and Buspar. She saw a psychiatrist on a monthly basis and cited a good relationship with him. She had also been seeing a new therapist for the past four years, maintaining a similarly good relationship.  The patients admission mental status exam revealed her to be neatly dressed, cooperative, and with normal, articulate speech, although her thought process was considered as quite circumstantial and occasionally vague. Mood was depressed and affect labile. Thought content was devoid of psychotic ideation or suicidal ideation. During her inpatient treatment, she was seen in a variety of therapies and kept on the aforementioned medications, with no adjustment of the doses of those particular medications.  Her mood was noted to vacillate though did not appear affected by change in medications as opposed to dependency issues. She was felt to have gained some insight into these issues by the end of inpatient treatment.  At issue in this case is whether the inpatient treatment services the patient received from July 2005 through August 2005 were medically necessary for treatment of her medical condition.Review of the submitted clinical evidence does not demonstrate the patient required an inpatient level of care during the period in question. Though the patient had concerns that something might have happened to her at a young age there was no need for the patient to examine these issues on an inpatient basis. As for her clinical presentation, there appears to be nothing that actually would have mandated inpatient treatment. Her admission mental status exam was largely unremarkable. She was not severely depressed and, perhaps as a reflection of this, none of her medications were changed in her month-long hospitalization. Overall, there were no convincing medical grounds for an inpatient level of care. Therefore, I have determined 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 60-year-old female who sustained a left radial neck fracture in March 2003.  She was treated by an orthopedic surgeon and referred for physical therapy (PT) after her splint was removed one month later. The patient made good progress with PT and Dynasplint therapy was initiated in April 2003 and continued through July 2003. The patients request for reimbursement for the cost of the Dynasplint therapy was denied by the Health Plan based upon a determination that the therapy was not medially necessary.The clinical information submitted provides no explanation as to why Dynasplint therapy was initiated and there are no physician records documenting the need for this therapy. The patients physical therapist noted the patient was making good progress from the beginning of her PT program. In April 2003 the therapist indicated the patient would be fitted for a Dynasplint; however the PT progress notes do not explain why the therapy was required in light of the patients consistent progress. As such, the available records do not contain sufficient information to substantiate the medical basis for the Dynasplint therapy. Based upon the information set forth above, 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 41-year-old male who carries the diagnosis of laryngopharyngeal reflux.  The patient is also a smoker. Trials of allergy medication, Prilosec (omeprazole) and Aciphex (rabeprazole) have not relieved his symptoms of throat irritation, excess clearing and the sensation of build up in the throat. A trial of Nexium (esomeprazole) therapy was prescribed and the enrollees provider submitted a request for authorization. The Health Plan denied the request citing a lack of medical necessity.Nexium is a non-formulary drug for this Health Plan. The Health Plans policy for non-formulary drugs clearly states that they may be approved if a patient has failed treatment with those drugs available on the formulary. The Health Plan offers omeprazole, rabeprazole and Protonix (pantoprazole) as formulary alternatives. This is a reasonable policy, and the patient did not undergo a trial of Protonix prior to his request for a trial of Nexium. As such, 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: Upheld Decision of Health Plan

The patient is a 58-year-old female with a history of basal cell carcinoma. She currently has three relatively small, superficial lesions (1cm by 0.5cm by 0.1cm, 0.8cm by 0.6cm by 0.1cm, and 0.6 by 0.4 by 0.1cm) located on the upper back and shoulder. The patient requested consultation with a plastic surgeon for removal of the lesions. The Health Plan denied her request based upon a determination that plastic surgery consultation is not medically necessary.The patient reports she had several facial lesions treated by a plastic surgeon.  She now has three relatively small lesions located on less cosmetically sensitive parts of the body.  The management of lesions this size is not complex; the surgical treatment of small basal cell carcinomas is certainly within the purview of a dermatologist. The anticipated wounds can be readily closed without undermining or flap closures. Specialized plastic surgery is not medically indicated. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.