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

The patient is a 66-year-old female with symptomatic collagenous colitis. She had been treated with 5-ASA products and prednisone, but due to side effects prednisone was discontinued. She was started on Entocort and has had good results. The Health Plan has determined Entocort is not medically indicated for treatment of the patients medical condition. Though the FDA indication for Entocort is for treatment of mild to moderate active Crohns disease involving the ileum and/or the ascending colon, there are numerous published studies in the medical literature regarding the safety and efficacy of Entocort for treatment of collagenous colitis. The patient has failed conventional treatment for this disease. The submitted clinical information documents that she has had good results with Entocort without adverse side effects. As such, continued use of Entocort is medically reasonable and indicated for treatment of the patients collagenous colitis. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 41-year-old male with erectile dysfunction. He had a complete physical examination and no specific etiology was identified. Treatment with Viagra was not successful but subsequent treatment with Levitra was successful. The Health Plan has denied authorization for Levitra because there is no known organic cause for the enrollees dysfunction. The cause of erectile dysfunction is irrelevant to the treatment. Regardless of the cause of erectile dysfunction, medications such as Viagra and Levitra are considered first-line therapy. This patient has experienced benefit from Levitra after having failed Viagra. Based upon these results, treatment of the patients erectile dysfunction with Levitra is medically necessary. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 63-year-old male with erectile dysfunction. Treatment with a vacuum erection device was ineffective. Treatment with Viagra led to side effects such as heartburn and headache. He has tried Cialis with good results and his provider has recommended continued treatment with Cialis. The Health Plan has denied authorization for Cialis in part because there is no documentation of an underlying medical condition causing the patients erectile dysfunction. At age 63 this patient most probably has some level of vascular disease, which is at least contributing to his erectile dysfunction. Regardless, the treatment of erectile dysfunction is results oriented and is not directed at the cause of the dysfunction. Medications such as Viagra and Cialis are considered appropriate first-line therapies for the treatment of erectile dysfunction. It is documented that Cialis has been effective for this patient where other treatments have failed. As such, it is evident that Cialis is an effective, medically necessary treatment for this patients erectile dysfunction. Therefore, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old female with chronic hepatitis C (genotype 1a) and Stage 3 fibrosis who failed to achieve viral remission on pegylated interferon and ribavirin therapy. Her treating physician has recommended maintenance interferon therapy based upon the hypothesis that decreasing (but not eliminating) viral load over a prolonged period of time may benefit clinical outcomes of the patients disease. There are no compelling data that support the treating providers hypothesis outlined above. The proposed approach is experimental and controversial and awaits the results of completed controlled trials that will then be able to be critically evaluated. The results of analysis of such trials are necessary before interferon maintenance therapy for non-responders can be justified. There is no evidence regarding the safety or efficacy of the proposed therapy. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 41-year-old female who has multiple reasons for severe intractable lymphedema, most significantly, ovarian cancer and severe infection. She has an active life and has been severely impaired by lymphedema. The patient indicates her condition has greatly limited her ability to perform her daily activities. The submitted evidence indicates the patient tried compression stockings without success. She has requested coverage for a Flexitouch pump. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the patients lymphedema. Severe intractable lymphedema can be a very difficult problem to treat. This patient has tried manual lymphatic drainage, which was successful, but she is unable to self-treat because of carpal tunnel and Raynauds syndrome. The patient has experienced a well-documented, dramatic reduction in her lymphedema over six months using the Flexitouch pump. Continued use of the Flexitouch pump is likely to reduce infections and the frequency of doctor visits. Given that the patient and her treating specialists have documented significant benefit from use of the Flexitouch pump, I have determined the requested equipment 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 an 85-year-old female who was transferred to a SNF following hospitalization for treatment of pneumonia. In addition, the patient had multiple comorbidities including dementia and functional decline. While in the SNF, the patient received skilled physical and occupational therapy from 6/1/04 to 6/16/04. The patient made minimal gains during this time period except in endurance. Endurance training does require receipt of services from skilled personnel. The patient remained in the SNF until 7/8/04. The Health Plan has denied coverage for the services the patient received from 6/18/04 to 7/8/04. The patient did not make any clinically significant gains after 6/1/04. Skilled rehabilitation services are provided with the goal of enabling a patient to reach maximum functional status. Once maximum functional status is reached, it is reasonable to provide continued endurance training at a non-skilled level. The records provided demonstrate the patient had reached maximum functional status by 6/1/04 and there was no indication that continued therapy would benefit the patients condition. In fact, the records provided demonstrate the continued therapy did not increase the patients functional level. 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

The patient is a 39-year-old female who has requested labial reduction and removal of excess perianal tissue. Based upon the information provided, it appears the patient first raised the issue with her primary care physician in September 2003 when she complained of labial tissue rubbing against her thighs during physical activity. On exam, the primary care physician noted hypertrophy of the labia minora and referred the patient to a gynecologist. The gynecologist noted the labia minora were large but without erythema or induration and referred to the patient as having a variation of labia minora. The gynecologist also apparently discussed the risks of labial reduction with the patient to include scarring, nerve damage, and lymphedema. At the patients request she was referred to another gynecologist for a second opinion; a nurse practitioners note did not indicate any labial abnormality but did question the presence of a hemorrhoid or skin tag in the perianal area. The patient was then referred to a plastic surgeon for consideration of a labial reduction and removal of excess perianal tissue. The Health Plan has denied authorization and coverage for the requested procedure indicating it is not medically necessary. The submitted clinical information reveals no medical indication for a labial reduction and removal of excess perianal tissue. The patients providers notes indicate there was no evidence of erythema or induration. In addition, there is no evidence that conservative therapies have failed to help the patients condition. Furthermore, the requested procedure could cause pain and disfigurement. 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 50-year-old male with a recurrent grade III abdominal liposarcoma, status post two resections and alternative immunotherapy. He now has progressive disease. The patient is largely asymptomatic and has had no chemotherapy or radiotherapy. He is in good clinical condition. A request has been made for coverage for insulin potentiation therapy. The Health Plan has determined the requested therapy is not medically necessary for treatment of the patients medical condition. There are shreds of scientific data that provide a rationale for insulin potentiation therapy with chemotherapy in an effort to augment chemotherapy response. Cancer patient trials, however, are limited to anecdotal reports and none involve soft tissue sarcomas. As such, there is no basis to recommend insulin potentiation therapy prior to standard treatment outside of a clinical trial. Therefore, I have determined 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 an 11-year-old male with a diagnosis of short stature. Based on the documentation provided, it appears the patient began growth hormone (GH) therapy in March 2004. The heights of the parents have not been provided. When seen in December 2004, the patient was age 11 and had grown more than 10cm in the previous year. Prior to this the patient had generally grown at a normal rate near the third percentile. A request has been made for continued use of growth hormone therapy. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition. The submitted records show that the patient had no delay in bone age, had at least one normal response to clonidine GH stimulation test (peak 18ng/ml), and two normal levels of IGF-1 and a normal GH dependent IGFBP-3 level. Thus, GH deficiency is improbable. The patient had a significant growth response to GH therapy. It seems that puberty had advanced at least to axillary odor. The patients father indicates the patient had a pre-GH therapy growth rate of less than 5cm a year and at least a doubling of that rate on GH therapy. The patients predicted adult height based upon bone age and height in March 2004 would lie in the 55-56 range. Based upon these findings, the patient does not meet medical necessity criteria for consideration of GH therapy. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old female status post knee surgery with restricted knee range of motion. The patients provider prescribed an ERMI Flexionater and a neuromuscular stimulator for home use. The patients provider indicates use of this equipment has resulted in an improvement in the patients range of motion to 130 degrees. The patient has requested reimbursement for the ERMI Flexionator and neuromuscular stimulator. The Health Plan has denied the request on the basis the equipment at issue was not medically necessary.The submitted evidence documents the patient experienced improvement in range of motion with use of the ERMI Flexionater and neuromuscular stimulator. A study by Talbot, et al. demonstrates the efficacy of neurostimulation for patients undergoing knee rehabilitation.  In the case of this patient, there is documented evidence the equipment at issue has been beneficial. It is unlikely that the patient would have experienced this degree of improvement with manipulations and injections. Therefore, I have determined the equipment 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 two-year-old twin who was born premature and has chronic lung disease. The patients parent is requesting authorization for Synagis injections for the winter months. This request has been denied by the Health Plan.Analysis and Findings:The patient does not meet the nationally accepted guidelines for consideration of Synagis. Specifically, the American Academy of Pediatrics recommends Synagis before the start of the RSV season for children with chronic lung disease who have required medical therapy for chronic lung disease within six months before the anticipated start of RSV season, and who are less than two-years-old. Although this patient has chronic lung disease, she is not less than two years of age. In addition, she does not meet other qualifying criteria for consideration of Synagis. Therefore, Synagis is not recommended for this patient. Accordingly, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old female who has requested a Cox-2 inhibitor after a trial of non-steroidal (NSAID) medications. The patient has tried a number of NSAID medications without success. The Health Plan has recommended other NSAID medications for the patient prior to consideration of a Cox-2 inhibitor. The Health Plans policy is reasonable and appropriate and consistent with evidence-based standards.There is no advantage over Cox-2 inhibitors over traditional NSAIDs. There is some potential advantage for individuals with gastrointestinal intolerance of NSAIDs but this advantage is questionable and has not been established in the evidence-based literature. The Health Plan is offering the patient appropriate medications for treatment of the patients condition. There is no evidence that a Cox-2 inhibitor is medically necessary at this time. Therefore, I have determined that 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 63-year-old female with a history of hepatitis C on treatment and neutropenia. Shortly after beginning treatment the patients ANC dropped. Instead of reducing the dose of the patients medications, the patients provider instituted treatment with Neupogen, which resulted in an improved white blood cell count. The Health Plan indicates the provider should have reduced the dose of the patients medications prior to considering Neupogen. Therefore, the Health Plan has denied reimbursement for Neupogen.It has been established that patients who respond to hepatitis C therapy are those who take 80% of the dose of medication 80% of the time. Neutropenia is a well-known side effect of this treatment. If one is able to treat hepatitis C without having to reduce the dose, theoretically it would be beneficial for the overall SVR. However, a review of relevant literature does not reveal any large, randomized, prospective studies addressing this issue. In fact, the studies set forth above indicate that further studies are necessary and no firm conclusion can be drawn regarding this issue at this time. In this instance, it would have been reasonable for the patients provider to reduce the patients dose to 80% in an attempt to correct the patients neutropenia. It was not medically necessary for the patient to begin treatment with Neupogen without first attempting dose reduction. Therefore, I have determined the medication 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 male who suffered a brain injury resulting from his jumping out of a moving ambulance in January 2004. His wife reports his behavior has been altered and that he exhibits psychological problems. He was evaluated by the Centre for Neuro Skills and inpatient rehabilitation was recommended. The Health Plan has recommended a multidisciplinary evaluation as an alternative to inpatient care. A review of the information provided indicates the patient has some psychological problems. In addition, a review of the record indicates the patient is independent with gait, hygiene, grooming, and bathing. He is independent in all areas of basic self-care. Based upon this information, a multidisciplinary inpatient admission is not medically necessary. The recommended evaluations by the Health Plan are indicated and appropriate to create an appropriate treatment plan for this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 53-year-old female with a history of chronic fatigue syndrome, fibromyalgia, obstructive sleep apnea, arthritis, and chronic headaches. She has been tried on all anti-inflammatories, Risperdal, Zonegran, Prozac, and Diazepam without benefit. The patients current medication regimen includes Welbutrin, Effexor, Fiorinal, Ambien, Soma, and Nortriptyline. She continues to have fatigue and constant pain. The patient also is participating in a chronic fatigue group. Her primary care physician has recommended Provigil to help improve the patients energy. The Health Plan has denied authorization and coverage for Provigil on the basis it is not medically necessary for treatment of the patients medical condition. Based upon the submitted medical records, it does not appear the patient is currently responding to most of the medications that she has tried in the past. She does have obstructive sleep apnea as confirmed by sleep studies, which may contribute to her fatigue. Provigil has an excellent safety profile with minimal effects on the cardiovascular system. Given the failure of the patients previous and current treatment regimens, a trial of Provigil is medically reasonable and appropriate. Therefore, I have determined that the requested medication 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 61-year-old male who has a history of right knee pain and degenerative joint disease. He received a series of Synvisc injections in December 2003. His physician indicates the patient experienced unsatisfactory results with the first series of injections. He has recommended the patient receive a second series of injections to achieve optimum results. The Health Plan has denied authorization and coverage for Synvisc injections on the basis the injections are not medically necessary. The patient has a degenerative knee joint. In light of the failure of the first series of Synvisc, a second series of Synvisc injections are neither medically indicated nor medically necessary. Further Synvisc injections will not alleviate his condition. Other treatment options including cortisone or knee replacement should be considered. Therefore, I have determined that the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old female with rheumatoid arthritis. The patients treatment regimen includes Remicade, Arava, prednisone, ibuprofen, and Excedrin. The patient has apparently had severe pain related to her rheumatoid arthritis and secondary degenerative joint disease, and recently underwent a hip replacement. The patients provider states the patient was given Actiq for breakthrough pain in association with her osteoarthritis prior to her hip replacement.The materials provided demonstrate the patient received an extensive array of narcotic medications in June, July and August 2004, including, oxycodone, OxyContin, Endocet and Kadian. Records from 8/31/04 indicate the patient was in no acute distress though she continued to take OxyContin 80mg three times daily. Included in the patients providers assessment were total body pain and chronic opioid therapy. A request has been made for reimbursement for Actiq. The Health Plan has denied this request on the basis that Actiq was not medically indicated for treatment of the patients medical condition. Based upon the information provided, it appears the patient has rheumatoid arthritis, secondary degenerative joint disease, and a chronic pain syndrome. Her pain syndrome has led to treatment with extensive narcotic medications, which does not address the cause of her pain. Prior to her hip replacement, Actiq was prescribed without indication, in what was apparently an escalating regimen of narcotics. The records note that after the hip replacement the patient continued to require OxyContin for pain control, though the ongoing cause of pain is not clearly described and it is known if she continued to receive other medications as well. Actiq is a short-acting nasally-administered narcotic with clearly limited indications (i.e., breakthrough pain in cancer patients). It is not intended for use in other pain syndromes. This patient was prescribed Actiq without appropriate indications. Therefore, I have determined that the medication 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 51-year-old female with left acetabular posterior wall fracture, right ankle fracture, odontoid process fracture, and right wrist fracture. She was transferred to a skilled nursing facility (SNF) on 11/24/04 for physical therapy to improve transfer. She is non-weight bearing in both lower extremities and has a halo device. The records indicate non-weight bearing of right lower extremity is to continue through 1/13/05. The patient has been recommended for restorative nursing activity as of 12/10/04. She wishes to receive additional SNF services. The Heath Plan has determined further SNF services are not medically necessary for treatment of the patients medical condition. Review of the submitted clinical information indicates the patient does not meet medical necessity criteria for SNF services. There is insufficient evidence that the requested services are likely to provide benefit and restoration of function. Patients such as this patient (i.e., non-weight bearing status) generally undergo limited rehabilitation courses until their orthopedic issues resolve. Based upon the information provided, the patients injuries preclude significant benefit from physical therapy until her bones are able to tolerate weight bearing. Therefore, 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.