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

The medical history describes a young male patient with congenital adrenal hyperplasia who developed Crohns disease documented with colonoscopy and biopsy at age eight after four months of cramping and abdominal pain, diarrhea, and fever and weight loss. The impression was mild to moderate colitis, most likely Crohns disease based on typical endoscopic appearance including skip lesions. Biopsies showed acute and chronic inflammation with ulceration, cryptitis, and crypt abscess. The patient has been treated with medications including steroids. Colonoscopy was repeated in January 2005 when the patient was age 10 and again was compatible with Crohns disease although the biopsies were quiescent. The patients parent has requested authorization and coverage for use of Zithromax, which has been denied by the Health Plan as not medically necessary.The case history is compatible with Crohns disease based on the history, colonoscopic examination, pathology, and family history.Crohns disease has been suspected of being a chronic infectious disease since it was first described on the basis of pathological similarity to tuberculous enteritis and a bovine disease caused by M. paratuberculosis. Experimental animal models did not succeed in establishing a relationship. Most recently, there has been renewed interest in the role of M. paratuberculosis in human Crohns disease. As indicated in the materials provided, M. paratuberculosis DNA has been detected in Crohns disease tissues and the organism has even been cultured from the blood of some patients with Crohns disease. There are many descriptions of anti-tuberculous treatments of Crohns disease in the medical literature involving small numbers of patients. There are also two meta-analyses that have examined the many clinical case series describing the treatment of Crohns disease with anti-tuberculous therapy; these show a trend towards improvement with this treatment. The fundamental problem, however, has changed little with the application of modern sensitive molecular methods to the problem. It is still not known whether Crohns disease is caused by this organism or is permissive in allowing its presence in patients with Crohns disease. In addition, question remains as to whether anti-tuberculous treatment has some limited efficacy because it treats M. tuberculosis or because of the well-known, non-specific effect of antibiotics. The most that can be stated with certainty is that randomized double blind clinical trials may be justified.Though the role of Zithromax in treatment of Crohns disease is being studied, it is not widely accepted and there is no evidence to establish equal or superior efficacy compared to usual treatment. As such, there is insufficient evidence Zithromax is likely to be effective for this patient. Accordingly, 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: Overturned Decision of Health Plan

The patient is a 49-year-old male who is HIV positive and under the care of a HIV care physician who has requested a recombinant human growth hormone (Serostim) to treat severe lipohypertrophy (also referred to as visceral adipose tissue accumulation or lipodystrophy).He is described as having massive accumulation of intra-abdominal fat, which interferes with his activities of daily living and has caused shortness of breath and exacerbated his asthma by compressing the diaphram and causing obstructive lung disease. In addition, both a neurologist and a neurosurgeon have diagnosed neuralgia parasitica causing numbness of the thighs, legs and feet. The cause of this is nerve compression caused by progressive increase in abdominal girth due to the visceral fat accumulation of HIV lipodystrophy. Activities of this normally active and fit patient have been severely curtailed.At issue is whether the requested injections are medically necessary for treatment of the patients medical condition.Lipohypertrophy is a relatively newly recognized condition in patients with HIV and the cause is unknown. It is believed to be multifactorial, with HIV infection, insulin resistance and antiretroviral medications all playing some role. To date, there is no FDA approved treatment for this condition; however, results of clinical trials of human growth hormone are under review. Liposuction is often ineffective and cannot be performed on intra-abdominal fat and the fat often quickly reaccumulates anyway. While diet and exercise may help, they do not reverse the condition. Metformin and testosterone replacement may also play a role, but have not been proven effective.The results of a placebo controlled, double blind trial with 245 HIV patients testing rhGH in abnormal visceral adipose tissue accumulation show significant improvement in patients who received rhGH. There are also numerous pilot studies that suggest it may be the most effective treatment thus far, and there are many reports of dramatic improvement in certain patients with lipophypertrophy. As such, use of growth hormone in this patient is medically appropriate and indicated.Based upon the information set forth above, I have determined that the requested injections are 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 23-year-old female with approximately a two-year history of bulimia nervosa with episodes of binging and purging up to three times per day. Each binge lasted one to two hours with the patient sometimes eating to the point of physical pain. The patient also noted having grown increasingly depressed in the seven months prior to admission following the breakup of a relationship with her boyfriend, with subsequent lethargy, increasing social isolation, and irritability. This was compounded by her use of amphetamine, particularly flagrant in the three to four months prior to her inpatient admission in October 2002. Because of the perceived cycle of the patients binging and purging as well as the use of amphetamine, she was thought to be in need of inpatient psychiatric treatment.Review of the records provided indicates the patient was admitted with a body weight of 123 pounds, with her ideal weight being 120 pounds plus/minus 10%. She was mostly maintained on a regimen of Prozac 60 mg per day with which she had been treated in prior weeks. The remainder of the notes indicate the patient complied entirely with meal plans and maintained her weight with absolutely no episodes of binging or purging. She was also able to tolerate some therapeutic passes without any resumption in binging or purging. The prescribed dosage of Prozac was eventually lowered to 40 mg. The patient did have one instance of lightly cutting on herself, having done so due to a perceived lack of emotional outlet, what with no longer binging or purging. This sort of behavior remitted with staff redirection.Overall, despite the patients bulimia nervosa and amphetamine abuse, her presentation did not seem to reflect any particularly acute or urgent need for inpatient treatment. Specifically, her weight was entirely normal, she was not acutely depressed, and she was fully and immediately compliant with the therapeutic program with not a single episode of binging or purging. None of the submitted notes reflect the patient being notably depressed. In fact, the notes actually point to how euthymic she appeared. Hence, while treatment was indicated for this patient, it could well have been first approached from a partial hospitalization or intensive outpatient perspective.  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 44-year-old female who is 52 weighing 125 pounds with a breast size of 38C. She had a breast reduction in 1994. She is complaining of upper shoulder and neck pain as well as breast discomfort with aerobic activity. She has been receiving chiropractic for her neck and back pain without sustained relief. She is requesting authorization for breast reduction surgery.The patient previously underwent breast reduction in 1994 but feels her breasts still interfere with her ability to exercise, and are unsightly. The submitted photographs do not depict pathologic macromastia. The physical examination does not describe typical findings that would satisfy the accepted medical necessity criteria for breast reduction coverage. The amount of tissue that could be removed would make little difference in the total weight and distribution of breast tissue as it pertains to the patients symptoms. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 61-year-old female who has a history of post-traumatic herniated lumbar discs at L3-4 with lumbar radiculopathy. She has under gone provocative L3-4 discogram and microdecompressive lumbar discectomy at L3-4 in November 2004. In addition, the records indicate the patient also has deep vein thrombosis (DVT) and was taking Coumadin therapy at the time of the procedure. Since the patient has a history of clotting complications, the patient states it was best for her to undergo the least invasive procedure possible. She is requesting reimbursement for the procedure at issue. Percutaneous laser discectomy (PLD) is an investigational and experimental procedure without established clinical efficacy. Despite anecdotal evidence and reported successes, validation of its clinical benefit remains elusive. Furthermore, there were other proven treatment modalities available to this patient at the time she underwent surgery. Therefore, I have determined that the procedure at issue was 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: This 61-year-old woman has degenerative disc disease. She underwent laser disc surgery in November 2004. She is requesting reimbursement for the procedure. The Health Plan has denied this request indicating the procedure at issue is considered experimental.There is no data to support laser discectomy over standard open surgery. The standard procedure could have easily been performed in this case (even with her blood clot history). There is no medical justification for performing the laser procedure in this case.Therefore, I have determined that the procedure at issue was 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 61-year-old female with disc degeneration and herniation at L3-4 who underwent provocative lumbar discography and subsequent laser disc decompression surgery at L3-4 in November 2004. The issue in this case is whether the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I recommend the denial be upheld. Laser disc decompression/microdiscectomy via laser thermodiscoplasty has not been proven to likely be more beneficial than standard microdiscectomy and/or interbody fusion. Therefore, I have determined that the procedure at issue was 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 28-year-old female who has requested authorization for evaluation by a cardiothoracic surgeon for treatment of thoracoscopic sympathectomy. There is no documented evidence the patient has attempted conservative treatment. The Health Plan has denied coverage for the requested consultation on the basis it is not medically necessary for treatment of the patients medical condition.There is no evidence of medical necessity for referral to a cardiothoracic surgeon for evaluation at this point. There is no objective evidence of trial and failure of conservative measures in this case. The patient should explore and try all non-operative measures to see if any of these modalities will provide effective treatment before pursuing invasive operative procedures. Therefore, I have recommend that the requested consultation 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 62-year-old male with moderate to severe chronic pain related to microvascular decompression of the trigeminal nerve. He is being treated with Neurontin for this condition. Records submitted demonstrate he is experiencing significant sedation from the Neurontin. He is seeking authorization for Provigil to mitigate the sedating effects of the Neurontin. Records indicate Provigil has been beneficial with regards to the sedating effects of Neurontin. The Health Plan has denied authorization for Provigil.The patients condition is chronic and unrelenting. Provigil is a reasonable and commonly utilized therapy prescribed to improve the excessive daytime somnolence associated with the use of pain medication. For this patient Provigil is reasonable and medically indicated and has already benefited the patient. Therefore, I have determined 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 62-year-old woman with severe persistent asthma. A spirometry performed in December 2004 showed a normal pattern on the flow-volume loop and an FEV1 of 127% of predicted value. According to the information provided, the patient was unable to perform a post-bronchodilator test because she fainted. Her pulmonologist read the study as within normal limits. The patient has requested coverage for use of Xolair in treatment of her asthma. A note dated May 2005 from her primary care physician states the patient has had multiple flares resulting in multiple corticosteroids treatments, putting the patient at risk for hyperglycemia and osteoporosis.The Health Plan has denied coverage for Xolair indicating the patients IgE level was beyond the recommended treatment level and she did not have demonstrable airway reactivity, indicated by an increase in FEV1 after bronchodilator challenge. The patients IgE level was 728 IU/ml and she weighed 159 pounds (72.2 kg).At issue is whether Xolair is medically necessary for treatment of the patients medical condition.Xolair is indicated in patients with moderate to severe asthma and positive skin test reactivity to aeroallergens. This initial study had patients with FEV1 between 40-80% of predicted value, a change of FEV1 of more than 12% after bronchodilators, with total IgE between 30-700 IU and a body weight of less than 150 kg.According to the records provided, the patients IgE level is above the 700 IU criteria. The dosing chart provided by the drug manufacturer states that patients with levels above 700 IU should not be dosed. Though there is a need to reduce the use of systemic corticosteroids, it appears other diseases such as allergic bronchopulmonary aspergillosis, vocal cord dysfunction or other pulmonary illnesses, which may mimic asthma, should be considered. In any event, the use of Xolair is not medically indicated based upon the information provided. Therefore, I have determined that the requested medication is not medically necessary for the 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 with history of spasmodic dysphonia for approximately 10 years and dystonia since March 2004. Per review of the submitted medical records, the patients spasmodic dysphonia has improved with speech therapy. The patients provider has requested authorization for acupuncture for treatment of the patients dystonia. The Health Plan has denied this request indicating acupuncture is not medically necessary for treatment of the patients condition.Review of the submitted clinical information indicates the patient has a history of spasmodic dysphonia for approximately 10 years with favorable response to speech therapy. With regard to the patients dystonia, she has failed physical therapy. She has attempted yoga and attends support groups, but continues to experience symptoms. Review of the submitted medical literature reveals that in addition to conventional methods for treatment of dystonia, there are complementary or alternative methods including acupuncture, homeopathy, massage, and biofeedback therapy. Since there is evidence in support of acupuncture for treatment of dystonia, a trial of the requested therapy would be medically reasonable and appropriate in this case. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should undergo a trial period of acupuncture at a frequency of twice a week for four weeks with re-evaluation at the end of the trial period. If there is documented evidence acupuncture has been beneficial for the patients condition, additional acupuncture should be authorized. If there is not documented evidence acupuncture has been beneficial for the patients condition, additional acupuncture should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 53-year-old female who has worsening neck pain and paresthesia in both arms. The patient has a past history of cervical disc disease. In addition, the patient complains of low back pain and pain in the left buttock, which radiates down the left leg. The back pain has been increasing since at least March 2005. The patients provider has ordered an MRI of the cervical and lumbar spine to assess for disc disease and spinal stenosis. At issue is whether an MRI of the patients lumbar and cervical spine is medically necessary for evaluation of the patients condition.Review of the submitted information indicates the patients symptoms, their duration, and her present medications are sufficient to warrant an MRI of the lumbar and cervical spine. It is well established that MRI is the best imaging examination of the spine. The MRI results will be helpful for more definitive treatment of this patient by a specialist such as a neurologist or orthopedic surgeon. Therefore, I have determined that the requested MRI is medically necessary for evaluation 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 four-year-old boy with reactive airway disease from age six months. He was initially treated with albuterol, which he did not tolerate and he was empirically switched to Xopenex for the next two years. His symptoms improved and he was taken off his daily nebulizer treatments. In December 2004, he began having recurrent symptoms. The patient was again tried on albuterol, but was reported not to have tolerated it well. His parent is seeking authorization for Xopenex, which the Health Plan has denied on the basis Xopenex is not medically necessary.Xopenex is the pure active isomer of albuterol. Clinical properties including side effects are similar with both agents. There is little or no clinically conclusive data that Xopenex is superior to albuterol. Multiple dose albuterol vials contains an agent to suppress spillage of the open containers. The agent contains benzol and some allergists suggest using only single dose vials to avoid the agent. In addition, lower doses of albuterol may reduce side effects yet still be effective in relieving symptoms of reactive airway disease. 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

This 51-year-old male with multiple medical problems requests growth hormone (GH) for presumed adult GH deficiency (AGHD) based on non-specific symptoms, a low IGF-1 on several occasions and the response to an arginine/GHRH stimulation test. The patient is obese with diabetes, hypertension, sleep apnea, and dyslipidemia. At the time of his initial evaluation for possible hypogonadism he complained of some slight decrease in energy and decreased libido with some degree of erectile dysfunction.The evaluation by his endocrinologist revealed a normal to low normal testosterone, free testosterone, and bioavailable testosterone concentrations. The rest of the pituitary function tests and an MRI of the pituitary were also normal. An IGF-1 concentration was low. This lead to an arginine/GHRH stimulation test, which was abnormal. There is no evidence of AGHD in this patient. The diagnosis is usually made based on the clinical context, which is suggestive of some disorder of the hypothalamic-pituitary axis. Other causes for the patients symptoms could be his obesity, hypertension, sleep apnea or the medications he is taking. These must be considered before undertaking a course of testing for AGHD. Furthermore, all tested pituitary hormones appear normal in this patient and his MRI shows no structural lesion in the pituitary.The diagnosis of AGHD is based on the clinical context, signs and symptoms, as well as the results of biochemical testing. The patients signs and symptoms are sufficiently non-specific, and GH stimulation tests sufficiently inaccurate, that it is possible to have a false positive diagnosis. As such, there is insufficient evidence growth hormone therapy is medically indicated for this patient. 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 56-year-old male with degenerative joint disease of the left knee. X-rays show severe degenerative joint changes in all three components. In February 2004, the patient underwent arthroscopy, debridement and partial medial meniscectomy. The patients physician has recommended the patient use the Bionicare System. The Health Plan has denied coverage for the requested equipment on the basis it is not medically necessary.There is no Class I published data establishing the Bionicare System as an effective treatment of degenerative joint disease. The efficacy of this treatment remains unproven. Conservative therapies are likely to be more beneficial for this patient than the requested equipment. Therefore, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.