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

The patient is a 47 year-old female who underwent a gastric bypass operation in 2000 at a weight of 348 pounds and a BMI of 57.9.  She lost about 135 pounds and then began to regain her lost weight. The patients current weight is 282 pounds, with a BMI of 46.9.   She has a large ventral hernia and is requesting a Lap Band procedure in order to lose weight and reduce the chance of hernia recurrence.  The Health Plan has determined that the Lap Band procedure is not medically necessary and therefore, has denied authorization and coverage for the procedure.The patient and her provider are requesting authorization for the Lap Band procedure in order to correct her weight regain and minimize the chance of hernia recurrence after surgical repair.  The patients surgeon indicated there is an 80% success rate with the gastric bypass operation.  The Buchwald study found only a 61.6% success rate for the gastric bypass and other published data showed even lower long-term success rates for the super morbidly obese patients with a BMI greater than 50.  The patients inadequate weight loss and weight regain following gastric bypass are not unexpected or surprising. The Obesity Surgery article referenced above is one of a very few articles that addresses the revision of a failed gastric bypass operation. Conversion of a proximal to a distal gastric bypass results in significant metabolic deraignment as the patients provider noted. There is no scientific data that demonstrates a long-term benefit to Lap Band placement in this situation. The notion that a more restrictive operation will promote further weight loss is not a scientifically proven fact. Based upon the information set forth above, 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

This is a 45-year-old female patient who is postoperative from a gastric bypass procedure.  She is now facing the problem of excess skin following substantial weight loss. She was evaluated by two plastic surgeons and was advised to undergo panniculectomy to relieve her intertrigo. This procedure was authorized and scheduled, but the patient has requested that body contouring (abdominoplasty) be performed at the same time as the panniculectomy. The Health Plan denied authorization for the abdominoplasty based upon a determination that it is not medically necessary.Upon review of the submitted documentation, there appears to be a functional indication for a panniculectomy. However, there is no documentation of a functional problem or medical condition related to the excess abdominal skin. The abdominoplasty desired by the patient is a cosmetic procedure, and therefore is not medically warranted for treatment of her condition. 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 an 11-year-old male with idiopathic short stature that may be the result of familial short stature combined with a constitutional delayed adolescence. The patients mother is 410 tall and his father is 54 tall, resulting in a mid-parenteral height of 53.5. His bone age was 9 years and 0 months at the age of 10 years and 10 months, and he was near 48 inches in height at that time, which would give a predicted height near 54, his mid-parenteral height potential. His growth has been well below the third percentile. There have been several IGF-1 levels performed in the low range for age and stage of sexual development, but he had one growth hormone level above 10 after provocative testing. The patient had normal thyroid tests and celiac disease was ruled out. He appears to have been followed by an endocrinologist.At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.The Food and Drug Administration (FDA) has recently approved growth hormone for the treatment of idiopathic short stature as a medically indicated therapeutic intervention to promote growth velocity and final adult height. Based on the FDA criteria, the patient is an appropriate candidate for growth hormone therapy. It is likely that the patient will respond well to growth hormone in that his IGF-1 levels have been consistently low. Positive interval growth responses would be required to continue therapy until epiphyseal fusion.Based upon the information set forth above, I have determined the requested therapy 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 43-year-old female who is status post lumbar fusion and laminectomy in March 2005. She has an on-going complaint of left leg and lower back pain.  The patient was evaluated by an interventional pain specialist and sacroiliac (SI) joint arthrogram and piriformis, trochanter and sacroiliac joint injections were recommended for evaluation and treatment of her pain.  The Health Plan denied authorization based upon a determination that the procedures are not medically necessary.This patient is most likely experiencing post-surgical fusion/laminectomy back pain. The information provided in the record does not adequately demonstrate the need for SI joint, piriformis and trochanter injection therapy. Additionally, the current medical literature does not support the efficacy of these procedures. The article by Van Tulder is one example, and this study does not recommend injection therapy for the treatment of lower back pain. There is no class I data available to validate a supposition that injection therapy will improve long-term outcomes in the treatment of lower back pain.   Therefore, I have determined the requested procedures are not medically necessary for evaluation and 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 57-year-old male with the diagnosis of Peyronies disease. This has reportedly been present for eighteen months and has been associated with erectile dysfunction. In his report from October 2005, the urologist described the patients symptoms as reduced (penile) rigidity along with some penile shortening but no significant curvature. The patient is reported as still being able to achieve vaginal penetration and his libido is described as healthy. Physical examination at that time revealed fairly diffuse Peyronies plaque on the dorsal and lateral aspect of the mid penis.The patients urologist recommended transdermal Verapamil gel in order to avoid surgery. In addition, Cialis has been recommended for the patient.At issue is whether the requested medications are medically necessary for treatment of the patients medical condition.This patient has been diagnosed as having Peyronies disease. His primary, medically treatable problem associated with this condition is erectile dysfunction. Cialis, an oral PDE-5 inhibiting medication, is a medically appropriate and indicated treatment for the patients erectile dysfunction and should be authorized.As for the treatment of the underlying Peyronies disease with transdermal Verapamil gel, there is no significant, peer-reviewed, objective, documented literature currently available indicating that this use is efficacious. There are other treatments (short of surgery) available for treatment of Peyronies disease. Depending upon the patients current status, oral treatments such as vitamin E or Potaba may be appropriate as well as intra-lesional injection therapy with steroids. At this time there is no evidence that transdermal Verapamil gel is likely to result in an improved clinical outcome in this case. Based upon the information set forth above, I have determined that although Verapamil gel is not medically necessary for treatment of the patients medical condition, Cialis is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial of the requested medications should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old man with a history of osteoarthritis in his left knee. He is status post a meniscectomy. The patient has received Synvisc injections without significant relief. His provider has recommended a trial of therapy with the Bionicare system. The Health Plan has denied this request on the basis that the requested device is not medically necessary for treatment of the patients condition.The efficacy of an electric stimulator such as the Bionicare system for the treatment of pain secondary to osteoarthritis remains unproven at this time. No prospective study has been conducted to warrant its general use. The risks, benefits and long-term results of such therapy remain unknown. There is no evidence that the use of the Bionicare system is likely to result in an improved clinical outcome. Therefore, I have determined the requested device 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 59-year-old female with almost a 30-year history of diabetes mellitus type II. Her blood glucose was not controlled on a variety of oral medications. Her HgA1C in October 2004 was 9.3%. Novolog was added in the spring of 2005. The patients HgA1C dropped from 9.3% to 8.4% on metformin 1000mg twice a day, glyburide 10mg twice a day, Avandia 8mg once a day, and Novolog twice a day. The patient experienced several hypoglycemic reactions on this regimen. In the summer of 2005 Novolog was discontinued and the patient was started on Byetta 5mcg twice daily and the oral medications were continued as above. Lab results from October 2005 indicate the patients HgA1C had dropped to 7.3%. The patient has requested authorization and coverage for Byetta. The Health Plan has denied this request on the basis that Byetta is not medically necessary for treatment of the patients condition.Review of the submitted medical records reveals the patient achieved better control of her blood sugar with Byetta, metformin, glyburide and Avandia than with Novolog, metformin, glyburide, and Avandia. She did not experience hypoglycemia while on Byetta and no side effects were reported.Byetta is the synthetic version of a hormone produced by the intestinal tract. Byetta slows down digestion, stimulates insulin production and decreases post-prandial glucagon levels. The results are better blood glucose control, lower pre- and post-prandial blood sugars, decrease in appetite, and weight loss. The only side effect of Byetta is initial nausea, which usually subsides. Since Byetta is a synthetic natural hormone of the body (like insulin), there should be no contraindications with any other drugs. Clinical studies have shown that Byetta is indicated for patients with diabetes mellitus type II who take sulfonylureas and/or metformin. Thiazolidinedione derivatives (TZDs) such as Avandia, and Actos are insulin sensitizers like metformin. Studies are being conducted using TZDs and Byetta. Many endocrinologists are using Byetta in type II patients in conjunction with TZDs.The patient experienced good results with Byetta, metformin, glyburide and Avandia, leading to improvement in her health and reduction in hypoglycemia. Therefore, continuation of Byetta is medically appropriate and indicated. It would also be appropriate to consider lowering the dose of metformin, glyburide and Avandia in conjunction with Byetta.Based upon the information set forth above, 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 58-year-old female with cystic mastopathy. A mammogram performed in October 2003 showed a 2.6 cm circumscribed mass in the left breast. Several small benign-appearing masses were also present in both breasts. This was unchanged from October 2002. The submitted records do not include mammogram reports from 2004 and 2005; however, an addendum to the ultrasound report of August 2005 stated that there had been no interval change. Ultrasound of both breasts was performed in August 2005. Two simple cysts were seen in the left breast, the largest measuring 1.4 cm. Exam of the right breast was negative.The patients 53-year-old sister has breast cancer and a paternal aunt was diagnosed with breast cancer at age 40. The patients clinician is requesting a screening MRI of the breasts because of increased risk.  The Health Plan has denied coverage for the requested MRI on the basis that it is not medically necessary.There are several indications for MRI of the breast including pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high risk patients, and problem solving. An indication for non-malignant disease is evaluation of breast implants. The high risk patients are those with a personal history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or 2 gene. High risk patients also include biopsy proven atypia, lobular carcinoma in situ, radial scar, and prior mantle radiation.This patient does not have any of the above-mentioned indications for a breast MRI and she is not at sufficient risk to be considered for screening at this time. Therefore, I have determined the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This case involves a 55-year-old woman with a diagnosis of major depressive disorder, post-traumatic stress disorder (PTSD) and generalized anxiety disorder (GAD). She is in psychotherapy and receives psychotropic medication from her primary care physician. She has been in therapy with the psychotherapist for an extended period of time. The patient has requested reimbursement for the outpatient therapy she received from January 2004 onward and is seeking authorization for continued outpatient psychotherapy.There are several issues that are presented by this case. The first is that there is no end point to the proposed psychotherapy; it seems there is an expectation that therapy will go on in perpetuity. Secondly, it appears the patient is receiving a sub-optimal dose of antidepressant medication. She should be evaluated by a psychiatrist skilled in psychopharmacology so that an effective medication regimen can be devised and implemented. The psychotherapy the patient received beyond January 2004 was not medically necessary. The patients condition is chronic and does not appear to have improved during the period at issue. Furthermore, she has a better chance for improvement with psychotropic medications than with continued, ongoing psychotherapy. 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: Overturned Decision of Health Plan

A 47-year-old female patient with a BMI greater than 50 is requesting authorization for the duodenal switch procedure. She outlined a number of comorbid conditions including hypertension, hyperlipidemia, joint pain, back pain, and asthma. The patient has completed a psychological evaluation with a positive recommendation. The Health Plan does not dispute the appropriateness of the patients candidacy for weight loss surgery, but rather the type of surgery the patient should have. The Health Plan has indicated that Roux-en-Y gastric bypass is safe and effective for the surgical treatment of morbid obesity and that the duodenal switch procedure is not medically necessary.The available scientific data does not show an increase in risk, long or short-term, when comparing the biliopancreatic duodenal switch procedure to other surgical weight loss procedures. In fact some of the most common protein deficiencies may be more common in patients who have undergone the Roux-en-Y gastric bypass procedure than those who have had the duodenal switch procedure. Duodenal switch has a far better long-term success rate with regard to sustained weight loss than the gastric bypass operation. These facts are confirmed in the literature provided by the patient. Given the similar safety profile of the two procedures, the superior long-term success of the duodenal switch procedure over gastric bypass supports its medical necessity in this case.Based upon the information set forth above, 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: Overturned Decision of Health Plan

A twenty-three year-old female with a cystic bone lesion of the proximal humerus involving the proximal diaphysis, metaphysis and a portion of the humeral head is requesting treatment with an out-of-network orthopedic specialist.Reviewers Findings:  The reviewing physician found that the patients request for a referral to an orthopedic surgeon who specializes in the treatment of bone tumors is medically appropriate.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 12-year-old male who was diagnosed with ADHD and requires growth hormone supplementation. He has been under the care of a psychiatrist for several years and has taken the following medications: Dexedrine, Concerta, Adderall, Strattera, Wellbutrin and Tenex. The patients provider described the indications and the reasons for discontinuing each of the medications prescribed in an attempt to control the patients ADHD. The patients provider also noted concerns related to small stature, the impact of stimulants on growth and the need for growth hormone supplementation. The provider initiated an off-label trial of Provigil and found that the patient tolerated the medication well and had a remarkable clinical response. The provider requested authorization and coverage for Provigil, but the request was denied by the Health Plan based upon a lack of medical necessity.A significant number of medications utilized for children are off-label. Antidepressants are one example.  Prozac is a rare exception to the general rule that there are very few non-off-label antidepressants for children. Multiple other antidepressant medications are prescribed by physicians despite their off-label status. There is a clear precedent for the off-label use of a medication for children and adolescents. In this clinical context, there is a well-founded rationale for not utilizing standard medications to treat the patients ADHD and there is clear documentation that the patient has responded well to Provigil without untoward side effects. Additionally, a review of the literature does reveal support for the use of Provigil and its effectiveness in treating children with ADHD. Based upon the information set forth above, 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: Overturned Decision of Health Plan

The patient is a 58-year-old male who has requested authorization for a bariatric surgery consultation.  He is 61, weighs 329 pounds, and has a body mass index (BMI) of 43.4. In addition, he has significant comorbid conditions. The Health Plan has denied authorization and coverage for the consultation with a bariatric surgeon based upon their determination that it is not medically necessary for treatment of the patients medical condition.With a BMI of 43 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that bariatric surgery will be beneficial for this patient. The fact that there is no documentation of medically supervised weight loss should not preclude a consultation for bariatric 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 patient needs to be evaluated by a bariatric surgeon to determine whether he should proceed with weight loss surgery. A consultation with a bariatric surgeon is medically indicated and necessary for evaluation of this patients morbid obesity.Based upon the information set forth above, I have determined that the requested consultation is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. In addition, if upon consultation with a bariatric surgeon, weight loss surgery is recommended and the patient undergoes a formal psychological evaluation and is found to be an appropriate candidate for weight loss surgery, the surgery should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 44-year-old male who underwent ACL reconstruction in December 2004. Following surgery he was prescribed a continuous passive motion (CPM) machine, which he used for nine days. The patient paid out of pocket, and is now requesting reimbursement for the CPM device and related accessories. The Health Plan has denied this request based upon their determination that the equipment at issue was not medically necessary.The use of the CPM device aids in regaining motion following surgery. CPM therapy is beneficial to the healing and rehabilitation processes. Many surgeons prescribe the CPM machine for their patients postoperatively and such prescriptions are consistent with the surgical communitys standard of care. The use of the CPM device was medically appropriate and indicated in this clinical setting. 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.