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

The patient is a 50-year-old female seeking authorization for lower body contouring to improve the results of liposuction of the thighs. She has seen a number of providers regarding body contouring. The Health Plan has denied authorization for the requested procedure.The photographs and other information submitted provides no evidence that the requested procedure is medically necessary. There is no evidence the patient has functional deficits which could be corrected by the requested procedure. In addition, there is potential the requested procedure would not fully improve the results of the previous liposuction. There is no medical justification for the requested procedure. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The submitted records indicate the patient has depression and diabetic peripheral neuropathy, which has been painful and disabling. Prior treatments were not sufficiently helpful in controlling depression and pain. It is reported that when the patients dose of Cymbalta was increased to 120 mg per day the patient was greatly improved and was able to discontinue multiple other medications. A letter from the patients spouse supports the clinical benefit and no note is made of adverse effects. A letter from the patients provider also reports benefit but does not relate the patients clinical status on a lower dosage. The patient has requested authorization and coverage for Cymbalta 120 mg per day. The Health Plan has denied this request.The patient has diabetes mellitus, neuropathy and depression. FDA indications for Cymbalta include depression and diabetic peripheral neuropathic pain. Multiple prior medications were ineffective. Cymbalta was reported effective and tolerated at a relatively high dose. Doses of 120 mg per day have been reported in aggregate as not more effective than lower dose of 60 mg per day. However, individual patient variability is considered in clinical practice. Some patients may not tolerate low doses of a medication while others may tolerate higher than usual doses with increased benefit as well. In the case of this patient, the submitted medical records do not demonstrate the patient has had insufficient benefit at 60 mg of Cymbalta per day. Therefore, I have determined the requested prescription is not medically necessary at this time. The Health Plans denial should be upheld at this time. However, if there is documented evidence a trial of Cymbalta 60 mg per day resulted in insufficient benefit, the patients request for Cymbalta 120 mg per day should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 39-year-old male with HIV, lipodystrophy and an inadequate response to arginine/GHRH. The patient has multiple somatic symptoms, which may or may not be related to growth hormone deficiency. The patient has requested authorization and coverage for growth hormone therapy. The Health Plan has denied this request indicating the requested therapy is not medically necessary for treatment of the patients condition.The patient meets medical necessity criteria for growth hormone therapy. The submitted evidence indicates he has a low IGF-1 (101). In addition, the patient is HIV positive and has lipodystrophy. Furthermore, the patient has had an inadequate maximum response to arginine/GHRH stimulation testing (a basal level of 5.4 and a stimulated level of 3.9). For these reasons, 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 58-year-old female with hip pain. Radiographs have been obtained which reveal significant arthritis of the hip. A request has been made for an MRI to further evaluate the patients hip. The Health Plan has denied this request on the basis that an MRI will not impact the patients treatment because the only treatment for the patient is hip replacement.The Health Plans denial is correct. The patients radiographs reveal significant osteoarthritis. Treatment for this patients condition is hip replacement. Because a diagnosis has been established, an MRI is not indicated. An MRI will not add any new or important information that is not already known. Regardless of the MRI results the patient has severe osteoarthritis and would benefit from hip replacement. Therefore, I have determined the requested MRI is not medically necessary for evaluation of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 31-year-old female who underwent augmentation mammaplasty approximately nine years ago. She was seen and evaluated by her primary care physician in May 2005 for complaints of sudden onset of bilateral breast pain, flu-like symptoms and lymphadenopathy. Further evaluation by a plastic surgeon included appropriate examination and radiological and ultrasound examinations. None of the patients studies have been revealing as to pathology. However, the patient has continued to report bilateral breast pain. The patients plastic surgeon has requested authorization for removal of the patients breast implants.The submitted medical records do not demonstrate removal of the patients breast implants is medically indicated. It appears the patient requires further workup to identify the cause of the mastodon and lymphadenopathy. The proposed procedure involves several significant complications. Furthermore, given the lack of information regarding the cause of the patients symptom, the likelihood the proposed procedure will result in symptomatic relief is unknown. Based upon the information provided, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 50-year-old female with a diagnosis of severe osteoporosis. She was seen by an endocrinologist who recommended Forteo for the patient. The patient was instructed how to inject herself by a pharmaceutical representative in the endocrinologists office on 10/27/04. The patient apparently suffered an unspecified complication after three months of treatment and was not to continue to take Forteo or the medication for her multiple sclerosis. The patient is now seeking a follow-up appointment with the endocrinologist. The Health Plan has denied this request and indicates the patient can be managed by her primary care provider (PCP) with communication between the PCP and endocrinologist.The Health Plans denial should be overturned. The patient likely needs treatment for her osteoporosis. The PCP has not provided the patient with an alternative treatment plan since the patients request for a referral to the endocrinologist. As such, there is no evidence the patients osteoporosis is receiving appropriate management. Furthermore, given the failure of Forteo further evaluation by the endocrinologist is necessary to develop a new treatment plan for the patient. Therefore, I have determined the requested referral 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 44-year-old woman with a variety of non-specific somatic complaints diagnosed as multiple sclerosis by her family physician. The submitted information includes no evidence of a definitive diagnosis of multiple sclerosis by a neurologist. The patient had a minimally abnormal MRI, which was not suggestive of multiple sclerosis, a normal CSF evaluation, a normal SSEP evaluation, and borderline abnormal Visual Evoked Response. Her recent neurologic exams by several neurologists are negative. The patient has requested authorization and coverage for another MRI of the brain as well as an evaluation by a neurologist. The Health Plan indicates the requested services are not medically necessary for evaluation of the patients condition.The Health Plans denial should be upheld. The patient does not meet clinical or paraclinical definition of multiple sclerosis. The submitted records indicate the patient has seen several neurologists who are of the opinion the patient does not have multiple sclerosis. Further neurologic opinion and repeat MRI at this time are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 25-year-old male with a long-standing history of depression and stimulant abuse, abstinent from 2000 to 2003, but suffering continued symptoms of notable loss of energy and motivation, oversleeping, overeating, poor self-esteem and a very bleak outlook. The patient had received Lexapro 30 mg, Effexor XR 300 mg and Neurontin 800 mg for some months, but with no improvement. Because of the extent of his depression and relapse of stimulant use the patient was admitted to residential treatment in April 2005 where he remained until July 2005. Past trials of Prozac, Zoloft, Celexa, and Wellbutrin had only led to increased anxiety and difficulty with sleep continuity. Past trials had also included Depakote and Lamcital, but both ended because of a perceived lack of benefit. At the time of his admission to residential treatment, the patients depression was rated approximately 8/10 and admission diagnoses included Major Depression, Recurrent, Severe and Polysubstance Dependence, with rule-out of Bipolar Disorder.Chart notes evidence the patient as quite depressed with continued tendency to oversleep and overeat with very poor motivation or improvement in outlook. Lithium and Abilify were added to his regimen and he eventually improved. On many occasions he was noted as also considering returning to stimulant use once out of the program.Given the extent of the patients depression and stimulant abuse to counter it, with a fairly wide variety of antidepressant trials tried on an outpatient basis but to no avail, residential treatment did appear indicated. The chart notes document the patients depression as quite prevailing with a concurrent concern about his imminent return to stimulant abuse. Given the strong comorbidity between the patients depression and substance abuse, residential treatment was the optimal treatment milieu in which to find an improved medication course as well as interrupt his return to stimulants.Based upon the information set forth above, I have determined the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 62-year-old male who was seen and evaluated by his primary care physician and referred to a dermatologist for his psoriasis. The patients physician noted the patient wanted to see a dermatologist regarding a cyst of his back. The cyst is not described. The patient was referred to a dermatologist who noted the patients complaint about the cyst of the back, which are not described but diagnosed as epidermal inclusion cysts. Surgical excision of the cyst has been recommended. The Health Plan indicates the patients medical records do not demonstrate surgical excision is medically necessary.The Health Plans denial should be upheld. The submitted medical records mention the cyst of the back in several places but do not describe the size of the cyst or medical indications for the proposed removal. As such, there is no evidence the requested procedure is medically warranted. 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 49-year-old woman with nearly a two-year history of progressive slowing and rigidity of the right arm. She is seeking a fluro-dopa PET scan for definitive diagnosis of Parkinsons disease. The submitted records indicate the patient has shown a response to Sinemet and a movement disorder specialist has diagnosed probable Parkinsons disease. The Health Plan has denied coverage for the requested PET scan on the basis PET scanning has not been shown to be efficacious for evaluation of the patients condition.PET scanning is an investigational tool in the management of Parkinsons disease. There has been no proven long-term benefit of PET in the treatment of Parkinsonian disorders. While use of PET may confirm a definitive diagnosis of Parkinsons disease, it will not change the patients therapy, which at this time is not disease modifying. Therefore, I have determined that the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 49-year-old woman with an extrapyramidal neurological disorder, possibly Parkinsons disease, which appears to respond to dopaminergic medication. She has been advised to undergo a fluro-dopa PET scan. The Health Plan has denied coverage for the requested PET scan on the basis it is considered investigational for evaluation of the patients medical condition.PET scanning can be very useful in certain clinical settings. However, in cases such as this, clinical observations generally provide the information required to appropriately manage the patients disorder. PET scanning is not likely to have clinical value in this setting. Therefore, I have determined that the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 49-year-old woman who has been diagnosed with probable Parkinsons disease. She has rigidity and has had some response to Sinemet. The patient has requested authorization and coverage for a fluro-dopa PET scan to evaluate dopamine density in basal ganglia. The Health Plan has denied coverage for the requested PET scan on the basis it is considered investigational for evaluation of the patients medical condition.The efficacy of PET scanning in diagnosing Parkinsons disease has not been established. This condition continues to be diagnosed based on clinical factors. PET scanning in this context will not play any role in the ongoing care and management of this patient. The proposed PET scan is academic and is not likely to be superior to standard diagnostic modalities. Accordingly, I have determined that the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 54-year-old male who has had back pain since June 2003. The patients symptoms improved 40% following a lumbar injection in January 2005. His pain improved 90% post second lumbar facet injection in March 2005, but has returned. The patients provider would now like to perform radiofrequency treatment of the patients lumbar facets in order to achieve more lasting pain relief. The Health Plan has denied coverage for radiofrequency treatment indicating the requested therapy is not medically necessary for treatment of the patients condition.Review of the submitted records indicates the patient has tried conservative therapies without sustained benefit. The submitted information includes a study showing statistical improvement post radiofrequency ablation as compared to a sham study. Given that the patient has not been able to obtain lasting relief from other treatment modalities, radiofrequency treatment is medically reasonable and appropriate. Therefore, 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: Overturned Decision of Health Plan

The patient is a 45-year-old man who underwent ACL reconstruction. Postoperatively the patient utilized a continuous passive motion (CPM) machine. The Health Plan has denied reimbursement for utilization of the CPM machine on the basis it was not medically necessary for treatment of the patients condition.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. A CPM machine was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 32-year-old female with a body mass index (BMI) of 40.4. The patient has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery. She wishes to undergo gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 40.4, gastric bypass surgery is medically indicated and necessary for this patient, as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the 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 obese.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 13-year-old female who has been diagnosed with obsessive-compulsive disorder who has been treated with Lexapro 15 mg daily for two years following a course of Zoloft. When seen in July 2004 by a pediatric endocrinologist, she had shown a declining growth in height from the 50th percentile to below the 10th percentile, with most of the drop off occurring over the past two years. At this time she was described as obese with acanthosis nigricans and at Tanner stage 2-3 in breast development. She had a dyslipidemia with low HDL and raised triglyceride and peptide levels consistent with insulin resistance, while her liver enzymes were raised at AST of 51 and ALT of 60 raising the possibility of fatty liver disease or early non-alcoholic steato-hepatitis. The patient also had a raised LDL cholesterol level. Her bone age was delayed by one year giving her an adult height prediction of between 5 and 51. The patient had several normal IGF-1 tests and normal IGFBP-3 tests. She had a normal growth hormone (GH) response to one of two stimulation tests. She had normal thyroid functions, CBC and metabolic profile apart from the raised liver enzymes, and a normal brain MRI. Her parents are of normal height (father is 62) and the patient had a normal birth delivery. A request has been made for authorization and coverage for GH therapy. The Health Plan has denied the request indicating GH therapy is not medically necessary for this patient.Based on the information provided, it appears unlikely the patient has GH deficiency: she passed GH stimulation series, her IGF-1 and IGFBP-3 levels were normal, and she had a normal pituitary image on MRI. However, the patient had clearly fallen in skeletal growth rate over recent years. She has gained weight coincident with the use of selective serotonin re-uptake inhibitors (this is an increasingly recognized side effect) with clinical and lab evidence of insulin resistance. She may have liver disease complicating this or else due to another cause. Coincidentally, she had been found to have a high level of cortisol on one occasion albeit she had no striae or hypertension to support a diagnosis of Cushings syndrome. An appended note for March 2005 suggests that Lupron had been started to delay bony maturation. The patient had been given GH therapy but no progress measurements in response to the treatment were provided. Based upon the information provided, the patient does not meet the criteria for GH therapy on the basis of medical necessity and growth hormone therapy may even worsen her insulin resistance status. 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 52-year-old male with a history of alcohol dependence, first admitted to residential treatment in 2002 due to consuming a fifth of vodka per day, with corresponding hepatic compromise. He completed seven weeks of residential treatment, continuing in his diversion program thereafter, remaining abstinent for the next 17 months. Thereafter, he relapsed approximately six times prior to his next admission to residential treatment in June 2004, where he remained until July 2004. His most recent use appeared to have been five to six martinis per sitting and he initially submitted his nephews urine for alcohol screening, later submitted his own which tested positive for an alcohol metabolite. The patient had also been treated for post-traumatic stress disorder and for depression (deemed depressive disorder NOS), much of this stemming from his experience in the Iran-Iraq war. He was admitted with previously prescribed Wellbutrin XR and Seroquel, which he continued on while in residential treatment.A request has been made for residential substance abuse services the patient received from June 2004 to July 2004. The Health Plan has denied this request indicating the services at issue were not medically necessary.The patient clearly warranted renewed treatment for his alcohol dependence though his drinking was not nearly as flagrant as appears to have been the case in 2002. The patient was entirely devoid of withdrawal symptoms or particular cravings. In addition, the patient was not afflicted with notable depressive symptoms - his antidepressant medication, for instance, was left at the same dosage as that with which he was admitted. All told, the patients level of acuity did not appear to be such that he could not have been treated at a less intensive level of care, e.g., intensive outpatient treatment or partial hospitalization. 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.