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

The patient is a 68-year-old female with bronchiectasis. According to the information provided the patient was diagnosed with bronchiectasis with mucoid pseudomonas infection by her pulmonologist. Thereafter, the patient was started on inhaled tobramycin after a hospitalization in December 2003. The patients condition improved after home treatment with inhaled tobramycin. The patient was also started on daily azithromycin as well as bronchodilators. Since starting inhaled tobramycin the patient has improved symptoms and quality of life.Pulmonary function tests performed in May 2004 indicate moderate to severe obstructive lung disease with an FVC of 58%, FEV1 of 56% and FEV1/FVC ratio of 70%. It appears the Health Plan has denied further coverage for inhaled tobramycin on the basis that there is no scientific evidence supporting its use in patients with non-cystic fibrosis induced bronchiectasis.The inability of patients with bronchiectasis to effectively clear secretions results in frequent pulmonary infections. One of the more difficult organisms to treat is pseudomonas. Mucoid pseudomonas is usually seen in patients with bronchiectasis resulting from cystic fibrosis. In those patients inhaled tobramycin has been beneficial in decreasing symptoms and hospitalizations. Regarding non-cystic fibrosis patients, Barker, et al. reported a decrease of sputum pseudomonas density in bronchiectasis with inhaled tobramycin. In addition, Drobnic, et al. reported a decrease in risk for hospitalization in patients treated with inhaled tobramycin in non-cystic fibrosis bronchiectasis. Furthermore, Orriols, et al. suggests that long-term inhaled tobramycin may be safe and lessen disease severity in non-cystic fibrosis patients with bronchiectasis and chronic bronchial infection with pseudomonas. Moreover, it is evident tobramycin has been beneficial for this patient.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Heath Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old woman with chronic asthma, diabetes, and arthritis. The patients provider indicates the patient has difficulty walking when her asthma and arthritis are severe. Therefore, the patients provider has recommended a power-operated vehicle (POV) and walker holder. The Health Plan has denied authorization for the requested equipment on the basis it is not medically necessary for this patient. Review of the submitted medical records does not demonstrate a POV is medically necessary for this patient. A wheelchair was prescribed in February 2004 to be used with prolonged walking or standing episodes. Treatment notes dated 8/20/04 indicate the patient is independent for self-care except that she requires assistance for meal preparation and housekeeping. The submitted documentation does not demonstrate the patient is bed or chair confined or unable to ambulate within her house without use of a POV. Therefore, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 63-year-old male with metastatic prostate adenocarcinoma who has been under the care of a medical oncologist for the last four years. He has received appropriate medical treatment, which has included an LHRH blocker, Zoladex, an anti-androgen, Casodex, Zometa, and other chemotherapeutic agents including Taxotere. Despite aggressive treatment, the patients condition is worsening with more bone pain and a rising PSA (140 in August 2004). The patients oncologist wants to add Thalomid to the patients current treatment regimen. The Food and Drug Administration has not approved Thalomid for use in prostate adenocarcinoma. The Health Plan has denied coverage for Thalomid.The patients condition is deteriorating despite utilization of appropriate and aggressive medications. The use of Thalomid in the treatment of prostate adenocarcinoma is not uncommon. In addition, there is evidence indicating Thalomid is an appropriate treatment option for this patient  particularly based upon his deteriorating condition despite appropriate therapy. Therefore, although off-label, I have determined Thalomid is appropriate and medically necessary for this patient. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old female requesting a DEXA scan to screen for osteoporosis. Her providers progress notes of 9/17/04 indicate the patients mother and grandmother had osteoporosis. The patient indicates her grandmother, mother, and sister became aware of osteoporosis after breaking bones and losing height. The Health Plan indicates further information is required before a DEXA scan can be authorized.Screening for osteoporosis in post-menopausal women less than age 60 is recommended by most professional and regulatory authorities if there is at least one risk factor present. Based upon the information provided this patient has at least one risk factor present. Therefore, a screening DEXA scan is medically necessary for evaluation of this patient. As such, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 64-year-old morbidly obese female with a history of diabetes, hypertension, and juvenile asthma. She has requested authorization and coverage for a panniculectomy. The Health Plan has denied the patients request on the basis that a panniculectomy is not medically necessary for treatment of the patients medical condition.Without evidence of skin breakdown or intractable skin rash, this patients request for panniculectomy is cosmetic in nature. Her morbid obesity would be more appropriately addressed with gastric bypass surgery than with panniculectomy. Panniculectomy as a stand-alone procedure would not improve any of the patients stated medical conditions. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 40-year-old male who has a history of obesity. His current weight is 260 pounds. His provider indicates he has central obesity and gynecomastia. The patient has requested authorization and coverage for liposuction of the breast area. The Health Plan has denied this request indicating the requested procedure is considered a cosmetic procedure.The patient has requested liposuction for treatment of gynecomastia. Liposuction alone has not been demonstrated as an effective treatment for male gynecomastia. In addition, based upon the information provided, the patient does not meet medical necessity criteria for reduction mammaplasty for treatment of gynecomastia. There is no evidence the patients condition has been unresponsive to conservative treatment. 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 53-year-old female who is requesting authorization for a power-operated vehicle (POV). She has a history of knee pain and rheumatoid arthritis. She was evaluated for a POV and was found to be neurologically intact with 5/5 upper extremity strength. The Health Plan has denied authorization of a POV but authorized a manual wheelchair.The Health Plans denial should be upheld. The Health Plan is offering the patient appropriate and medically indicated equipment. The information submitted demonstrates the patient does not meet nationally accepted medical necessity criteria for authorization of a POV. She is neurologically intact and appears to have the upper extremity strength to operate a manual wheelchair. There is no documentation demonstrating the patient cannot operate a manual wheelchair. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 42-year-old female who weighs 256 pounds and is 52 with a BMI of 47. In addition, she has comorbid conditions of hypertension and asthma. She has undergone a psychological evaluation and is considered an appropriate candidate for bariatric surgery. She has requested authorization and coverage for gastric bypass surgery.With a BMI of 47 the patient meets nationally accepted criteria for consideration of weight loss surgery. In addition, it is unlikely that the patient will be able to lose weight and maintain the weight loss through non-surgical means. 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. Furthermore, the patient has undergone an appropriate psychological evaluation and is considered an appropriate candidate for weight loss surgery.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 47-year-old woman with several medical problems including supraventricular tachycardia, asthma, diabetes, and rheumatoid arthritis. She indicates she has difficulty ambulating and therefore, has requested authorization for a power-operated vehicle (POV). The Health Plan has determined a POV is not medically necessary for the patient. A four-wheeled walker has been authorized by the Health Plan to assist with the patients mobility.Review of the submitted medical records does not demonstrate a POV is medically necessary for this patient. The patient has been noted to be ambulatory within her two-story home with a single-point cane. The patient is able to ambulate the stairs using the cane. In addition, based upon the information provided, there is no access in the home for a POV. The Health Plan recommends a four wheeled-walker as an alternative, which in this case is more clinically appropriate. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 44-year-old man who has lost 130 pounds since undergoing weight loss surgery in 2002. The patient indicates he experiences rashes due to excess skin. He also complains of low back and testicular pain due to the weight of the pannus. The patient wishes to undergo surgical removal of the excess skin. The Health Plan has determined the requested procedure is not medically necessary.Though the patient complains of painful rashes due to an overhanging pannus, the submitted exam notes do not document a rash. In addition, there is no evidence medical therapies have been pursued as an alternative to surgical intervention. Furthermore, based upon the information provided, it appears the patients low back pain is multifactorial and pre-existing. Thus, the requested procedure would not be expected to improve this condition. Moreover, testicular pain is not documented in the patients physicians evaluations, nor is there documentation of this problem on the physical examination. Thus, there is insufficient evidence that the patients condition results in a functional deficit. As such, 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 13-year-old female with a history of reflex sympathetic dystrophy to her left knee after a fall in March 2004. The patient has experienced progression of symptoms including increasing pain in the left leg with changes in skin temperature and color changes to the skin. She was diagnosed with reflex sympathetic dystrophy. The patient has been followed by a pediatric neurologist and a physical therapist. She also underwent a single course of steroid injection. The patient then underwent a trial of Dynatron sympathetic therapy, with reported benefit. A request has been made for continuation of Dynatron sympathetic therapy. The Health Plan has denied this request indicating the requested therapy is not medically necessary for treatment of the patients medical condition. Review of the literature regarding all forms of functional electric stimulation as treatment for reflex sympathetic dystrophy reveals there are no placebo-controlled or even randomized studies supporting the therapy. Additionally, the description of the mechanism of the treatment has not been evaluated. The electrical stimulation required to reach the spinal cord reflex arc is significantly more than the stimulation provided in functional or therapeutic electrical stimulation. Yet, the technology reportedly uses lower stimulation thresholds than other electrical stimulants, which are more tolerable. This does not appear to be logical from a physiological standpoint.Though standard therapeutic electrical stimulation has been shown to relieve pain in patients with chronic pain, over time the frequency and duration of the stimulus need to be increased and eventually it becomes ineffective. Given no objective evaluation of the involved technology and the lack of physiological basis, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 42-year-old female who has a history of long-standing migraine headaches and comorbid chronic back problems and depression. The medical records indicate that she has been tried on a variety of medications in an attempt to control her frequently occurring migraine headaches. She has requested an increase in her monthly Imitrex prescription from 9 to 18 tablets. The Health Plan has denied this request indicating the requested prescription increase is not medically necessary for treatment of the patients migraines. Review of the submitted medical records indicates the patient requires vigorous prophylactic treatment for her headaches. The requested quantity of Imitrex is likely to result in rebound headaches. This condition is frequently noted in patients who take large quantities of medications aimed at the acute treatment of migraine headaches. Further attempts at prophylactic headache treatment are medically indicated and likely to be more effective than the requested regimen. Therefore, I have determined the requested prescription increase 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 51-year-old female with onychomycosis. She is seeking reimbursement for Lamisil tablets for treatment of onychomycosis. The information provided does not demonstrate the patient had a physical impairment or comorbidities. Prior to Lamisil tablets the patient had tried some topical treatments without success. Lamisil is indicated for patients with onychomycosis who have functional impairment and/or comorbid conditions and have laboratory confirmation of tinea. The patient did not meet any of these criteria at the time Lamisil was prescribed. Therefore, there is no evidence demonstrating Lamisil was medically necessary 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 24-year-old female with a diagnosis of major depression, recurrent, rule-out bipolar disorder, and concurrent personality disorder  not otherwise specified (predominantly borderline). She was admitted to residential treatment on 4/9/04 due to feeling increasingly depressed. This involved feeling very anxious, engaging in self-damaging behavior such as biting herself, hitting her head against the wall, hitting her head with a telephone, and feeling like screaming. Her sleep had also been quite poor with increasing nightmares and memories of past sexual abuse. At times, she felt as though she was back in the various abusive situations, with a degree of dissociation. She also had a very poor appetite and experienced weight loss.The patient was treated with a combination of Effexor, Trilafon, and Trileptal with some degree of improvement of her anxiety, depression, and irritability. On 4/24/04, she noted, When Im depressed, it doesnt mean I will self-harm and when I feel intense urges to self harm, it doesnt mean Im depressed. Im usually agitated. I can go home for days without depression and forget I even was depressed. Mostly I feel like self-harming afternoon and evenings. The patient was later noted to have some degree of acting out, e.g., lying on the floor in a fetal position for about 30 minutes during which time she was crying. She was amenable to staff and intervention. On 4/25/04, she told her psychiatrist I am learning a lot/growingits not an issue of safety. I am safe. I just want to continue to get the benefits from the program. I do feel more stable. Her psychiatrist felt that based on clinical criteria, continued inpatient treatment was not mandatory. By the point of discharge on 5/6/04 the patient was not actively suicidal.A request has been made for reimbursement for residential treatment services received from 4/26/04 through 5/6/04. The Health Plan has denied the request on the basis that residential treatment was not medically necessary as of 4/26/04.Analysis and Findings:The majority of the patients presentation appears spurred by underlying character pathology, predominately borderline in type. Though medications were also indicated, her psychiatrist felt the patient was sufficiently stable to not warrant any further inpatient treatment as of 4/26/04. Chart notes pertaining to affective display point to a fair degree of vacillation akin to that inherent in her self-abuse. To that extent, accompanied by no further active self-abuse or any true suicidal ideation, a lower level of care as of 4/26/04 would have been medically reasonable and appropriate. 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 39-year-old male who underwent evaluation with polysomnography for suspected obstructive sleep apnea. In a letter from the patients physician it is noted that the patient has a history of hypersomnia, as well as excessive daytime sleepiness. The information submitted does not indicate any other associated symptoms or findings such as witnessed apneas, mood disorder, cardiovascular disease or hypertension. Polysomnography performed on 8/8/04 shows an AHI of 2.8 with an oxygen saturation nadir of 92% during a total sleep time of approximately 86 minutes. The subsequent CPAP titration study shows an AHI of 1.3 with oxygen saturation stable above 90%  total study time was 314 minutes. Sleep efficiency for the initial study was calculated at 25.4% with sleep efficiency for the titration study calculated at 86.5%. Periodic limb disorder was also noted in the titration study with a PLM arousal index of 32 episodes per hour. The patient is on Klonopin, although there is no indication for what purpose. In addition, early on during the CPAP titration study, the patient was given Ambien 10mg. The patient has a body mass index of 24. He is seeking authorization for CPAP.Although this patient has symptoms of excessive daytime sleepiness, he does not meet currently accepted criteria for the diagnosis of sleep apnea. Current Medicare guidelines support the use of CPAP in patients with mild obstructive sleep apnea (AHI 5-15) with excessive daytime sleepiness. However, this patients AHI is 2.8. He also does not have significant oxygen desaturation. The numbers for improvement in sleep efficiency between the initial polysomnogram and the titration study are significant in this case, but changes in AHI are minimal and oxygen saturation was not improved during the titration study. It may be that sleep efficiency calculation improved secondary to the patient taking Ambien at the start of CPAP titration. Based upon this information, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old female with chronic daily headache. She has failed multiple prophylactic medications. She has some features of basilar migraine. It is unclear whether she has ever taken a channel blocker. She is also on Vicodin. She cannot take triptans or ergots secondary to cardiac dysrhythmias. She is seeking authorization for Actiq.Actiq is approved for the treatment of cancer pain after other medications fail. Actiq is not approved for the treatment of headache. There are other narcotics available for this patient. In addition, there are multiple other prophylactic medications available to the patient. Furthermore, given the patients chronic headache there is risk for overuse of Actiq, which could have adverse consequences. Based upon this information, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 38-year-old female who is two years post-operative from gastric bypass surgery for morbid obesity. Following the procedure the patient experienced complications. She is stated to have lost 100 pounds. The patient is seeking authorization for a panniculectomy. The Health Plan has determined the patient does not meet medical necessity criteria for the requested procedure. The Health Plans denial should be upheld. The submitted medical records do not demonstrate a panniculectomy is medically necessary. There is no significant evidence provided in the documents submitted that suggests an inflammatory process within the patients panniculus. In addition, there is no significant evidence of skin ulcerations, intertrigo, and utilization of conservative therapy. As such, there is no evidence that the proposed panniculectomy is reconstructive in nature or medically necessary. 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.