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

The patient is a 50-year-old female who is status post gastric bypass surgery in 2003 with a weight loss of over 100 pounds.  Her weight is apparently stable at 148 pounds.  The patient complains of skin rashes, body odor and back pain due to her excess abdominal skin. The record includes several entries regarding rashes and infections in the area of the umbilicus.  In December 2005 her provider noted she also has another infection in the umbilicus and still will use her bactroban for this. The September 2005 office note states recurrent infection of umbilicus and describes the area as wet, red, tender, and slightly edematous. The May 2005 office note reflects her providers observations that skin folds in, around and in umbilicus get(s) itchy and red. Lotrimin usually helps and that there was unusually redundant skin about umbilicus, with what appears to be an erythematous, slightly scaly rash inside it.  The patient was examined by a plastic surgeon in March 2005 who noted there is no evidence of a rash in the intertriginous area on examination today.In making a determination as to whether the requested surgery is cosmetic or medically necessary, it is appropriate to consider the criteria set forth in the American Society of Plastic and Reconstructive Surgeons position papers for Abdominoplasty and Treatment of Skin Redundancy Following Massive Weight Loss. The ASPRS requires uncontrollable intertrigo of the skin folds of the panniculus.  Neither recurrent infection around the umbilicus or the downward level of the pannus (bottom edge) as it relates to the symphasis pubis are inclusion criteria for medically necessary abdominoplasty or panniculectomy.    Although the patient did have recurrent infection around the umbilicus, a review of the office notes provided did not reveal any evidence of intertrigo in the sub-pannus skin (the skin between the underside of the pannus and the native mons tissue).  The level of her pannus is not a factor in the determination.  The patient lists numerous complaints in her appeal letter, but the record did not include corresponding documentation from her providers to clinically support these complaints. Based upon the information set forth above, I have determined the requested surgery 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 61-year-old female with a body mass index (BMI) less than 46.1. The patient also has a number of comorbid conditions including irritable bowel syndrome. She has undergone a psychological evaluation and has been found to be an appropriate candidate for weight loss surgery. She believes Lap-band is likely to be the most beneficial procedure for treatment of her condition. The Health Plan has denied authorization and coverage for a Lap-band procedure. Current scientific literature does not demonstrate that Lap-band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. The Lap-band results in the slowest and least amount of weight loss when compared to other procedures. All told, gastric banding is less efficacious than alternative weight loss procedures and is not indicated in this case. 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 58-year-old female said to have Lyme disease for whom extended treatment with IV ceftriaxone (Rocephin) has been prescribed.  The record contains a letter from the patient noting that she was diagnosed with Lyme disease in July 2003 and that she has chronic knee pain.  There is also an October 2005 record of the patient presenting to the emergency department with palpitations. There was no note documenting that the patients knees were painful or other abnormal findings in the extremities. Her laboratory studies at that time (CBC, electrolytes, EKG and chest x-ray) were within normal limits.  Additional labs results from 8/22/05 show reduced CD8/CD7 lymphocytes (normal 60-360; the patients value was 32) and  August 2005 labs indicate that a single Lyme IgG Western Blot was positive (i.e., two bands present). Notes from an office visit with her provider in January 2006 indicate the patient has had (a) some salt and some potassium wasting and that she was somewhat stressed. There is no recorded evidence of cardiac, neurological or joint disease. The patient has requested reimbursement and continued coverage for IV therapy with Rocephin.  The Health Plan does not consider the therapy medically necessary and has denied her request.There is no clinical history supporting a diagnosis of Lyme disease and no evidence of a positive IgM Western Blot in the record. The patient did have a positive IgG Western Blot, but given the lack of clinical indications of acute Lyme disease, this was most likely a false positive result as often occurs. In this case, the diagnosis of Lyme disease has not been substantiated and treatment with IV Rocephin was not necessary.  Even if there is good evidence of Lyme disease, there is no support for treatment with IV antibiotics for a period of over 30 days.  The paper by Krupp cited above is a blinded, randomized trial of 28 days of Rocephin for post Lyme disease fatigue. The group that received the antibiotic did have improvement in fatigue but there was no improvement in measures of cognitive function. Because there are significant adverse effects associated with antibiotic therapy, the authors concluded that there was no indication for Rocephin therapy for patients with Lyme disease who complain of fatigue. Indeed, except for documented cardiac or neurological disease, there is no indication for a months treatment with Rocephin. Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 42-year-old woman with a reported family history of breast cancer who presented with a palpable breast abnormality. An excisional breast biopsy was performed by her surgeon and an assistant surgeon was utilized during the procedure. The operative notes do not document any unusual or extraordinary aspects to the performance of the procedure. The Health Plan denied coverage for the assistant surgeons services citing a lack of medical necessity. According to the guidelines offered by the American College of Surgeons, the use of assistant surgeons for procedures should not be billed unless the most recent Medicare claims database indicates that the procedure has used an assistant in more than 5% of cases and an assistant is medically necessary. The procedure at issue does not meet guidelines of sufficient complexity to require the use of an assistant surgeon and therefore, was not medically necessary. Accordingly, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 62-year-old male with diabetes mellitus type 2 (DM2) of 13 years duration.  He has required insulin in addition to oral agents to control his blood glucose.  Despite multiple daily injections of long and short action insulins, his diabetes has not been well controlled. A hemoglobin A1c of 8% and wide fluctuations of blood glucoses from 44 to 330mg/dL accompanied by a 30-pound weight gain evidences this. The patients excess weight has contributed to difficulty with the management of his hypertension and the development of sleep apnea. On the recommendation of his endocrinologist, the patient has requested authorization for an insulin pump.  The Health Plan denied his request based upon a determination that the requested device is not medically necessary.This patient does not have good control of his blood glucose. This can lead to chronic complications and there is already evidence of retinopathy.  His endocrinologist placed him on a regimen of multiple daily injections in an attempt to improve his blood glucose control.  Nonetheless, he has had further deterioration of his diabetic management.  The patients hemoglobin A1c has increased from 7.5% to 8.0% and he has experienced wide fluctuations in his blood glucose readings.  The increased insulin has resulted in weight gain and weight-related complications.  His endocrinologist has recommended an insulin pump to improve his blood glucose control and decrease the amount of insulin required.  It is believed that the pump will also eliminate the risk of further weight gain. The patients endocrinologist would like to see a hemoglobin A1c of less than 6.5, which is in line with the recommendation of the American Association of Clinical Endocrinologists.  She believes that an insulin pump is medically necessary to achieve this goal. The patient meets medical necessity criteria for authorization of an insulin pump. He has a diagnosis of insulin dependent diabetes on multiple daily injections with poor glycemic control (A1c > 7.0) and a history of severe hyper and hypo glycemia.  Additionally, the patients provider has recommended the pump for tighter blood glucose control and treatment of diabetes-related complications such as weight gain and sleep apnea.  Therefore, I have determined the requested device 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 38-year-old female with a diagnosis of Behcets disease. She has had inadequate disease control despite treatment with various agents including azathioprine, cyclosporine, methotrexate, colchicines, and long-term steroids. The patient continues to have oral and genital ulcerations, joint inflammation, and rashes. A history of psoriasis is also noted, but there are no indications of GI symptoms in the records provided. The patients rheumatologist requested authorization for a trial of TNF inhibition to treat the patients Behcets disease and the Health Plan approved a three-month trial of Remicade. The patient and her provider have expressed a preference for Enbrel, and have requested authorization. The Health Plan denied their request based upon a determination that Enbrel is not medically necessary.The diagnosis of Behcets disease is not in dispute and the Health Plan has recognized the need for a trial of TNF inhibition. At issue is the choice of TNF agent. The Health Plans authorization of Remicade is medically appropriate based on the greater number of anecdotal and uncontrolled treatment reports available for Remicade than for Enbrel, and the broader effectiveness of Remicade that has been described in those reports. Remicade has been noted to control the mucosal ulcerations, skin rashes, joint inflammation, uveitis, and constitutional symptoms of Behcets disease.  Reports on the use of Enbrel have noted benefits primarily for mucosal and skin lesions, and it is not yet clear if Enbrel does control the more dangerous aspects of the illness. In addition, given that the diagnosis of Behcets disease is often presumptive, the possibility remains that an alternative diagnosis will become apparent at some point, and that diagnosis is frequently Crohns disease (which confusingly may present without bowel symptoms in its early phases). This possibility lends further support for the choice of Remicade rather than Enbrel.Based upon the information set forth above, I have determined the requested biologic 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 12-year-old female with advanced sexual development who was projected to have short adult height. According to a note from a pediatric endocrinologist dated October 2005, when the patient was 410 at 11 years and 10 months she was to be given both Lupron Depot injections and growth hormone. The provider comments however in this note that Unfortunately the growth hormone has not been very beneficial. She is considering using Humatrope. I dont really believe that there will be a significant difference between the two medications. He also comments that a recent bone age was 13 years and that the patient will likely not attain a height of 5 without immediate action. The mid-parental height target was 53.5. There is a cousin who had early puberty and became a 510 adult. A note from another endocrinologist dated May 2005 indicated that the patient had a normal rate of growth at the 25th percentile for height albeit she had been at the 50th percentile earlier in her life. She began breast development at 10 years and 1 month and at this examination she had progressed to Tanner 3 breasts and Tanner stage 4 pubic hair. The predicted adult height was 51, which is the mothers height. This endocrinologist did not recommend growth hormone therapy. Normal growth hormone levels were given which appear to be in response to a stimulation procedure. There was no IGF-1 level documented. A bone age report from September 2005 indicates a reading of 11 years (though the number of months is not legible) while one from May 2005 estimated the bone age to be 12 years. A note from a pediatrician dated September 2005 indicated that the patient had a height of 410.75. She had apparently grown 3.5 cm on growth hormone and was back to the 50th percentile.At issue is whether growth hormone therapy was/is medically necessary for treatment of the patients medical condition.Review of the records provided demonstrates the patients reported bone ages are confusingly inconsistent with each other. On balance, it does seem likely that the patient will have an adult height approaching that of her mother. The patient has a normal rate of growth, she does not have growth hormone deficiency and she does not meet the Food and Drug Administration criteria for use of growth hormone in idiopathic short stature. The use of Lupron Depot to attempt to prolong her growth period appears reasonable and should be supported until epiphyseal closure.  Based upon the information set forth above, 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

The patient is a 59-year-old female with type II diabetes mellitus who is also overweight. In September of 2005 her hemoglobin A1c was 8.8%. At that time she was on metformin 850 mg twice per day and Humalog Mix 75/25 44 units in the morning and 24 units in evening. The patients other medications included hydrochlorothiazide, Lasix, gemfibrozol, atenolol, Celexa, felodipine, lisinopril and Zetia.  In September of 2005 she was started on Byetta 5 mcg twice per day in addition to the metformin and Humalog Mix. The patients hemoglobin A1c dropped to 7.7% in December of 2005. During this timeframe her Humalog Mix dose was reduced to 30 units in the morning and 10 units in the evening and she lost three pounds. The patients treating endocrinologist has requested authorization for Byetta 10 mcg twice per day.  The Health Plan denied her request based on a determination that the medication was not medically necessary.Byetta is in a new class of type II diabetes drugs known as incretin minetics.  These drugs  `mimic` the effects of naturally occurring hormones from the intestinal track and can help the body to make more of its own insulin.  People with type II diabetes do not produce sufficient levels of this hormone. Byetta has been shown to improve blood glucose control, lower postprandial blood glucose levels and to decrease appetite. In animal studies it has also been shown to preserve beta-cell function. The drug, like insulin, is a synthetic version of a naturally occurring hormone and there should be no contraindications for its use.The FDA has approved Byetta for patients with type II diabetes mellitus who take sulfonylureas and/or metformin. The limited approval is due to the fact that the clinical studies were performed with only those two medications. Studies of Byetta in combination with thiazolidinediones (TZDs) have just now been submitted to the FDA and are waiting for approval.  Studies of Byetta in combination with insulin are also currently being conducted.  The FDA does not approve Byetta in patients with type I diabetes or patients with longstanding type II diabetes who are on multiple injections and have very little beta-cell reserve. The patient has type II diabetes mellitus with insulin resistance and appears to have beta-cell reserve. Her blood glucose was not well controlled on insulin and metformin. The addition of Byetta improved the patients blood glucose control and resulted in a reduction of her insulin dose and a weight loss. Her hemoglobin A1c decreased to 7.6% and her insulin dosage was decreased. An increase in the dosage of Byetta to 10 mcg twice per day will most likely improve the patients metabolic status further and may help to prevent long-term complications.  Many endocrinologists are using Byetta in patients with type II diabetes such as this one, and are seeing positive results.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 36-year-old female who has been under the care of a neurologist who is a sleep medicine specialist for sleep-disordered breathing. The patient had a home trial of CPAP during the moth of September 2005 with good results. She has requested authorization for a CPAP device. The Health Plan has denied this request on the basis that a CPAP device is not medically necessary for treatment of the patients medical condition.Upon review of the submitted clinical information it appears the patient experiences problems during the day that are consistent with sleep-disordered breathing. The eight-day trial of a CPAP device in September 2005 gave positive clinical results. The patients neurologist is overseeing her care and feels there is a need for CPAP based on the entire clinical setting. Accordingly, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive a two-month trial of CPAP therapy. If during the two-month trial the patients symptoms are relieved, then CPAP therapy should be continued.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 48-year-old male who is status post left total hip replacement in February 2005.  Following surgery a 1.5cm leg length discrepancy was identified, with the left leg being longer than the right.  He has experienced persistent leg and back pain over the past year and has been treated with extensive physical therapy (PT).  The patient is requesting continued PT with Pilates/core strengthening.  The Health Plan has denied his request based upon their determination that the requested therapy is not medically necessary.It has been determined via radiographs that the patient has a 1.5cm leg length discrepancy.  This deficit is fixed, and will not change with PT or Pilates.  He has previously had 73 session of PT and was discharged with a recommendation for continued strengthening through a home exercise program.  The therapists notes indicated he was instructed in the home program and the patient should be able to continue further strengthening independently. While Pilates is another form of strengthening, there is no evidence that it is of superior efficacy to the type of treatment the patient has already received.  A review of the PT progress notes did not demonstrate that the prior therapy was deficient.  It was extensive and covered multiple strengthening and stretching exercises.  The patient has reached a plateau with skilled PT and Pilates techniques would not change this.  He should continue with his home program and utilize a heel lift.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 16-year-old female with a longstanding history of self-mutilation that involved cutting and burning, binging and purging behaviors, propensity for intense interpersonal relationships, lack of identity with chronic feelings of emptiness and boredom, and dissociated periods with lapses in memory. She was previously hospitalized in New Orleans in March 2005 and thereafter placed in a residential treatment facility from April to May 2005. She was admitted to the latest residential treatment facility in June 2005 and was diagnosed as having mood disorder NOS, eating disorder NOS, identity problem, and borderline traits and her ongoing treatment with Abilify was continued.  The record indicates the medication was felt to be useful in decreasing impulsivity and dissociated symptoms. The patient had a previous diagnosis of formal borderline personality disorder.The patients admission status examination found her to be pleasant and cooperative, and noted that she had admitted to masochistic thinking but reports that the last of this was at the beginning of her second hospitalization. The patient later expressed that her symptoms had gotten much better even prior to admission.  She also reported that she had been abandoned by a close friend and that event had triggered her three-day elopement to New Orleans.A review of the progress notes from the treating facility points to a patient who was consistently pleasant, devoid of adverse behaviors and who subjectively stated her mood as good or pretty good, with little objective evidence to the contrary.  At times, her affect was noted as disconnected, without further edification, but in other instances she was noted to have a great time, and was described as bright and laughing. The patient was involved in a number of therapies and her Abilify was maintained at the previously prescribed 7.5 mg level. The record reflects only one session with the admitting psychiatrist.  The majority of the patients periodic evaluations were conducted by a psychiatric nurse practitioner.  The patients father requests reimbursement and coverage for ongoing residential treatment services.  The Health Plan did not consider the admission or continued services medically necessary, and has denied her parents request.The patient does appear to suffer from borderline personality and there is chronicity associated with the disorder. However, she was devoid of active psychiatric or behavioral symptoms at the time of her referral to the residential treatment center.  Appropriate admission to residential treatment requires an acuity of symptoms that truly necessitates 24-hour care. In this instance, the patient was not actively ill, by either objective or subjective assessment.  She herself noted that she had gotten much better prior to admission. There is no evidence to support the need for residential treatment.  Therefore, I have determined the services at issue were/are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.