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

The patient is a 41-year-old female with a diagnosis of recurrent miscarriage. The record provided for review did not include prior pregnancy information or the full details of the patients previous workup. She was tested for immunologic abnormalities in August 2005. A serum NK cell assay revealed a normal percent killed NK cells and an elevated %CD19+/CD5+ level. A serum IgG for phosphoethanolamine was borderline positive. The patient was advised to undergo intravenous immunoglobulin (IVIG) therapy and had five treatments. The patients request for reimbursement was denied by the Health Plan based upon a determination that IVIG therapy was not medically necessary. The possible etiologies for the diagnosis of recurrent miscarriage are chromosomal, uterine structural, ovulatory or immunological. The treatments for immune factors, and especially their efficacy, are highly controversial. IVIG treatment for reproductive disorders and for recurrent miscarriage has been investigated in small studies for the better part of the last decade. Although a few of the studies evaluating IVIG treatment in properly characterized patients with repeated pregnancy loss showed modest benefit, others studies have shown no benefit at all. Thus, there is yet no clear efficacy    established. According to the 2004 Practice Committee Opinion of the American Society for Reproductive Medicine, IVIG treatment for recurrent miscarriage is an experimental treatment: IVIG as a treatment for recurrent pregnancy loss should be evaluated in patients who are informed, consenting participants in an institutional review board approved randomized clinical trial. For the management of recurrent spontaneous pregnancy loss IVIG therapy is an experimental treatment. There are other available therapies that are likely to be effective for patients such as this one and no indication that the standard approaches to treatment have been exhausted. Therefore, I have determined the therapy at issue was 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 that indicates that she has been sewing for 46 years, but her excess arm skin is impeding her ability to work.  The patient has undergone gastric bypass surgery.  Prior to her bypass, she had excess arm skin and arm lipodystrophy.  The gastric bypass did not create extra skin but probably has resulted in a decrease in arm fat, which makes the arm skin looser. The weight loss should have improved the patients ability to perform her job properly and therefore her complaints of functional impairment are not substantiated by the record. At issue is whether a bilateral brachioplasty is medically necessary for treatment of the patients condition.The submitted medical records and photographs of the patient demonstrate hanging skin and subcutaneous fat but no indication of medical necessity for the proposed brachioplasty. There is no evidence of any skin rash or infection on the patients arms. In addition, as noted above, her claim that she cannot perform her job is not substantiated by the submitted clinical information. Moreover, there is no evidence in the peer-reviewed medical literature showing that excess arm skin causes arm fatigue or that brachioplasty improves arm function. In summary, the records do not convincingly document that this patient has a functional problem related to her arm skin. 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: Overturned Decision of Health Plan

The patient is a 17-year-old male with a diagnosis of schizoaffective disorder. He was admitted to acute inpatient psychiatric care in May 2006. He had failed attempts with traditional medications and was started on Clozaril after he became acutely psychotic and was determined to be a danger to others. The Clozaril induction went well with the Health Plan authorizing continued inpatient services until May 2006, at which time they felt he could be managed at a lesser level of care. The records reveal that on the day of the non-authorization the patient had an elevated blood pressure and a tremor. Both of these side effects were thought to be an adjustment to the Clozaril medication. The attending physician continued to lower and then discontinued the Seroquel and started propranolol. The patients blood pressure came under control with the tremor decreasing. In May 2006 the patient was discharged to a less intense level of care.At issue is whether inpatient psychiatric services were medically necessary beyond May 2006.The progress notes and physician notes document that the patient was responding to Clozaril and was less sedated with improvement in his psychotic thought process. The increase in blood pressure on the day of the non-authorization was a concern with the attending psychiatrist as evidenced by the progress notes, which stated there was a need to continue to monitor the patient at the inpatient level of care. The attending psychiatrist did not feel that a PHP could adequately monitor the patient at that point in time. The patient stabilized and was discharged in May 2006. The submitted records demonstrate continued care was necessary beyond May 2006 due to the medical necessity of 24/7 monitoring by medical and nursing staff. As such, I have determined the services at issue were 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 49-year-old woman who has requested authorization for extended therapy with intravenous antibiotics for treatment of Lyme disease.The medical information provided includes office records from the patients family practitioner and extensive records from a rehabilitation hospital where the patient was managed for six days in early June 2006. The admission physical examination was recorded as normal. Although there is a lengthy list of other medical problems in the record, detailed information about these conditions has not been provided.Information regarding the Lyme disease consists mostly of statements about central nervous system Lyme disease. There is no data to support this diagnosis in the record.  Documentation of negative serologies for Babesia microti [twice] as well as negative Western Blots for Lyme disease are included. Positive tests for Bartonella and Ehrlichia from 2003 are cited in the patients providers letter.The patient has received extensive therapy for central nervous system Lyme disease.   The record documents IV Rocephin from December 2004 through January 2005, three separate courses of 30 days of IV azithromycin, and an additional two weeks in which both drugs were given together.The Health Plan has denied authorization for extended antibiotic therapy and related supplies citing a lack of medical necessity.The patient already received a month of treatment with IV Rocephin in 2004-2005 plus an additional two weeks of therapy with this drug, as well as IV azithromycin in the summer of 2006.  This greatly exceeds the recommended antibiotic therapy for any form of Lyme disease.  She also does not have clear evidence of this or any other infection.The evidence provided does not meet diagnostic criteria for Lyme disease. The CDC approach (screening test followed by Western Blot studies) remains the accepted route to a serological confirmation of Lyme disease. In this case, both the IgM and IgG Western Blots were negative. Even if there was sufficient evidence of Lyme disease, there is no support for more than 30 days of treatment with IV antibiotics.  Indeed, except for documented cardiac or neurological disease, there is no indication for a months treatment with Rocephin. Accordingly, 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

This patient is a 46-year-old female with an apparent history of depression who has been treated with Serzone for several years. Her provider indicates the medication is essential in her treatment despite the consistently reported side effects of fatigue and hypersomnia. The patients provider notes a positive response to a trial of Provigil and has requested authorization for the medication. The Health Plan denied the request citing a lack of medical necessity.The FDA-approved indications for Provigil do not include the treatment of idiopathic hypersomnolence or hypersomnolence as a side effect of another medication. The use of Provigil to offset the sedating effects of the patients Serzone may encourage polypharmacy and is not a generally recommended approach. Although the patients provider indicates that Sezone is essential to the patients treatment, there is no objective evidence of a trial of other antidepressants that may be less sedating than Serzone. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 15-year-old male who presented to his pediatrician with a complaint of sore feet bilaterally almost one year ago. X-rays were taken and were negative for heal pathology. The patient was seen by an orthopedist who prescribed non-steroidal anti-inflammatory drugs (NSAIDs) and apparently did not see a need to continue following the patient. In November 2005 the patient saw a podiatric specialist who noted pain and gait abnormality and diagnosed the patient with bilateral plantar fasciitis. The patient continued follow up visits with the podiatric specialist in December 2005, January 2006, April 2006 and May 2006. At this point in time, the patients podiatric provider has recommended endoscopic plantar fasciotomy (EPF) and has submitted a request for authorization of the procedure. The Health Plan denied the request citing a lack of medical necessity.During the past eight months the patient has been treated with NSAID therapy, ice therapy, stretching exercises, physical therapy, orthotics, strappings, and immobilization with a CAM walker. In May 2005 it was suggested that the patient undergo EPF due to the fact that he has been unresponsive to prior treatment modalities. The record reflects an appropriate course of conservative care for the treatment of the patients plantar fasciitis. His podiatric specialists recommendation for surgical intervention is reasonable and medically indicated at this juncture. Therefore, 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: Upheld Decision of Health Plan

The patient is a 61-year-old female who has a history of hyperlipidemia, depression and insomnia. She has been on Lipitor 40mg and Zetia 10mg. She was initially started on therapy because her LDL was 217. With Lipitor 40mg alone her LDL decreased to 163. With Lipitor 40mg and Zetia 10mg her LDL was 65. At issue is whether Zetia is medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The submitted documentation indicates the patient has hyperlipidemia. There is no history of coronary artery disease or risk equivalent (diabetes), and no history of hypertension. By NCEP ATP III guidelines, the optimal LDL is below 130. Given the patients low risk factor profile, the formulary medications offered by the Health are likely to be sufficient to bring the patient to an appropriate LDL level.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A sixty-three year-old female diagnosed with stage III ovarian cancer is requesting authorization for participation in a clinical trial.  Reviewers Findings:  The reviewing physician found that the best management of a patient with ovarian cancer is enrollment in a clinical trial.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 20-year-old female who has had an eating disorder since she was 13 years of age. She has retained her ideal body weight but has induced significant changes in weight by restriction and binging. The record indicates that in January of 2006 the patient moved to New Mexico to attend college. She had a personal crisis in March 2006 and her eating disorder was reactivated. She returned to California in April 2006 and was living with her parents.  She entered a specialized intensive outpatient program (IOP) for eating disorders in May 2006 and continued to attend this program through July 2006. The patient reports that she continued to experience symptoms of an eating disorder, anxiety and depression. Additional notations in the record state that she was still eating erratically, suffered from body dysmorphia, had transient suicidal thoughts, had thoughts about self-mutilation and continued to manipulate her diet with periods of no food, then binging.The patient has requested reimbursement for the IOP for eating disorders she attended from May 2006 through July 2006.  The Health Plan denied the requesting citing a lack of medical necessity for the IOP level of care.The patient has a seven year history of an eating disorder and went into crisis after the loss of a significant relationship. She became socially withdrawal as manifested by dropping out of school and returning to live at home with her parents. A recommendation was made that the patient enter a residential program. The IOP was selected as the least restrictive program that could potentially be effective. The patient was appropriate for the IOP level of care when admitted in May 2006 despite the fact that she had not been previously hospitalized. The records reflect that the patient received intensive treatment including individual, group and family therapy modalities.  By July 2006 she was no longer having suicidal thoughts or demonstrating self-injurious behaviors. She remained apprehensive regarding the transition to less intensive outpatient treatment and it was necessary to consistently reinforce treatment recommendations. Her IOP mental health provider recommended that future therapy address long-term issues and indicated a readiness for standard outpatient care. The termination of IOP care after July 2006 does not dismiss the need for the patient to continue individual therapy at a frequency that may need to exceed one time per week. Continued oversight and medication management by a psychiatrist is consistent with the standard of care.  Based upon the information set forth above and the supposition that the patient was discharged from the IOP in July 2006, I have determined the services at issue were 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 34-year-old male who sustained an anterior cruciate ligament (ACL) tear and underwent ACL reconstruction. An electronic controlled thermal therapy unit (cold therapy unit) was utilized postoperatively. The patients request for reimbursement for the cold therapy unit has been denied by the Health Plan on the basis that it was not medically necessary.Cold therapy units are extremely useful postoperatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, he experienced better pain relief and less swelling than would have been expected with ice packs alone. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 68-year-old woman who has had an ulcer of her right lower extremity for approximately two years. It recently measured 2.2cm x 1.7cm. The ulcer was reportedly initiated by a thorn. Treatment has included Doryx, Biafine cream, silver nitrate and Dynacin, all of which have been ineffective. The patient reportedly is a diet controlled pre-diabetic. At issue is whether Regranex is medically necessary for treatment of her leg ulcer.Based on the submitted clinical information, it is medically necessary that this patient be treated with Regranex. The other standard therapies have been tried and failed. It is common medical practice to use Regranex in this clinical setting regardless of the patients diabetic status if other standard therapies have been ineffective. The success rate of Regranex is significant and the risk/benefit ratio is highly favorable. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a 42-year-old male with a several year history of pain and burning in the feet. He was evaluated by a neurologist who diagnosed polyneuropathy. Initially this was felt to be related to alcohol abuse, but subsequently the patient was diagnosed as having diabetes. He was on oral agents with poor control and is now on insulin with better control. The patient has persistent foot pain and was recently prescribed a TENS unit by the provider who has been managing his diabetes. It does not appear that the usual pharmacologic treatments have been attempted. The patients provider submitted a request for authorization of the TENS unit.  This request was denied by the Health Plan citing a lack of medical necessity.A TENS unit is not an accepted therapy for the treatment of diabetic neuropathy. Although there have been some small studies on this treatment approach, they have generally not been well controlled and the evidence regarding efficacy is mixed. This patient has never been treated with the usual pharmacologic remedies according to the information provided in the record. Medications such as amitriptyline, Lyrica, or Cymbalta are often effective in relieving this type of symptoms.  Additional consultation with a physician experienced in the treatment of diabetic neuropathy, such as a neurologist, may provide the patient with an opportunity to explore other appropriate treatment modalities.  Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 19-year-old female who underwent ankle arthroscopy for sinus tarsi syndrome and impingement syndrome in January 2006. On the first post operative visit a continuous passive motion (CPM) machine was prescribed to improve healing. The surgeon relates in a letter that CPM machines, when used post-operatively, reduce adhesions and the chance of hematoma and/or edema and improves outcomes. The patients request for reimbursement for the prescribed device was denied by the Health Plan based upon a determination that the CPM machine was not medically necessary.Standard physical therapy following joint surgery is still considered more effective than the use of a home CPM machine according to the current literature. In this particular case the device was used prophylactically to defer the chance of adhesions, edema and hematoma; it was not utilized to treat an actual condition. For these reasons, I have determined the device at issue was 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 43-year-old female who has had a several year history of shooting right-sided pain in the neck, arm and body and headaches. She complains as well of swelling in the right axilla and other soft tissue areas of her right side extremities. Recent neck pain and headache has been associated with feelings of sweating and tachycardia. She has been seen by a neurologist. The submitted records include a negative plain spine x-ray and a normal EMG of pertinent peripheral nerve areas. On physical exam no discrete swelling or lumps have been noted. A Bruce exercise test performed because of substernal discomfort was normal and the patient exercised to Stage 4. Neurology exams are within normal limits. There has been some physical therapy without significant relief. A skin biopsy showed a non-specific resolving dermatitis. MRI of the cervical spine has been requested but denied by the Health Plan on the basis that it is not medically necessary.The patients records provide no basis for the necessity of an MRI of the cervical spine. No history, signs or symptoms are documented indicating that a structural abnormality of the cervical spine may be the cause of the patients pain. Furthermore, x-rays of the cervical spine were normal. The Health Plan is correct; there is insufficient evidence to demonstrate the requested MRI is medically necessary. 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 woman who has requested authorization for a bone mineral density measurement. She is concerned because several members of her family are being treated for osteoporosis. She had a normal quantitative computed tomography (QCT) scan three years ago, and now wishes to have a repeat bone mineral density measurement because of her concerns over developing osteoporosis. The patient has no other risk factors for a fragility fracture. She is apparently taking oral contraceptives. At issue is whether a bone density study is medically necessary.Beyond the family history, this pre-menopausal patient has no other criteria that would justify screening for osteoporosis. She is taking birth control pills and therefore is already on estrogen and progesterone. Based on the recommendations of the U.S. Preventive Services Task Force, the American Association of Clinical Endocrinologists, and the American College of Obstetrics and Gynecology, a bone density study is not clinically indicated in this setting. Therefore, I have determined the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.