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

The patient is being treated for hepatitis C, type 1b. After three months of therapy, the patient has not cleared his virus and he has not had a 2-log drop in viral count. The patients providers recommend the patient receive a full year of therapy. The Health Plan indicates that continuation of Peg-Intron and Rebetol therapy is not medically indicated given the patients insufficient response to the initial therapy.The Health Plans denial should be upheld. It is not the standard of care to retreat patients who have not responded to an initial course of Peg-Intron and Rebetol therapy. The article by Fried, et al. cited above clearly shows that if a patient does not respond to Peg-Intron and Rebetol therapy within three months (i.e., experiences a 2-log drop in viral count or undetectable viral count), there is a 97% certainty that the patient will not respond to continued therapy. Thus, continuation of Peg-Intron and Rebetol therapy is not likely to benefit the patient and is not medically indicated. Based upon the information set forth above, I have determined that 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 56-year-old female with a body mass index (BMI) of 38. The patients provider indicates the patient has comorbid conditions including diabetes, gastroesophageal reflux disease, and osteoarthritis. The patient has undergone a formal psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan indicates weight loss surgery is not medically necessary for treatment of the patients medical condition. Based upon the evidence provided, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. The severity of the patients comorbidities is not documented in the records provided. The most recent information regarding the patients medications indicates she has been taking Elavil, Protonix, Effexor, and hydrochlorothiazide. There is no mention of diabetes in the records provided. The patients lab values revealed a HemA1c of 5.5 and glucose of 113. Furthermore, the degree of reflux and presence of Barretts disease is unclear. With a BMI of 38, and without evidence of severe or intractable comorbidities, the patient does not meet medical necessity criteria for weight loss surgery. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 47-year-old woman with new onset of chronic daily headaches with migraine features. Her headaches are disabling, causing frequent ER visits and missed time from work. The patient has been under the care of a neurologist and pain management specialist. She obtains relief from triptans. She has failed multiple preventive medications including Depakote and Neurontin as well as Elavil. She has had moderate relief of pain with prior Botox use. A request has been made for additional Botox injections. The Health Plan has denied coverage for Botox therapy on the basis it is not medically necessary for treatment of the patients medical condition. The patient has intractable headache, which has features of migraine. Review of the records provided indicates the patient has responded to Botox in the past. In addition, this patient has failed multiple migraine preventive agents and has severe disability related to her migraines. Therefore, I have determined that 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 50-year-old obese female who has requested authorization for Xenical. The patient is 54 weighing 172 pounds with a body mass index (BMI) of 29.5 and has been unsuccessful with dieting. The Health Plan has denied authorization for Xenical. The patient meets nationally accepted criteria for authorization of Xenical. Xenical is indicated for patients with a BMI of greater than 30 or for patients with a BMI of greater than 27 with comorbid conditions such as diabetes and hypertension. This patient has a BMI of greater than 27 with comorbid conditions. The average weight loss with Xenical is 12 to 15 pounds  usually within the first six months. Furthermore, there is substantiated evidence that Xenical combined with lifestyle change and weight management support is beneficial for the treatment of obesity. Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old female with a history of morbid obesity and is status post gastric bypass in 2000. She also experiences depression and anxiety. The patient has been experiencing upper arm pain since she underwent debulking surgery following her weight loss. The patient has not responded to medications, sympathetic block, and physical therapy. She is taking methadone 5mg every 8 hours and is seeking an increase in her prescription to 20mg twice daily. The Health Plan has denied this request indicating the requested prescription increase is not medically necessary.Upon review of the medical records provided I have determined the requested prescription increase is not medically necessary for treatment of the patients medical condition. The alternative option set forth by the Health Plan is more clinically prudent as isolated treatment of the patients pain without multidisciplinary interventions as offered in a chronic pain treatment center has failed her. The patient is likely to obtain longer lasting pain relief from participation in a pain management program. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 26-year-old female with a body mass index (BMI) of 64. She also has comorbid conditions including shortness of breath, back pain, and gastroesophageal reflux disease. The patient has had a psychiatric evaluation. The examining psychiatrist indicated the patient is not an appropriate candidate for weight loss surgery due to a history of major depressive disorder and an eating disorder. The psychiatrist believes the patient is at risk of non-compliance with pre- and post-operative requirements. With a BMI of 64 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. 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. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not obtained psychiatric clearance for weight loss surgery. Psychiatric clearance must be obtained prior to surgical intervention. Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition depending upon psychiatric clearance. Therefore, the Health Plans denial should be overturned. If the patient obtains psychiatric clearance for weight loss surgery, gastric bypass surgery should be authorized. If the patient does not obtain psychiatric clearance for weight loss surgery, gastric bypass surgery should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a four-year-old male with a diagnosis of autism who has been receiving speech therapy to treat the issues of delayed receptive language skills, social skills, and pragmatic speech. The patient has undergone developmental assessment including applied behavioral analysis evaluation, Rosetti Infant-Toddler Language Scale, and the Preschool Language Scale 4th Edition. He had difficulty completing the standardized testing. The informed testing and observation are the primary tools used to evaluate progress. The patients parents have requested coverage for continuation of the patients speech therapy. The Health Plan has denied the request on the basis that speech therapy is not medically necessary for treatment of the patients condition. The diagnosis of autism does not appear to be in dispute and based upon the evaluation of the child neurologist and psychologist, the patients diagnosis is substantiated. It is not uncommon for preschool age children with moderate to severe autism to be incapable of completing standardized testing. Many of the tests are not valid in children without autism until age three. In addition, the goals set in speech therapy typically are not on a linear scale as is seen with a physical scale such as the FIM or WeeFIM. Gains in autism can fluctuate and thus trends rather than discrete trial progress need to be followed. This is more a failure of the medical communitys understanding of autism and the poor quality of tools that are available to measure progress than a demonstration of lack of progress. Therefore, the speech therapists documentation of progress toward the goals is sufficient evidence that the patient is progressing. Because speech therapy is considered standard of care in autistic children with receptive expressive and pragmatic speech delays and since the patient is making progress, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should undergo a reevaluation in six months to determine if progress is still being made.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 36-year-old female with a history of back and neck pain secondary to a motor vehicle accident that occurred in February 2004. The patient has spondylitic disease at C5-6 and C6-7 and herniated nucleus pulposus at C5-6. The submitted clinical records demonstrate no evidence of myelopathy or radiculopathy. The patient consulted a neurologist who recommended the patient undergo anterior cervical discectomy and fusion with orin plates. The Health Plan indicates the proposed surgery is not medically necessary for treatment of the patients medical condition. Review of the submitted evidence reveals no clinical indication for the requested surgery. The clinical documentation reveals no evidence of a radicular component. Nerve conduction studies were positive for carpal tunnel syndrome. There is no electrodiagnostic evidence of radiculopathy. Without evidence of radiculopathy, the requested surgery is not indicated and will not be beneficial. Continuation of conservative treatment is likely to be more effective in relieving the patients pain than discectomy and fusion. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 21-year-old female with a body mass index (BMI) of 55. She is requesting authorization for gastric bypass surgery. The patient also has a number of comorbid conditions. The patient indicates she has made multiple attempts to lose weight without long-term success. The Health Plan indicates it is medically necessary for the patient to meet her preoperative weight loss goal prior to undergoing bariatric surgery. The Health Plans denial should be overturned. There is not significant additional risk to the patient if she weighs 340 pounds versus 317 pounds when gastric bypass surgery is performed. There is no randomized, blinded study demonstrating that preoperative weight loss results in a better clinical outcome. There is no specific medical reason to require the patient to undergo preoperative weight loss from a technical or evidence-based point of view. Therefore, I have determined that it is not medically necessary for the patient to meet her preoperative weight loss goal prior to authorization of bariatric surgery. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a six-year-old male with a history of chronic eczema. The patients mother indicates the patient has attempted multiple treatment medications without sustained benefit. The patients mother has requested coverage for homeopathic treatment. The Health Plan has denied coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. There is no evidence-based research showing homeopathy to be safe and/or effective for treatment of eczema. Ultraviolet therapy, the alternative treatment recommended by the Health Plan, is medically appropriate and reasonable for treatment of eczema. The patient is likely to experience a better clinical outcome with ultraviolet therapy than with homeopathy, an unproven therapy. As such, I have determined that the requested therapy is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old female patient has requested coverage for breast implant surgery. The patient has Poland syndrome, which has resulted in the underdevelopment of the right breast. A plastic surgeon evaluated the patient in December 2004 and noted the patient has severe breast asymmetry. The plastic surgeon has recommended the patient undergo bilateral breast augmentation and bilateral breast mastopexy for breast reconstruction. The Health Plan has denied authorization for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition. Review of the submitted clinical evidence reveals the patient has an incomplete variant of Poland syndrome with marked breast asymmetry. The issue at hand relates to what mode of surgical intervention to pursue. There have been varying opinions given by the consulting surgeons regarding the appropriate surgical intervention. It is doubtful the patients scoliosis and musculoskeletal complaints are related to breast asymmetry. The patient consulted a plastic surgeon who recommended bilateral breast augmentation and bilateral breast mastopexy for breast reconstruction. It appears the patient will benefit from reconstruction of the abnormal right breast via techniques described in the literature for treatment of Poland syndrome, together with left breast reconstruction to allow for symmetry. This is an acceptable, evidence-based approach. Unilateral (left) breast reduction may have significant psychological repercussions for the patient. Bilateral breast augmentation and mastopexy for breast reconstruction is more appropriate and should be authorized. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 56-year-old female with a lengthy history of dry eyes. She has undergone a number of treatments without benefit; however, samples of Restasis have been effective. The patient is now seeking authorization for Restasis. The Health Plan has denied this request and recommended a Schirmer test. Clinically, it does not make sense to stop Restasis and perform further testing. This patient underwent extensive treatment without benefit and Restasis has provided benefit. In addition, Restasis is appropriate for treatment of the patients condition. Therefore, there is no clinical reason to discontinue use of Restasis. Moreover, the Schirmer test is notoriously unreliable and will not provide value to this patients diagnosis or treatment. 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

The patient is a 40-year-old female with a body mass index (BMI) of 38. She has comorbid conditions including gastroesophageal reflux disease, hypertension, and sleep apnea. She has requested authorization for gastric bypass surgery. She has undergone a formal psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary for treatment of the patients obesity. With a BMI of 38, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. 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 47-year-old female who was admitted to a skilled nursing facility (SNF) following an auto versus pedestrian accident, which occurred on 11/24/04. She was admitted to skilled care on 12/6/04 and discharged on 12/17/04. The patient reached contact guard assist (CGA) with physical therapy on 12/14/04. At that time, she was also CGA with toileting and LB bathing. She continues to receive physical therapy at home. There is no evidence that her home environment was assessed as safe and accessible. The patient has requested authorization for additional SNF services. The Health Plan has denied the request indicating the submitted documentation does not demonstrate additional SNF services are medically necessary. Inpatient rehabilitation is provided to patients who have care needs that cannot be met in the home. The submitted evidence indicates the patient was sent home in a dependent state. There is no evidence that at the time of discharge appropriate services were in place to meet the patients care needs. The patient had not met her maximum rehabilitation potential at the time of discharge and she could have benefited from continued rehabilitation services. Based upon the documentation provided, it is unclear what services the patient requires at this time. Therefore, I have determined the Health Plans denial should be upheld at this time. However, the Health Plan should provide a full home health care evaluation to determine the type of care the patient requires.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 56-year-old female who is requesting relief for a number of symptoms that she relates to excess skin following her weight loss after gastric bypass surgery. A significant problem is irritation from the folding skin in the abdomen (the pannus), particularly in the region of psoriatic plaques. The patient has been followed over the years by dermatology for treatment of psoriasis. Treatment has consisted of primarily topical medications. Her psoriasis is assuredly a chronic illness, with no cure available. However, the patients examinations have consistently revealed significantly more inflammation on the psoriatic plaques in the infra-pannus region. This is also demonstrated in the photographs provided. The patient consulted a plastic surgeon who discussed a panniculectomy, abdominoplasty and brachioplasty with the patient. The Health Plan has determined that the requested surgery is cosmetic in nature and not medically necessary for treatment of the patients medical condition. The submitted records and photographs demonstrate an obvious need for more aggressive treatment of the patients pannus, which is a super-inflamed area of psoriasis. This patient meets medical necessity criteria for a panniculectomy. The complicated region of psoriasis in the skin fold area of the pannus represents as uncontrolled intertriginous dermatitis and thus, constitutes a medical indication for panniculectomy. However, based upon the evidence provided, an abdominoplasty and brachioplasty are not medically indicated. As such, I have determined that although a panniculectomy is medically necessary for treatment of the patients medical condition, an abdominoplasty and brachioplasty are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 40-year-old woman with neck and back pain diagnosed as rheumatoid arthritis. Although the rheumatoid factor is positive, the patients symptoms are atypical for rheumatoid arthritis. She has been treated with methotrexate and prednisone for her arthritis. Based upon the information provided, it appears a referral to a rheumatologist has been authorized. Laboratory tests were performed on 8/25/04. An ELISA test for antibody to Mycoplasma fermentans was slightly above normal at 109. This was the IgG while the IgM and IgA values were normal. The patient believes she should see an infectious diseases specialist because of this positive test. The Health Plan has denied coverage for the requested consultation on the basis it is not medically necessary. There is some evidence of an association between Mycoplasma fermentans and arthritis. However, there is no scientific data indicating that detecting and treating Mycoplasma antibodies in a patient with rheumatoid arthritis has any impact on the disease process. Referral of this patient to an infectious diseases specialist is unnecessary and is very unlikely to benefit the patient. Therefore, I have determined that the requested consultation is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a two-year-old female has requested revision of the scars resulting from suture ligation of accessory digits. The patient has been seen and evaluated by a plastic surgeon. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is cosmetic and therefore, not medically necessary. The records provided include a referral from the patients primary care physician and the consultative note of the plastic surgeon. No photographic evidence has been provided. These records do not document evidence of any functional deficiency. The patient has scar tissue on the ulnar side of the fifth digits bilaterally, which would be expected with removal of the extra digits. There is no documentation supporting the medical necessity of the requested procedure. 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.