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

The patient is a 60-year-old female who has an approximate one-year history of dry eyes and chronic eye irritation. Her physician has indicated the patient has attempted a number of treatments including artificial tears, lubricant ointments and Alamast, which were ineffective. Her physician also indicates she has had an excellent response to Restasis. The patient stopped taking Restasis in July 2004 and her physician states her condition has worsened since stopping Restasis. She is requesting further treatment with Restasis.The clinical evidence demonstrates prior to Restasis the patient had been treated for approximately one year with little benefit. Restasis is a newer but increasingly accepted therapy and, based upon the patients medical records, appears to be benefiting her condition. Although the Health Plan has concerns regarding the results of the patients Schirmer test, this is a rather variable and not overly accurate test - positive rose bengal findings are more helpful for patients such as this patient. The reality is no single test is better than the clinical impression. Furthermore, Restasis has been beneficial for this patient and is known to be effective in treating this patients condition. The patient has already failed other available treatments. Therefore, there is no need to re-institute these treatments. Because the patient is benefiting from Restasis and has failed appropriate alternative therapy, I have determined that the requested medication is medically necessary for the 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 53-year-old female with a history of a cyst on her right eye. The cyst has apparently recently grown in size. The patients provider has recommended excision of the cyst. The Health Plan has denied this request.The clinical evidence does not demonstrate the medical necessity of the requested medication. The submitted photographs do not provide clear or objective evidence of the patients condition. The drawing in the ophthalmologists record shows a moderate pinguecula with only a tiny extension onto the cornea. These are common, benign and virtually never require surgery. If they enlarge and extend onto the cornea, they are classified as pterygium. A decision to proceed with surgery would then be based on the extent to which the pterygium extended into the visual axis. There is no evidence of this in this case. Furthermore, inflamed pinguecula usually respond to topical therapy. There is no evidence this patient has attempted a trial of topical therapy. Moreover, a biopsy would be indicated prior to consideration of surgery after failure of topical therapy. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old female enrollee who has a protuberant and enlarged abdomen. In addition, the patient indicates she experiences discomfort due to the excess skin. Her plastic surgeon has recommended removing approximately 5.5cm of fat centrally, which extend laterally to 3cm in thickness. The Health plan has denied this request indicating the requested procedure is cosmetic in nature and not a covered benefit.The patient is requesting abdominoplasty to address her large abdomen. There is no evidence of rashes on examination, and per her plastic surgery consultation, the abdominal fat is primarily intra-abdominal. The patients complaints include shortness of breath, back pain and diabetes. There is no historical basis that the abdominoplasty would help these problems, particularly in this patients case where the problematic fat is actually inaccessible by modern techniques. As such this patients complaints are cosmetic in nature. Therefore, I have determined that the requested procedure 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

This patient is a seven-year-old male with a diagnosis of ADHD and anxiety disorder. He is also being seen by a neurologist and was given a diagnosis of PDD. However, the documentation submitted does not support a diagnosis of PDD. The patients family is requesting occupational therapy/sensory integration therapy to address the patients attention deficit disorder.I have reviewed all current literature associated with ADHD & sensory integration therapy. The vast majority of evidence is against sensory integration. Clinical experience evidences little if any benefit associated with sensory integration therapy and ADHD. There are no large studies or outcome studies supporting sensory integration therapy in this context. Furthermore, documentation submitted by the patients occupational therapist does not provide objective evidence of its effectiveness. Moreover, there are other established, effective treatments available for this patient. Therefore, I have determined that the requested therapy 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

This 51-year-old female with morbid obesity was seen and evaluated by a vascular surgeon for painful lumps in the leg. There was no venous or arterial disease identified, but as a precautionary measure, the vascular surgeon ordered an MRI, which was negative.There is no evidence of vascular disease in this patient. Clinically, the patients condition is due to obesity, most likely lipedema. Furthermore, there is no evidence the patients condition requires management by a vascular specialist. Based upon the information provided, the patient can be safely and effectively managed by her primary care physician. Therefore, I have determined that the requested referral is not medically necessary for the evaluation 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 56-year-old woman with irritable bowel syndrome (IBS) who has not responded to traditional therapies for this disorder. The records provided indicate the patient did respond to treatment with an approved therapy, Zelnorm. Since Zelnorm was discontinued the patients symptoms have returned. She has requested authorization for further treatment with Zelnorm. The Health Plan has denied this request on the basis that Zelnorm is not medically necessary for treatment of the patients medical condition.  Although the FDA approval for Zelnorm is limited to several weeks, IBS is a lifelong condition. It appears this patient has tried multiple other alternatives without relief. It also appears the patient has had a positive response to a low dose of Zelnorm. Since IBS is a chronic disease, it is well known that many patients will require re-treatment or require maintenance on Zelnorm in order to control their symptoms. Clinical experience with Zelnorm over the past two years provides sufficient evidence to support this pattern of use. In light of the information set forth above and given the patients good clinical experience with Zelnorm with no evidence of toxicity or side effects, continued use of Zelnorm is medically appropriate and indicated. Therefore, I have determined that 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 60-year-old female with pulmonary hypertension. Her physician has stated her pulmonary pressures are elevated. She is taking multiple medications for management of her medical condition. In addition, her physician has recommended the addition of Viagra to the patients medication regimen for treatment of her pulmonary hypertension.The patient is a 60-year-old female with pulmonary hypertension. According to a hospital summary dated 7/15/04, the patient has multiple medical problems including pulmonary hypertension, systemic lupus erythematosus (SLE), congestive heart failure, hyperlipidemia, diabetes mellitus, and status post DVT/PE. Current medications include prednisone, Lasix, Aldactone, KC1, metformin, Pravachol, Lexapro, Coumadin, Toprol XL, lisinopril and supplemental oxygen.According to an office visit note dated 7/7/04 with her rheumatologist, the patient was found to have connective tissue disease with anticardiolipin antibody, pulmonary embolism, and pulmonary hypertension. The rheumatologist was unsure if the pulmonary hypertension was due to the patients pulmonary embolism or was primary pulmonary hypertension. The notes state the patient has not yet been assessed by a pulmonologist. Thereafter, Viagra was prescribed for treatment of pulmonary hypertension. There is indication in the file that the patients provider had consulted with several experts and they elected to use Viagra as a vasodilator for the treatment of pulmonary hypertension.The records do not indicate if the patient underwent acute vasodilator challenge with right heart catheterization. Studies show the patients who show more than 20% drop in vascular resistance may benefit from calcium channel blockers. In general, use of vasodilators in primary pulmonary hypertension may benefit such patients.Other medications have shown promise in the treatment of primary pulmonary hypertension such as bosentan and epoprostenol. Both medications have been approved by the Food and Drug Administration for use in pulmonary artery hypertension. Viagra has been utilized in the treatment of pulmonary hypertension, but studies are preliminary and there have been no controlled clinical trials.This patients pulmonary hypertension is most likely resulting from an underlying medical condition such as her SLE, CAD or previous pulmonary emboli. Secondary pulmonary hypertension is treated by treating the underlying cause. The overwhelming majority of pulmonary hypertension cases are secondary in nature and diagnosis of primary pulmonary hypertension is rare, especially in a 60-year-old female. Based upon this information, the patients pulmonary hypertension requires further evaluation.As set forth above, evidence regarding the use of Viagra (especially in a patient whose diagnosis requires further evaluation) in the treatment of pulmonary hypertension is preliminary and there are other proven medications available for this patient. 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: Upheld Decision of Health Plan

The patient is a 29-year-old female who was found to have a tear in her left labia five months postpartum. The defect was noted on the exam of February 2004 and there is no documentation in a prior exam that the patient had been aware of it or that it had caused her pain or dyspareunia. The delivery note of 9/14/04 does indicate that the patient had sustained a left labial tear at delivery and that it had been repaired at that time. A request has been made for authorization for repair of the hole in the patients labia. The Health Plan indicates the requested services are not medically necessary for treatment of the patients medical condition.Labial tears and subsequent suboptimal healing are known and accepted risks associated with vaginal deliveries. Review of the records provided does not demonstrate that repair of the labial tear is medically necessary. There is no evidence the patient is experiencing pain or dyspareunia. As such, there is no medical justification for the requested procedure. Therefore, I have determined that the requested services are 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 is a five-year-old girl with cerebral palsy who is dependent for activities of daily living and mobility. She is unable to roll over. She is microcephalic and has limited hip abduction. There is no demonstrated purposeful movement and low potential for mobility. She was provided with a gait trainer issued in February 2003.The patient has a gait trainer already that appears to be adequate. There is no evidence that the patient will benefit from the use of any gait trainer. There is no evidence that the requested gait trainer is medically necessary. The Health Plan is offering an appropriate alternative in the form of a physical therapy evaluation to determine the patient's equipment needs. Therefore, I have determined that the requested equipment 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 patient is a 56-year-old female who was found to have decreased bone density in 2002. She has been treated with Actonel and Fosamax for over a year. She then started on Forteo and has been taking Forteo for approximately one year. She claims she was unable to tolerate prior medications and that her bone mineral density worsened. Her Health Plan has denied authorization for Forteo.The patients initial diagnosis of osteoporosis in March 2002 is not supported by the patient's bone mineral density. In addition, one cannot compare changes in bone mineral density results from equipment from different companies. This patients bone mineral density has been tested on different equipment. The small changes in the patients bone mineral density from 2003 to 2004 are statistically insignificant. She does not have severe bone loss and her bone mineral density has been continually average for her age. Furthermore, she has no fractures. Moreover, there is no objective evidence establishing how the patient was intolerant of bisphosphonates or that she has attempted alternative bisphosphonates. Based upon this information a prescription of Forteo is not supported. Therefore, I have determined that the requested medication 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 patient is a 39-year-old male who injured his knee in 2003 and subsequently underwent repair of a torn cruciate ligament. After surgery he was prescribed a continuous passive motion (CPM) device. The patients physician indicates the device was required in order for the patient to progressively gain range of motion in the joint and help assure appropriate progression and outcome. The patient is requesting reimbursement of this device.The efficacy of CPM as compared to conventional physical therapy for status post ACL repair has not been established in peer-reviewed literature. Literature indicates CPM as adjunct to physical therapy for joint rehabilitation does not demonstrate any advantages of CPM over conventional physical therapy. Other studies (see citations above) have not shown any improvement in outcome with CPM after total knee arthroplasty. In the absence of evidence supporting the use of CPM after total knee arthroplasty, I have determined the equipment at issue was not medically necessary for the 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 enrollee is a 47-year-old male who complains of severe dizziness and pressure in his head. He states that these problems make it difficult for him to work. He has seen his primary care physician. He has also been seen by a neurologist. The neurologist addressed many varied medical issues including the patients chronic headaches, mild chronic dysequilibrium, episodic vertigo, and positionally related lower extremity paresthesias. Specifically regarding the patients complaints of headache and dysequilibrium, no further neuroimaging was recommended, but he recommended referral to a neurotologist for further evaluation. The patients neurologic exam was documented as entirely normal.The Health Plan denied the referral to a neurotologist and has authorized referral to an otolaryngologist. The Health Plan felt there was no information that indicates a neurotologist evaluation was necessary, stating the patient has already had evaluations and consultations in the past. Evaluations date back to 1988 with an MRI exam and a consultation concerning dysequilibrium. The patient has requested an independent medical review requesting referral to a neurotologist.I support the Health Plans finding that this patient can be seen by an otolaryngologist or a neurologist. All board certified otolaryngologists are well trained to evaluate dizziness and dysequilibrium. This is a basic component of their specialty training. A consultation with an otolaryngologist has already been authorized. There is no information indicating that a neurotologist needs to evaluate this patient. Therefore, I have determined that the requested referral is not medically necessary for the evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old woman with a history of right elbow pain. Her physician recommended exercise, physical therapy, and ice for her pain, none of which provided relief. The patient then underwent extracorporeal shockwave therapy (ESWT), which was performed in September 2004. The Health Plan has denied reimbursement for these services indicating there is no evidence demonstrating ESWT is safe and effective for treatment of the patients elbow pain. ESWT is an unproven treatment for the condition of epicondylitis. The safety and efficacy of ESWT has not been established in the case controlled scientific literature. There is no evidence ESWT as compared to standard therapy is likely to result in a superior outcome. Therefore, I have determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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 who suffered a stroke in June 2004 secondary to an intracranial hemorrhage. She received acute rehabilitation and skilled therapy until 9/23/04. Her course was complicated by a gastrointestinal bleed. The patient made some improvements with therapy and was discharged home. She is currently receiving rehabilitation therapy at home. A request has been made for further acute rehabilitation therapy.The patient is receiving an appropriate level of service at home. The role of rehabilitation therapy at home is to teach patients and caregivers. Stroke patients reach maximum recovery approximately three months post stroke with very little gain thereafter. The patients condition is chronic and stable. Although she may make some gains, there is unfortunately no expectation that more intensive rehabilitation therapy will result in clinical improvement. The data and evidence are clear that more intensive rehabilitation therapy does not improve outcomes in severe stroke patients who have stabilized three months post stroke. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a 30-year-old female who has been diagnosed with acid reflux. In addition, the patient has trachea stenosis status post tracheotomy. The patient states due to the trachea stenosis she is unable to swallow pills. Therefore, her physician has recommended liquid Prevacid for treatment of her acid reflux. The Health Plan has denied this request indicating the patient has not tried and failed both Aciphex and Protonix.The Health Plan indicates if the patient tries and fails Protonix and Aciphex then a trial of Prevacid can be authorized. The documentation submitted does not demonstrate a failure of Protonix. It is not unreasonable for the Health Plan to require such trials prior to authorizing Prevacid. Regarding the patients need for liquid medication, a reasonable alternative would be mixing solid granules into food such as applesauce. Based upon the information presented, liquid Prevacid is not medically necessary for this patient. Therefore, I have determined that the requested medication is not medically necessary for the 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 52-year-old female with a body mass index (BMI) of 60. She has multiple obesity related comorbidities. She has a long history of multiple failed diets. In addition, she has obtained psychiatric clearance for gastric bypass surgery. The Health Plan has denied authorization and coverage for gastric bypass surgery on the basis it is not medically necessary for treatment of the patients medical condition. With a BMI of 60 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 clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. 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: Overturned Decision of Health Plan

The patient is a 24-year-old female with a body mass index (BMI) of 53. Previous attempts at medically supervised weight loss were unsuccessful. The patient has multiple obesity related comorbidities. She has obtained psychiatric clearance and wishes to undergo gastric bypass surgery. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary. With a BMI of 53 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 clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.