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

This patient is a 49-year-old female who began Bicilllin injections for the treatment of chronic Lyme disease in late 2005. She has also been treated for extended periods (i.e. several months) with oral antibiotics including rifampin, doxycycline and ciprofloxacin. There are a large number of serological tests for Ehrlichiosis included in the record. All of those for human monocytic Ehrlichiosis are negative; several of those for human granulocytic Ehrlichiosis are at or above the titers that may suggest disease states, most notably an IgG of greater than 1:640 in May 2005. The patients request for reimbursement for three Bicillin purchases made between March 2006 and August 2006 was denied by the Health Plan based upon a determination that the medication was not medically necessary.The duration of therapy for any form of late Lyme disease (e.g. arthritis or neurological disease) recommended by the Infectious Disease Society of America (IDSA) is a maximum of four weeks. The patient has received at least five months of treatment with Bicillin for her Lyme disease. Application of the CDC criteria to her Western Blot results does not allow a diagnosis of Lyme disease and specific clinical findings indicative of this infection are also lacking. In the event a diagnosis of Lyme disease was substantiated, there is no support from peer-reviewed studies for a treatment period of over 30 days. Evidence of Ehrlichiosis is also lacking as there is no documentation of clinical symptoms and no IgM response documented among the frequent tests for this disease. Even if this diagnosis was substantiated, Bicillin is not the recommended therapy and the patient had been more than adequately treated with the oral antibiotics she was given. Based upon the information set forth above, I have determined the medication 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: Overturned Decision of Health Plan

The patient is a 42-year-old male who injured his knee while skiing and subsequently underwent arthroscopic ACL reconstruction. Postoperatively he utilized a CPM machine as prescribed by his orthopedic surgeon for approximately three weeks.  He is requesting reimbursement for the rental cost of the device. The Health Plan denied coverage based upon their determination that the CPM machine was not medically necessary following the patients surgery. A CPM machine is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. Patient compliance appears to be high and many surgeons find that patients regain their range of motion faster and have better pain control with the device. The orthopedic community has recognized the benefit of early range of motion following this type of surgery and the use of the CPM machine postoperatively is medically appropriate. 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: Overturned Decision of Health Plan

The patient is a 41-year-old woman with breast hypertrophy. She has photographic evidence of macromastia and the typical symptoms associated with severe breast hypertrophy including complaints of shoulder, neck, and back pain, bra strap grooving and intertrigo. She has requested authorization for bilateral breast reduction surgery. The Health Plan has denied her request on the basis that the requested procedure is not medically necessary for treatment of her condition.Breast reduction surgery is medically necessary for this patient. She has documented breast hypertrophy and her complaints are typical for symptomatic macromastia. The constellation of symptoms in the context of breast hypertrophy is diagnostic for symptomatic macromastia, and additional workup is not required. The constant pull of heavy breasts against the upper torso is a mechanical problem and conservative treatments have been shown to be ineffective for symptomatic macromastia. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. The value of breast reduction in improving or correcting symptoms of macromastia is well documented in peer-reviewed scientific studies. As noted by Kerrigan, et. al., weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms are very unlikely to improve unless she has a breast reduction.  Although recent literature questions the correlation between volume of tissue resected and symptom resolution, studies have been performed to try to distinguish cosmetic from reconstructive breast surgery based on the volume of reduction.  The scientific validity of these studies is quite weak when compared to the more current literature.  Nonetheless, according to Schnur, the volume of reduction can be used to distinguish cosmetic from functional breast reduction surgery. Using the Schnur criteria, the anticipated total volume of resection for this patients surgery to be considered functional and medically necessary is approximately 310 grams per breast (body surface area of 1.60). Seitchik has also published criteria for insurance coverage, and according to his formula, the anticipated volume of this patients reduction is above coverage requirements. The planned reduction of 800 grams per breast is more than twice the amount that the literature suggests will differentiate a cosmetic from a functional reduction.Based upon the information set forth above, 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: Upheld Decision of Health Plan

The is a 46-year-old male patient who has Crohns disease and reports that although he has tried three different medications for this disease he continues to be symptomatic. He indicates that the use of Omacor has improved his symptoms by 80%. At issue is whether Omacor is medically necessary for treatment of the patients medical condition.The use of Omacor is not medically necessary for this patient. There are no double blind prospective studies demonstrating that Omacor is efficacious in patients with Crohns disease. There is only anecdotal information regarding the possible benefits of the drug. Omacor is not the standard of care is this setting and there is insufficient data supporting its efficacy to warrant its use in this case. 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 46-year-old woman who has a history of treatment resistant depression. The submitted clinical materials indicate she has attempted multiple trials of other medications without relief of her depression. Effexor XR, in a dose larger than that recommended by the manufacturer (450mg per day), has been beneficial for her. The Health Plan has denied coverage for this dosage on the basis that it is not medically necessary.Clinical experience often results in the off-label use of medications or in the use of medications in doses higher than those commonly used. As long as there are positive results for the patient and the patient understands the risks and benefits and consents to such, the proposed dosage is medically reasonable and appropriate. The patient should undergo regular medical monitoring to ensure that the higher dose of Effexor XR continues to be effective and does not cause untoward side effects. Accordingly, I have determined the requested dosage 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 43-year-old male who has significant coronary artery disease (CAD) and has had two stents placed. His cardiologist indicates he is in the high risk group, and has established a target LDL of less than 70 mg/dL. The patient was prescribed Lipitor 80mg in March 2006 but was functionally taking Lipitor 40mg. At that time Zetia was added to his medication regimen. Follow-up testing in April 2006, while on Lipitor 40mg daily and Zetia 10mg daily, indicated the patient had achieved his target LDL (61 mg/dL). He began a trial of Vytorin 10/80 in May of 2006 and his LDL was off target in June 0f 2006 (113 mg/dL). The patients request for authorization of Zetia was denied by the Health Plan citing a lack of medical necessity.This is a patient with known CAD for whom achieving and maintaining the declared LDL target of less than 70 mg/dL is very important. He did indeed demonstrate a failure of Vytorin and a change from Lipitor 40mg to Lipitor 80mg is unlikely to result in a decrease in LDL of 40 points or greater. As there is no data indicating the superior efficacy of Crestor, a trial of Crestor after treatment failures with Lipitor alone and Vytorin is not consistent with the standard of practice among specialists in cardiovascular disease. Given the demonstrated reduction in the patients LDL to 61 mg/dL while taking Lipitor and Zetia, I would support the continued need for treatment with Zetia and high dose Lipitor as prescribed by his cardiologist.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 50-year-old male with multiple sclerosis. He reports being hot all the time and therefore wishes to utilize a cooling vest. The Health Plan has denied authorization for the requested device on the basis that it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. There is no evidence the requested post-surgical cooling device is medically appropriate for this indication. The use of a cooling device for the treatment of multiple sclerosis has not been validated in the peer-reviewed literature. As such, there is no data demonstrating that the requested device is likely to be beneficial for the patient. Accordingly, 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 17-year-old male who was diagnosed as having pervasive developmental disorder and Aspergers disorder at the age of 12 years. Prior to his admission to the residential treatment center, the patient was in juvenile detention for about seven months, where he attempted suicide twice; the last attempt occuring in November 2005. The patient was admitted to residential treatment in July 2006. A review of weekly treatment updates dated in July 2006 and August 2006, along with group therapy and individual therapy notes shows no indication the patient is actively or imminently suicidal or homicidal, nor that he is psychotic. The patients symptoms and behavior appear to be are under good control and his behavior has not been described as aggressive, agitated or out of control. The record indicates the patient is compliant with the prescribed treatment plan. The patients parent has requested reimbursement and continued authorization for residential treatment services provided from July 2006 onward.  The Health Plan denied the request based on a determination that the services were/are not medically necessary.A detailed and intensive review of the clinical record, including documentation from the patients psychiatrist and individual therapist and the weekly group therapy updates, does not show the patient was at imminent risk of harm to himself or to others. There is no documentation indicating the patient was actively psychotic, that he demonstrated out-of-control/aggressive behaviors or that his medical or emotional status required 24-hour monitoring. The patient could have been effectively treated in a less restrictive setting from July 2006 onward.Based upon the information set forth above, 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 55-year-old woman with arthritis involving both knees. She had a series of Hyalgan injections in late 2004 through early 2005, which provided pain relief for almost one year. The patient has tried oral anti-inflammatory medications and corticosteroid injections according to her orthopedist. At this point in time, her pain has returned and she has requested authorization for a repeat series of Hyalgan injections for both the right and left knees. The Health Plan denied this request on the basis that the therapy is not medically necessary for treatment of her arthritis.The patient is relatively young and has severe arthritis in both of her knees. Non-steroidal anti-inflammatory medications and intra-articular injections have not been successful. The first series of Hyalgan injections was performed more than one year ago and resulted in significant pain relief. Although the patient is likely to require knee replacement eventually, for now a second series of Hyalgan injections is an appropriate non-surgical option to alleviate her pain. Therefore, I have determined 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: Upheld Decision of Health Plan

The patient is a 61-year-old female with presumed fingernail onychomycosis. A fungal culture has not been performed to confirm the diagnosis. There is no functional impairment noted. The patient has a reported history of hepatitis and has declined treatment with Lamisil. The patients request for authorization of Penlac was denied by the Health Plan citing a lack of medical necessity.The diagnosis of onychomycosis has not been confirmed. While it is medically appropriate to select treatment with Penlac rather than Lamisil due to the patients history of liver disease, it is not reasonable to treat her condition without a definitive diagnosis. In the absence of a confirmatory fungal culture, 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 61-year-old female with reactive airway disease, IgE mediated rhinitis, chronic sinusitis and seasonal and perennial allergies related to mite, mold and animal dander. She has moderate to severe asthma which is steroid dependent and her condition is deteriorating. The patient also has an evolving depression that is situational, secondary to her chronic allergic disease and its effect on her lifestyle and well-being. Her providers note of July 2006 indicates she is broadly allergic, mostly housebound and unable to tolerate therapeutic dosages of immunotherapy. The proposed treatment involves stabilization with Xolair over several months followed by immunotherapy. If the immunotherapy is better tolerated and she is able to reach maintenance status, the Xolair could be tapered off after six to twelve months. The hope is to eventually maintain stability with standard immunotherapy and routine medications.A consultation report from May 2006 noted wheezing, chest tightness, cough and dyspnea twice weekly despite multiple medications including Advair, Singulair, albuterol and antihistamines. The provider also noted the patient had four visits to the emergency room last year and has used oral prednisone and Kenalog multiple times in the past six months.  The clinical record indicates the patient has been compliant with all of her prescribed medications. Pulmonary Function testing dated June 2006 revealed a pre-bronchodilator FEV1 of 84% and a post-bronchodilator FEV1 of 97% and laboratory testing from May 2006 demonstrated a total IgE of 755 Iu/ml.The patients request for authorization of Xolair was denied by the Health Plan based upon a determination that the therapy is not medically necessary.Treatment with Xolair is medically necessary for this patient for several reasons. First of all, the record indicates the patient has received optimal medical care and has adhered to the prescribed treatment, yet her condition has worsened. Her quality of life is severely impaired and there is concern regarding the systemic effects of higher doses of corticosteroids. Secondly, the patients provider has documented that the patient was on appropriate steroid therapy and under fairly good control due to avoidance of allergen triggers when she was unable to demonstrate an FEV1 of less than 80%. Nonetheless, her FEV1 reversibility was 15%. Lastly, the manufactures requirement that patients have an IgE of less than 700 Iu/ml was an inclusion criteria for Phase I and II clinical trials and was not intended to preclude treatment in patients with an IgE greater than 158 Iu/ml.  This patients clinical condition warrants treatment with Xolair and its use is consistent with the standards of good medical practice. Based upon the information set forth above, I have determined 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 45-year-old female with a long-standing history of alcohol and cannabis dependence. She was admitted to inpatient treatment in June 2006 with a history of drinking 18 ounces of hard alcohol and a bottle of wine per day for the past 10 years and smoking marijuana every day for the past 30 years. Her relationship with her significant other was also noted as spiraling downward. The patient noted that her drinking had led to mood swings and much anger. She had also been referred to anger management class due to hostility. Family history was notable for alcohol dependence of her father and her mother who was described as crazy, but no other details are known. During her treatment the patient received Risperdal and Campral. She was also treated with a Librium protocol for detoxification from alcohol.  Finally, she was begun on Wellbutrin XL in July 2006.In July 2006 the patient was noted as tearful, angry, and emotionally labile. In July 2006 she was noted as exhibiting bizarre behavior, exact type unclear, but quite angry.  Later that day, the patient was able to attribute some of her display to abuse she suffered from her mother while growing up, and she appeared more insightful. In July 2006 she was noted as clearer, brighter.The patient has requested reimbursement for her 28-day inpatient stay. The Health Plan has denied this request indicating that inpatient chemical dependency treatment services were not medically necessary beyond July 2006.Review of the submitted clinical information demonstrates the patient had a very sizable history of substance dependence and that this was very much interfering with her domestic life.  It is also apparent that the patient was rather rageful, at least as of July 2006. The exact etiology for this is unclear, though she had somewhat improved by the middle of July 2006 such that she was seen as clearer, brighter.  In general terms, however, given her enormous substance intake over the years, it would not have been appropriate for her to simply detoxify and then leave a protected setting. Clearly, some more in-depth work around what sustained her substance abuse, as well as her depression and anger, was needed to give her any sort of chance to actually remit.  In the context of at least 10 years of heavy substance dependence, 5 days of inpatient treatment was not likely to be satisfactory. All told, I find that the patients 28-day inpatient stay was medically indicated and appropriate. Therefore, 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 67-year-old male with stage IV metastatic colorectal carcinoma. His disease is chemorefractory. His provider has recommended Sutent, citing the patients inability to tolerate traditional agents. The Health Plan has determined that Sutent is not medically necessary in this clinical setting.The Health Plans denial should be upheld. There is no compelling data supporting the use of Sutent in this setting. No significant trials of the proposed usage have been performed. There is inadequate data demonstrating small molecule tyrosine kinase inhibitors (TKIs) can be substituted for Ab (bevacizumab). Given the data available at this time, there is inadequate evidence the proposed therapy will result in any clinical benefit. 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: Overturned Decision of Health Plan

This patient is a 59-year-old female who has pancreatic cancer. A CT scan in June 2006 identified a new 1cm hypodense lesion in the posterior right liver, when compared to the February 2006 imaging. A CT scan of the chest in June 2006 was negative for metastatic disease. The patient is receiving chemotherapy and the body and tail of the pancreas and the spleen have been resected. The patients CA 19-9 is elevated and is increasing. The patients request for authorization of a PET scan was denied by the Health Plan based upon a determination that the diagnostic procedure is not medically necessary.The previous reimbursement standards for the Centers for Medicare and Medicaid Services (CMS) did not include pancreatic cancer on its list of indications for PET scan. However, the National Oncologic PET registry (NOPR) was developed in response to a CMS proposal to expand coverage for PET scans to include cancers and indications not presently eligible for Medicare reimbursement. The diagnosis, staging, restaging, and monitoring of pancreatic cancer is currently listed in the NOPR registry as an indication for PET scan. NOPR is implementing this registry for CMS and the registry has recently opened.The sensitivity of PET in the detection of pancreatic adenocarcinoma ranges from 61% to 100%. According to Kalra, et al, PET offers a reliable method of differentiating recurrent or residual tumor from inflammatory or scar tissue, detecting unsuspected metastases, and evaluating pancreatic cancer. Nishiyama, et al, indicated that FDG-PET and CT appear to have a complimentary role in the detection of distant metastasis in patients with pancreatic cancer. And finally, Ruf, et al, reported that although CT/MRI was more sensitive for liver metastases than PET, PET was more sensitive for local and extra-abdominal recurrences. Since the new liver lesion detected by CT is too small to further characterize and the CA-19-9 continues to rise, it is not unreasonable to evaluate the patient with a PET scan. The information obtained could be very helpful to the oncologist in planning the patients future chemotherapy. Therefore, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.