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

The patient is a 63-year-old male who was diagnosed with prostate cancer in July 2004. The patient was found to have an enlarged prostate with an elevated PSA of 9.2 on 2/5/04 and 9.9 on 2/13/04. Biopsy results showed adenocarcinoma at both bases of the prostate and a Gleason score of 3+3 on 8/10/04. The patients urologist discussed treatment options with the patient and ordered a CT scan of the pelvis. The Health Plan denied coverage for the CT scan indicating it was not medically necessary for evaluation of the patients medical condition. According to the American College of Radiology, ACR Appropriateness Criteria, pelvic CT has been used rather commonly to preoperatively stage prostate cancer. Unfortunately, multiple studies have indicated a poor accuracy for CT in staging this disease. Overall accuracy in staging was reported as 65% and 67%. Accuracy has been reported as low as 24% with regard to capsular transgression. Even with refined techniques in performing CT, it has been concluded that CT is of little value in staging the local extent of prostate cancer. A recent review of the literature on staging indicates that digital rectal exam, tumor grade, and PSA are more important predictors of spread in high-risk patients than the results of imaging studies. For pretreatment staging of clinically localized prostate cancer with a PSA of 10 or less and/or Gleason score of 2-6, CT of the pelvis has an appropriateness rating of 3 (out of 9) and is not recommended. Based upon the information set forth above, I have determined that the requested CT scan is not medically necessary for evaluation 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 32-year-old male with brain cancer and partial left side paralysis. He has undergone a biopsy and received chemotherapy and radiation therapy. He has also received rehabilitation. His other medical history is unremarkable. He is seeking authorization for acupuncture and claims it has aided in improved motor function. The information submitted does not document acupuncture is indicated for this patient. No records have been submitted demonstrating a documented objective response to acupuncture. Furthermore, no evidence has been submitted supporting the use of acupuncture for this patients condition. With such evidence lacking, there is no documentation indicating the medical necessity of acupuncture. Therefore, I have determined the requested therapy is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a one-year-old twin who was born 10 weeks premature followed by a two month NICU admission. The patients parents are requesting authorization for Synagis injections for the winter months. This request has been denied by the Health Plan. The patient does not meet the nationally accepted guidelines for consideration of Synagis. Specifically, the American Academy of Pediatrics recommends Synagis before the start of the RSV season for premature infants born at 29-32 weeks who are under six months of age. Although this patient was born premature, he is not under six months of age. In addition, the patient does not meet other qualifying criteria for consideration of Synagis. Therefore, Synagis is not recommended for this patient. Accordingly, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a one-year-old twin who was born 10 weeks premature followed by a two month NICU admission. The patients parents are requesting authorization for Synagis injections for the winter months. This request has been denied by the Health Plan. The patient does not meet the nationally accepted guidelines for consideration of Synagis. Specifically, the American Academy of Pediatrics recommends Synagis before the start of the RSV season for premature infants born at 29-32 weeks who are under six months of age. Although this patient was born premature, she is not under six months of age. In addition, the patient does not meet other qualifying criteria for consideration of Synagis. Therefore, Synagis is not recommended for this patient. Accordingly, I have determined 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 with a history of polycystic kidney disease. She obtained a consultation in Mexico and was advised to have surgery. The Health Plan has determined that surgery is not medically necessary for this patient. An ultrasound obtained in Mexico on 10/29/04 revealed six cystic lesions in the liver, the largest measuring 6 x 5 cm. The right kidney has a 6.5 cm cyst, and the left kidney has a 5 x 5 cyst and a 6 x 6 cm cyst. The cysts have grown since the last ultrasound performed in Mexico on 4/15/02. At that time, the largest liver cyst was 4.2 x 1.3 cm, and the kidney cysts were smaller. In January 2004, a kidney ultrasound confirmed polycystic kidney disease (PCKD); the left kidney was enlarged to 17.5 cm and the right kidney was 14 cm. Records demonstrate the patient was seen in 1996 for stomach pain with bloating and a sensation of needing to vomit. At that visit, she reported she had had symptoms for 10 years. In addition, the submitted notes reflect a consultation in January 2003 for epigastric pain and an ER visit in February 2004 for gastritis. In November 2004, it was noted the patient had pain in the left upper quadrant and back due to constipation. In PCKD, the increased size of the kidneys can frequently lead to intra-abdominal pressure and reflux. As the kidneys enlarge they can push the intestines into the pelvis, and can lead to altered bowel problems, such as constipation. In PCKD, abdominal or flank pain is not uncommon in the kidney or hepatic cysts, especially if there is cyst rupture, bleeding into the cyst, infection, kidney stone or tumor. Pain from the cysts is usually treated with conservative management; including rest and analgesics. Though the kidneys and sometimes the liver are slowly replaced with cysts and lose function, the kidney cysts are usually not removed unless they are tumorous. Resection of the cysts would likely be accompanied by loss of other kidney tissue, so it is generally avoided. However, enlarging cysts can lead to pain, and can be treated with percutaneous cyst aspiration or laparoscopic decompression. The patient has confirmed PCKD with enlarging liver cysts. It will be important to make sure she does not have cyst infection or tumor. Records indicate that a CT scan was scheduled for further evaluation. The patient needs continued follow-up with nephrology and gastroenterology. Though at some point she might benefit from cyst decompression, there are several other possible etiologies for some of her abdominal pain. Thus, at this time there is not sufficient evidence that the requested surgery is medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 34-year-old female with facial pain since March 2004. She also has some symptoms of TMJ dysfunction including joint pain and crepitus. She has been treated with a dental occlusal split, orthotics, and anti-inflammatory medication without benefit. Her attending providers have referred her to a tertiary center for further evaluation, diagnosis, and treatment planning. This consultation has been denied by the Health Plan. The requested consultation is medically indicated and reasonable. This patient has facial pain, TMJ pain, and crepitation with an altered chewing pattern. She has undergone conservative therapy without success and her treating providers have recommended the consultation at issue to assist in the evaluation and diagnosis of the patient. Based upon the patients history and lack of improvement, further evaluation is necessary. Therefore, I have determined the requested consultation is medically necessary for evaluation 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 64-year-old female with a 28-year history of trigeminal neuralgia, which is no longer responsive to a maximum dosage of Neurontin (3600mg a day). The patient has tried multiple pharmacological regimens with limited short-term success. She has consulted many providers, one of whom has recommended microvascular decompression. The Health Plan has denied coverage for microvascular decompression on the basis that it is not medically necessary for treatment of the patients medical condition. Microvascular decompression is a major neurological undertaking and carries substantial risk. As such, less invasive treatment options should be exhausted before the patient resorts to this procedure. Based upon the information provided, it does not appear there has been maximization of pharmacological therapy including Tegretol. If pharmacological therapy fails, the patient may be a candidate for a percutaneous destructive procedure such as radiofrequency rhizotomy, glycerol rhizotomy or trigeminal balloon compression. If this fails, then the patient may be a candidate for microvascular decompression. However, at this time 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 54-year-old female with a history of problems with snoring and moderate somnolence. A plan was made for testing with home oximetry as well as with Epworth scale. The latter resulted in a score of 11. It was also noted the patient had problems with choking at night. The patients provider recommended a laser uvulectomy for treatment of the patients hypertrophic and elongated uvula, which in the supine position results in partial obstruction of her pharyngeal airway and a choking sensation. The Health Plan has determined the requested procedure is not medically necessary for the patient. The patient has been diagnosed as having a hypertrophic and elongated uvula that results in symptoms of snoring and choking at night. Her physician states that she has partial obstruction of her pharyngeal airway. In addition, the patient has a history of difficulty with eating and the presence of moderate somnolence. Though these findings suggest mild obstructive sleep apnea, the requested procedure has not been proven to be effective in the treatment of obstructive sleep apnea. Furthermore, laser uvulectomy is not medically warranted for treatment of the patients snoring or choking sensation. 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: Upheld Decision of Health Plan

The patient is a 68-year-old man with a history of renal failure due to obstructive uropathy, which is likely due to a history of a long-standing enlarged prostate. He wishes to have a kidney transplant. The transplant team recommends he have urologic evaluation, and possible transurethral resection of the prostate (TURP) to decrease the risk of obstructive uropathy effect on the possible kidney transplant. The patient notes he has seen urologists in the past who have recommended he have a TURP procedure, but he has always refused. The patient believes his kidney failure is due to salt overload and he is attempting exercises to help his prostate. The patient does not wish to undergo a TURP procedure as recommended by his provider. He wishes to be listed for kidney transplant without urologic clearance. A note from Scripps hospital in December 2003 indicates that during the patients admission for kidney failure an ultrasound showed bilateral hydronephrosis. Furthermore, there is evidence the patient had a markedly distended bladder at the time of his presentation with kidney failure. Both of his kidneys and his bladder showed the effects of back pressure from bladder obstruction, which is commonly due to prostate problems in men. It is very likely that his kidney function failed due to obstruction of urine flow by his enlarged prostate. It is highly unlikely that the major cause of the patients kidney failure was from excess salt intake as the patient suggests.There is a high likelihood of early failure if a kidney was to be placed without fixing the patients obstruction. A transplant kidney is usually placed in the anterior pelvis, lower down than native kidneys and therefore, is at higher risk of reflux due to the surgical opening created in the bladder as well as less benefit from gravity. Urine usually has to flow uphill to produce back pressure on native kidneys; there is less of a gradient and therefore, easier reflux back into a transplant kidney if the bladder is obstructed. In addition, urinary tract infections are more likely when the bladder does not allow for emptying. The immunosuppression required for transplantation also increases risk of infection; adequate bladder emptying is required. The patient may have to wait several years for his transplant. Even if he has a TURP procedure now it is not clear that his bladder will function normally after a transplant. He may need to perform self-catheterization. Still, for the reasons stated above the patient does require a plan for adequate bladder drainage by a urologist before he receives a transplant. At the present time, a urologist might suggest other therapy than a TURP. In any event, it is essential this patient obtain clearance by a qualified urologist prior to his kidney transplantation. 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 41-year-old male who was seen by his physician on 9/28/04 because of non-traumatic headache. Though the progress notes from that visit discuss the patients symptoms, there is no documentation of a physical or neurological exam. The patients physician ordered a CT scan of the head. The Health Plan indicates a head CT is not medically necessary for evaluation of the patients medical condition. According to the American College of Radiology Appropriateness Criteria, screening patients with isolated, non-traumatic headache by means of CT or MRI is not warranted. There are exceptions to this statement including patients with a history of cancer or HIV, older patients (over age 50) or patients with thunderclap headaches or headaches radiating to the neck. This patient does not meet any of these exceptions. In addition, there is no documentation of any neurological findings. Furthermore, it does not appear the patient has received any conservative therapies. Based upon the information provided, there is no medical indication for a CT scan of the head. Therefore, I have determined that the requested CT scan is not medically necessary for evaluation 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 woman with hypertension, JNC Stage I. She was treated in the past with Diltiazem XR 240 mgm. The patients provider subsequently prescribed Hyzaar 50/12.5, which has been well tolerated. The Health Plan has denied coverage for Hyzaar on the basis it is not medically necessary as there are formulary ARB/HCT medications available to the patient. The Health Plans denial should be upheld. The medical records do not demonstrate that the patient has tried and failed the formulary ARB/HCT medications offered by the Health Plan. There is no scientific medical data to support the preferential use of Hyzaar over Benicar HCT or Diovan HCT. As such, there is no medical indication for use of Hyzaar at this time. 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 49-year-old female who is 52 and weighs 190 pounds. Her medical history is significant for diabetes mellitus, hypothyroidism, systemic hypertension, obesity, and previous tobacco use. She also has a history of a work-related back injury. The patient states she has pain in her neck, shoulder, and upper and lower back. Her provider indicates x-rays show thoracic strain as well as L4-L5 spondylolisthesis. Upon examination, the patients plastic surgeon noted significant abdominal dermatochalasis and a large abdominal pannus. A wide abdominal rectus plication (WARP) procedure was recommended. The Health Plan has denied coverage for the WARP procedure on the basis that it is not medically necessary. The patient wishes to undergo a WARP procedure to address her chronic back pain. She has been told she is not a good candidate for back surgery and she has refused gastric bypass surgery to address her obesity, which appears to be a contributing factor to her back pain based on the medical evaluations provided. The literature regarding the WARP procedure is minimal and controversial. The likelihood that this procedure will result in improvement in the patients back pain has not been established to the point that it can be considered a viable therapeutic option. There are more predictable therapeutic options available to this patient than the WARP 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 23-year-old female with previously diagnosed bulimia nervosa since age 12, with a past history of binging and purging at least once a day. The patient was previously treated on an inpatient basis for about 30 days, felt to have improved, but having suffered some relapse. As of her discharge from that inpatient stay, the patient had been in treatment with a nurse practitioner, seeing her once a month for medication treatment, as well as a therapist who was seen once to twice per week. Because of the level of relapse she had, the patient was referred for residential treatment by both her nurse practitioner and her therapist. The patient identified her ideal weight as 125 pounds and at admission, weighed 123.2 pounds, was normotensive, and devoid of lanugo hair though with multiple dental fillings as well as some cavities. Admission labs were unremarkable. Psychiatric evaluation noted the patient as coming to the interview willingly and is cooperative. She relates her story in a concise, logical manner. Somewhat thin but not excessively cachectic. Facial expression is happy, eye contact is good. Manner of relating to the interviewer was friendly, trustful, and actively cooperative. She is motivated for treatment. During her residential stay, her Celexa 80mg was continued and Effexor was added. Though this patient had suffered from bulimia nervosa, it does not appear that she was nearly as encumbered with it as she had been in the past, such that she needed something as intensive as residential treatment. Whether from standpoints of admission weight, labs or her mental status exam, there really appears to be a lack of evidence pointing to even a need for an inpatient program. Given that the patient was only seeing a nurse practitioner once a month prior, there could have been a number of other modalities instituted other than residential treatment, which could have been as or more effective. In addition, if the patients condition was at such a level that residential treatment was required, it is unclear why a psychiatrist was not involved in her treatment. Given the patients history and condition at the time of admission, intensive outpatient services or partial hospitalization would have been appropriate treatment considerations. The evidence does not support the need for residential treatment. Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 65-year-old female with a history of chronic depression, interstitial cystitis, and chronic fatigue syndrome for approximately a two-year period after extensive dental work and a subsequent infection that took seven weeks to remit. The patient has been homebound spending most of the day in bed due to the extent of the fatigue. She recently developed chronic diarrhea and gastritis that is being followed by gastroenterology. Though the patient indicates she participated in many trials of medications, it is unclear which medications she has taken short of the more recent Celexa and Trazodone. She also sees a therapist with whom she has been in treatment for many years. Her therapist has deemed it vital that the patient continue in supportive counseling to keep her from feeling alone, depressed, and frightened. Some of the therapists notes indicate things such as having symptoms of stress again-pulling hair, chewing rubber bands, eating uncontrollably, hasnt been cleaning the house or crying a lot, feeling very alone. A request has been made for continued outpatient therapy sessions. The Health Plan has denied the request indicating that the patient has been in therapy from 2002 to mid-2004 and is not likely to improve with continued therapy. Based upon the information provided, the patient is significantly depressed and anxious and outpatient therapy has been ineffective. In addition, a good portion of therapy actually preceded the more significant decline of the patient in the past two years. Furthermore, though the patient has also been in treatment with a psychiatrist, it is unclear just how aggressive a course of medicinal treatment she has had for her depression. Given that the patient is still seriously depressed despite years of outpatient therapy, and since attempts at medicinal treatment have not been exhausted, I have determined 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: Overturned Decision of Health Plan

The patient is a 65-year-old male with a long history of depression and substance abuse. In May 2004, he had an involuntary admission as a result of suicidality and substance abuse. Thereafter, he received 30 days of inpatient treatment. The Health Plan has denied coverage for the 30 days of inpatient treatment.The information submitted documents the patient met ASAM criteria for the inpatient services he received. The patients age, history, comorbid conditions, and current condition warranted 30 days of treatment. Moreover, the information submitted documents the services received were beneficial for the patient and well within the standard of care. It would not have been appropriate to treat this patient at a less intense level of care during the period of time in question. Therefore, I have determined the services at issue were medically necessary for treatment of the patients medical condition. The Health Plan denial should be overturned.