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

The patient is a 58-year-old male who has been managed by a dermatologist for psoriasis, which is apparently significant in both severity and extent of involvement. In addition, he has been treated with Enbrel with major benefit for his cutaneous disease. His dermatologist has requested authorization and coverage for continued Enbrel treatment for the patients psoriatic arthritis. The Health Plan has denied this request indicating the requested medication is not medically necessary for the patients medical condition.Review of the submitted records indicates the patient has psoriasis. There is no confirmation of a diagnosis of psoriatic arthritis or evidence that the patient has been examined by a rheumatologist. Thus, the nature of prior treatment is unclear. It is not known if the patient has received an adequate trial of methotrexate. Additional follow-up is needed to determine if the patient has significant arthritis. If so, the patient should undergo a rheumatologic evaluation to decide which type of arthritis is present (whether psoriatic or otherwise) and what treatment would then be appropriate. Based upon the information provided, there is no medical justification for continued use of Enbrel at this time. Therefore, I have determined that 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 63-year-old male on treatment with Hytrin for prostatism and Viagra for erectile dysfunction. A year ago the patient reportedly had a PSA of approximately four and has experienced increased levels of 9.2 on 5/5/04 and 9.3 on 5/28/04. On 7/16/04, the patient underwent a twelve core ultrasound-guided prostate biopsy, at which time digital rectal examination revealed some firmness on the right. One of the six biopsy cores on the right revealed prostate adenocarcinoma, Gleason grade six (3+3). Three of the six cores on the left revealed prostate adenocarcinoma, Gleason grade six (3+3) at two sites and Gleason grade seven (4+3) at one site.Partins Table probabilities depend on clinical staging, but whether considered T1c, T2a or T2b, the chance of this cancer being found to be organ confined to the prostate at the time of surgery is under 50%. Potentially curative procedures include surgery, specifically radical retropubic prostatectomy with pelvic lymphadenectomy, open or laparoscopic, and radiation therapy, brachytherapy or external beam. The patient wishes to undergo laparoscopic radical prostatectomy. The Health Plan has determined a laparoscopic radical prostatectomy is not medically necessary for treatment of the patients prostate cancer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 42-year-old female with a history of three cesarean sections. The patient reports she was involved in a motor vehicle accident shortly after her most recent cesarean section in November 2003. She subsequent experienced some incision problems that left her with an unwanted incision scar. The patient is seeking coverage for an abdominal scar revision. The Health Plan has determined the requested procedure is cosmetic in nature and therefore, not medically necessary.Review of the submitted clinical records indicates the patient was seen by a board certified plastic surgeon approximately six to seven months after her cesarean section and the motor vehicle accident for evaluation of a leaking saline breast implant and for her abdominal scar. The revision of the abdominal scar was discussed with the patient; however, there is no documentation to support the medical necessity of the requested procedure. There is no conclusive evidence that the scar is causing pain or functional problems. 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 52-year-old male who has a history of long-standing migraine headaches who has been treated with a large number of medications that have not provided the necessary relief. Some of the patients medications suggest comorbid problems such as low back pain, depression, and insomnia. The patient would like to obtain 27 Imitrex 100mg tablets per month for his migraine headaches. The Health Plan has determined the requested prescription is not medically necessary for treatment of the patients medical condition.Upon review of the consultation reports by his neurologists, it appears that the patient suffers from rebound headaches. This condition is frequently noted in patients who take large quantities of medications aimed at the acute treatment of migraine headaches. Further attempts at prophylactic headache treatment are medically indicated and likely to be more effective than the patients current regimen. Other non-pharmacological modalities such as stress reduction, cognitive therapy, and behavioral therapy may also be indicated since the patient experiences migraines and depression. Continued overuse of Imitrex is contraindicated. Therefore, I have determined the requested prescription 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 with thoracic outlet syndrome. She had tried physical therapy along with a home therapy program. The Health Plan has denied authorization for continued physical therapy on the basis it is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The requested therapy is not medically indicated for treatment of the patients medical condition. There is no evidence the patient requires continued supervised therapy. The patient should be able to obtain benefit from a home exercise program. 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

The patient is a 54-year-old woman with a long-standing history of gastroesophageal reflux disease (GERD) who has not had satisfactory relief with standard medical treatment including PPI medications. She describes chronic pain, inability to sleep, frequent regurgitation, and chronic heartburn. She is said to have endoscopic evidence of erosive esophagitis on endoscopy. The patient has apparently made lifestyle changes such as elevating the head of her bed and avoiding foods known to worsen reflux without satisfactory resolution of symptoms. The patient has consulted a provider who has recommended an endoscopic plication procedure as a superior alternative to conventional surgical techniques for control of the patients symptoms. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition.Conventional therapy for GERD is based on a stepped approach. The first approach to treatment is generally life-style modification including measures such as weight loss, which this patient has already adopted. The second approach is based on anti-secretory medications, which reduce gastric acid secretion and exposure of the esophageal epithelium to acid. For those patients who fail these measures, surgical control with fundoplication is the standard treatment accepted by the medical community.The endoscopic plication procedure (i.e., the Plicator procedure) is a less invasive alternative to fundoplication. The Plicator procedure has been described in numerous pre-clinical studies and in a recent case series report. The series reported on 64 treated patients with mild esophagitis (grade 1 or 2). A majority of patients experienced improved quality of life and decreased use of PPI medication over six months. A minority had normalization of acid exposure. This was not a randomized trial and no long-term results or comparison to surgical therapy was made. In the case of this patient (unlike those in the study), she has severe ulcerative esophagitis (grade IV). To date, there is no evidence demonstrating the Plicator procedure is superior to conventional therapy for patients such as this patient, and since this patient clearly would have been excluded from the above referenced study, there is no indication that she would have obtained substantial benefit over the short-term. Furthermore, although the Plicator device has been approved by the Food and Drug Administration, the Plicator procedure has not been accepted by the medical community or proven in randomized, long-term trials against conventional therapy. As such, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 37-year-old male with a history of daytime fatigue, anxiety, and depression. In evaluation of these symptoms, two separate polysmonographies have been completed. The first was a home study performed in September 2003. The patients provider notes the patients AH1 was 11 at that time. A second sleep study was performed in an observed situation in April 2004. The patients AHI at that time was 7.7 with the caveat that the technologist turned the patient on his side during the exam and the patients AHI while he was supine was 33. Oxygen saturation nadir of 89% was also noted. Physical examination of the patient by one otolaryngologist described the tonsils as 1+ and the oropharynx to be Mallampati class II. On fiberoptic endoscopy collapse of the nasopharynx and oropharynx was noted during the Muller maneuver. Examination by a second opinion physician documented the tonsils to be 2+ and an enlarged uvula. The patient has had an adequate trial of CPAP, having tried three different masks. This was not tolerated as the masks were inadvertently pulled off at night. A trial of use of an oral appliance yielded similar results. At this time authorization for tonsillectomy and palatopharyngoplasty has been requested. The Health Plan has authorized the tonsillectomy, but indicates palatopharyngoplasty is not medically necessary for treatment of the patients medical condition. The patient has documented mild or moderate obstructive sleep apnea (OSA), depending upon which numbers are used. The most common standards of care being used are allowance for treatment of OSA if AHI is greater than 15 in all cases. If the patients AHI is between 5 and 14, treatment is generally allowed if there is concomitant documentation of excessive daytime sleepiness, impaired cognition, mood disorder or insomnia, hypertension, ischemic heart disease or stroke. This patient meets these criteria. He has an AHI of either 7.7 or 11 and has documented anxiety and depression, having been treated by a psychologist with medication for these diagnoses. The patient also meets medical necessity criteria for surgery as treatment for OSA in that he has tried and failed CPAP. Current standard of care for stage one surgical treatment of OSA includes palatopharyngoplasty in conjunction with tonsillectomy, if the latter structures are present and hyperplastic. It is also becoming more common to include genioglossus advancement or tongue base reduction in this first stage, as success rates in treatment are repeatedly being shown to improve with these added procedures. Except for in children with adenotonsillar hyperplasia, Tonsillectomy alone is not an accepted, standard of care treatment for OSA except for children with adenotonsillar hyperplasia Given these findings, palatopharyngoplasty is medically appropriate and indicated for treatment of this patients OSA.Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 36-year-old male with chronic viral liver disease (hepatitis B virus) and HIV disease. While the patient was being treated with the current standard of care for his infection (pegylated interferon), he developed neutropenia, a known side effect of pegylated interferon therapy. The patients provider has recommended a course of Neupogen. The Health Plan has denied authorization and coverage for Neupogen on the basis it is not medically necessary for treatment of the patients medical condition.There are substantial data in the literature supporting the use of pegylated interferon as the best therapy for chronic hepatitis B. The use of any of the interferons is associated with a decrease in blood cell lines. As a result, the use of growth factor is occasionally required to allow continuation of therapy. The submitted records demonstrate the patients WBC counts did decrease to a potentially life-threatening level and did respond to WBC growth factor infusion. Thus, in order to allow the patient to complete his indicated interferon therapy WBC growth factor (Neupogen) is an appropriate and acceptable therapy. No other antiviral therapy has been successful. Neupogen will allow the patient to continue his indicated therapy. 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 34-year-old multiparous patient with pain and bleeding who wishes to undergo a hysterectomy. A pelvic ultrasound revealed a 2.6cm fundal fibroid with a normal endometrial complex and a 1.5cm complex cyst of the right ovary consistent with a hemorrhagic cyst. In the submitted records there is no documentation of the duration or the extent of the bleeding, intensity or quality of the pain or the duration of oral contraceptive treatment.The submitted documentation does not demonstrate the extent and quality of the patients pain and bleeding or indicate how long she has been on oral contraceptives. In general, abnormal uterine bleeding in premenopausal patients should be treated with a trial of oral contraceptives for three to six months, assuming that there are no medical contraindications to oral contraceptives. It should be noted that in this patients case, it is unlikely the fibroid described on ultrasound is responsible for her abnormal bleeding because it does not appear to impinge on the endometrium.Regarding the patients pain, again it is unlikely that the fibroid is a contributing factor given its size and location. Before hysterectomy is considered, a trial of oral contraceptives and/or NSAIDs should be given. The small cyst noted on the right ovary, if in fact it is a hemorrhagic cyst, may be responsible for some pain, but again, should respond to cycling on oral contraceptives.After a therapeutic trial of three to six months the patient should be re-evaluated. If at that time it is documented she has received insufficient relief from her pain and/or bleeding, a hysterectomy would be a medically reasonable option. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 36-year-old female who has painful varicose veins. She has tried compression stockings without relief. She indicates she is a teacher who is required to stand on her feet most of the day. She has requested authorization and coverage for vein stripping. The Health Plan indicates the patient does not meet criteria for vein stripping and therefore, has determined that the requested procedure is not medically necessary for the patients medical condition.The patient has painful varicose veins but no documented greater saphenous vein (GSV) reflux. The guidelines of Milliman Care state that varicose vein surgery will not be authorized without GSV reflux. These guidelines are medically reasonable and appropriate and within the standard of care for treatment of patients such as this patient.  Therefore, the vein stripping is not medically warranted for treatment of this patients varicose veins. As such, 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

This patient is a 42-year-old female with neck and shoulder pain, status post motor vehicle accident who has been diagnosed with cervicalgia, cervical spasm, and cervical radiculopathy. The patient has requested authorization and coverage for Botox injections for treatment of her neck and shoulder pain. The Health Plan has determined the requested therapy is not medically necessary.I agree with the Health Plans denial. This patient does not meet the indications for treatment with Botox injections. There is no class I evidence to support the use of Botox injections in non-specific pain syndromes status post motor vehicle accidents, and non-specific muscular pain or spasms. Thus, there is insufficient evidence that Botox injections are likely to benefit the patient. 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

The patient is a 44-year-old male with a history of persistent musculoskeletal pain. He has been seen by two orthopedists and a podiatrist, and has evidence of chondromalacia patellae as well as plantar fasciitis. Efforts to control his symptoms have failed, including trials of NSAIDs. The patients primary care physician (PCP) has referred the patient to a rheumatologist. The Health Plan has denied authorization for the referral on the basis it is not medically necessary for treatment of the patients musculoskeletal pain.Review of the submitted evidence indicates the requested referral is medically appropriate and indicated. Two orthopedists and a podiatrist, along with the patients PCP have been unable to control the patients symptoms. The PCP has explicitly acknowledged that more specialized help is needed as he has not been able to resolve the patients symptoms. The occurrence of normal labs do not necessarily mean there cannot be an inflammatory condition present; patients with spondylarthropathies often present with plantar fasciitis and normal labs, while hypermobility syndromes and fibromyalgia are expected to present with normal labs. A rheumatologist is the only specialist experienced in sorting out these possibilities. Whether this patient is found to have an inflammatory or systemic cause for his symptoms, his previous physicians have been unable to manage the patients problem. Rheumatologists are experienced in the use of various anti-inflammatory options (such as hydroxychloroquine, tetracyclines or colchicine) as well as the management of pain-related syndromes such as fibromyalgia and myofascial pain. As other providers have not succeeded in controlling this patients symptoms, there is potential a rheumatologist may be able to help this patient. Therefore, I have determined that the requested referral 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 seven-year-old male with a diagnosis of pervasive developmental disorder (PDD). The patient has been receiving speech therapy for receptive and expressive language delay associated with PDD. The patients mother has requested authorization and coverage for continued speech therapy. The Health Plan has denied this request on the basis that continued speech therapy is not medically necessary for treatment of the patients medical condition.The submitted documentation demonstrates the patient has been diagnosed with PDD by his treating physician. Review of the submitted speech therapy evaluation demonstrates the patients therapy has been directed at treatment of PDD rather than the limited diagnosis of phonological disorder. Furthermore, it appears the patients condition has improved with speech therapy and that he is likely to continue to benefit from speech therapy. Therefore, 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 continue to receive speech therapy once a week for a period of six months with re-evaluation at the end of the six-month period.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 48-year-old obese female with a history of high blood pressure and sleep apnea. She has a body mass index (BMI) of 35.8. She wishes to undergo weight loss surgery. She has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. The patients comorbidities would not be considered significant at this time. The Health Plan has denied the patients request on the basis that weight loss surgery is not medically necessary for treatment of the patients obesity.With a BMI of 35.8 and her documented comorbidities, the patient does not meet nationally accepted criteria for consideration of weight loss surgery. There is good potential this patient could obtain significant weight loss through conservative measures while avoiding the risks of weight loss surgery. Because this patient has the potential to lose weight through conservative means the benefits of weight loss surgery do not outweigh the risks. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 19-year-old female who has a history of bilateral breast macromastia. She underwent bilateral breast reduction surgery in July 2001. The patient also has a history of myelomeningocele and is wheelchair bound. The patient wishes to undergo another breast reduction procedure. The Health Plan has determined the requested procedure is not medically necessary for treatment of the patients medical condition.The patients complaints represent a special circumstance in which the usual indications for breast reduction surgery (i.e., low back pain, bra strap trauma) do not adequately apply. She is wheelchair bound and requires multiple transfers to and from her chair. Her ambulation is entirely dependent upon upper body movements. While the amount of breast tissue removed would not be of significant volume compared to most breast reduction procedures, this patients case is exceptional. The sheer volume of the patients breasts may be a hindrance to her ability to navigate her wheelchair and perform transfers. 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.