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

The patient is a 34-year-old male who is status post gastric bypass surgery and loss of over 150 pounds. As a result of the weight loss the patient has developed excess thigh tissue, which he would like surgically removed. The patients Health Plan has denied authorization for the requested procedure. The Health Plans denial should be upheld. There is no evidence the patient has chronic or recurrent skin infections that have not responded to medical therapy. Neither the patients medical records nor photograph provide objective evidence that the patient has a condition requiring surgery. In the absence of such evidence 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physisican 1: The patient is a 56-year-old male with a history of Achilles enthesopathy. The patients provider indicates the patient has not achieved prolonged relief with NSAIDs, stretching, functional foot orthotics, and a Dynasplint. The patients provider believes extracorporeal shock wave therapy (ESWT) is indicated for this patient. The Health Plan has denied authorization for the requested therapy on the basis it is considered investigational for treatment of the patients condition. The Health Plans denial should be upheld. There is insufficient medical literature showing that ESWT for treatment of plantar fasciitis results in an improved clinical outcome. Furthermore, there is no literature to support ESWT for the treatment of Achilles enthesopathy. The patient is likely to experience greater benefit from standard therapies than from use of this unproven procedure. As such, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Physician 2: The patient is a 56-year-old man with chronic foot pain. He has requested authorization and coverage for extracorporeal shock wave therapy (ESWT). The Health Plan has denied this request on the basis that ESWT is considered investigational for treatment of the patients condition. ESWT has not yet been shown to be efficacious for treatment of Achilles enthesopathy. There are no long-term studies demonstrating that ESWT will provide long-lasting relief in this clinical setting. Furthermore, it has been documented that ESWT can damage tissue and thus, risks clearly exist. As such, ESWT cannot be recommended at this time. I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Physician 3: The patient is a 56-year-old man who has been treated for left posterior heel pain with NSAIDs, function orthotics, physical therapy, and a Dynasplint. His diagnosis is Haglunds deformity with posterior calcaneal enthesopathy. After months of continued pain, a request for extracorporeal shockwave therapy (ESWT) was made. The Health Plan has denied this request on the basis that ESWT is considered investigational for treatment of the patients condition. ESWT has been approved by the Food and Drug Administration (FDA) for treatment of lateral epicondylitis and proximal plantar fasciitis. The application of ESWT to the posterior heel for treatment of insertional Achilles enthesopathy is an off-label use and is of unproven efficacy. There is no literature demonstrating that ESWT is more beneficial for treatment of the patients condition than surgical intervention. Accordingly, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is an 18-year-old female with a long-standing history of depression. She was first formally evaluated and treated in March 2003, at which time she reported experiencing depression and anxiety since the eighth grade. This was accompanied by neurovegetative symptoms consistent with major depression. She subsequently was treated with a variety of antidepressants including Paxil, Lexapro, and Wellbutrin, and most recently high-dose Zoloft. Since that time, her psychiatric illness has been compounded by polysubstance abuse, including amphetamine and cocaine, drug-dealing, chronic lying to her parents, and promiscuity. The latter was reportedly spurred by an initial rape when she was 13 that resulted in her activity. The patient noted suicidal ideation, short of frank attempt, in the 6th, 8th, 9th and 12th grades. She later tended to cut on herself, though the frequency of this is unknown. School performance was poor and she was suspended for drinking and leaving the premises. Due to recalcitrant drug use, promiscuity, lying, and failure to attend recommended outpatient treatment, she was admitted to residential treatment on 12/4/03. At that time she was diagnosed with major depression, recurrent and polysubstance abuse, though documentation also pointed to the patient as likely having chronic personality pathology, type unspecified. On 12/10/03, staff noted the patient as guarded/sullen with soft monotone voice and very poor eye contact and closed body language. On 12/12/03, her Zoloft was decreased and she was started on Wellbutrin. Through further adjustment of Wellbutrin, (eventually raised to a total of 300mg), and Zoloft (decreased to 50mg), she ultimately improved and by 1/19/04 the patients psychiatrist noted she reports stability with present medications. Sleeps okay, improved affect, feels motivated, and positive outlook. Medications have been beneficial without side-effect. A request has been made for reimbursement for the residential treatment services at issue. The Health Plan has denied the request on the basis that the services at issue were neither emergent nor medically necessary for treatment of the patients medical condition. Given the chronicity of the patients illness, with treatment having begun in March 2003 residential treatment was not emergent at the time of her admission in December 2003. It is true that at the time of her admission the patient was faring more poorly, failing to attend outpatient treatment and engaging in drug use and promiscuity. However, she was not acutely suicidal or psychotic and thus, the timing of transition to residential treatment was flexible. While residential placement was medically warranted at the time of her admission, it appears that she was decidedly stable by 1/19/04. Her psychiatrists note appears quite clear in this regard. Therefore, I have determined that although the services at issue were not emergent in nature, residential treatment was medically necessary for treatment of the patients medical condition until 1/19/04. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 42-year-old female with a body mass index (BMI) of 58 with multiple obesity related comorbidities. She has failed medical management and now wishes to pursue operative treatment. She has not had prior surgery. The patient has requested authorization and coverage for laparoscopic adjustable gastric banding (Lap-Band) surgery.  The Health Plan has determined the patient can be appropriately treated with Roux-en-Y gastric bypass. Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. The greatest expected weight loss with Lap-Band is 50% to 60% at three to five years out. A patient with a BMI of 58 will still be obese with a 50% weight loss. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not indicated in this case. 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 51-year-old male with a history of migraine headaches and epiphenomena consisting of olfactory hallucinations. His treating provider has recommended a second MRI of the brain. The patient had a previous MRI of the brain in June 2003 demonstrating a small, older lacuna infarct in the right basal ganglia (not the cause of either headaches or olfactory hallucinations), but otherwise normal. The Health Plan has denied authorization for the second MRI as not medically necessary. As set forth above, the patients initial MRI was otherwise normal except for an older lacuna infarct, which is not the cause of either the patients headaches or hallucinations. In the absence of previous findings or neurological signs and symptoms a second MRI is not medically indicated. This patient does not have focal neurological signs or symptoms. In addition, epiphenomena such as visual or olfactory hallucinations are commonly observed in patients with migraine headaches. Based upon this information, there is no indication that a second MRI is medically indicated. Therefore, I have determined the requested MRI 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 47-year-old woman with chronic neck pain and osteoarthritis. The patients comorbid conditions include epilepsy, depression, and hypertension. She is status post two posterior decompressions of the cervical spine and has chronic migraines. The patient has taken ibuprofen for temporomandibular related pain without relief. She has also been on Mobic. An esophagogastroduodenoscopy confirmed active ulcer disease. The patient is requesting coverage for Bextra for her pain. The Health Plan has denied the patients request on the basis that Bextra is not medically necessary for treatment of the patients chronic pain. Bextra is not medically necessary or indicated for treatment of the patients chronic pain. Review of the submitted medical records indicates an esophagogastroduodenoscopy confirmed active ulcer disease. In light of this finding, NSAIDs and COX2 inhibitors are contraindicated in this patient. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 42-year-old male with a history of back pain with radiation. His physician indicates the patient tried physical therapy and other treatments without success. In August 2004, the patient was provided a Saunders lumbar traction unit. The patient indicates the device helped reduce his pain. The Health Plan has denied reimbursement for the equipment at issue on the basis that it is considered experimental for treatment of the patients medical condition.The patient received an appropriate course of physical therapy without change in symptoms beyond the use of traction. Unfortunately, the available literature does not support use of traction for treatment of lower back pain. There is no evidence that the Saunders lumbar traction unit is superior to standard pain management modalities for treatment of patients such as this patient. As such, I have determined that the equipment at issue was 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. Physician 2: The patient is a 42-year-old man who has had a long history of back pain. He has tried several modalities without relief. He has been using a Saunders lumbar traction unit since August 2004 at the recommendation of his physician. The patient reports the lumbar traction unit has helped with reduction of his pain. He has requested reimbursement for the equipment at issue. The Health Plan has denied the patients request. The Health Plans denial should be upheld. There is no data to suggest that the Saunders lumbar traction unit is effective for the treatment of chronic low back pain. To date, no Class I data exists. Lumbar traction for the treatment of low back pain is of unproven efficacy at this time. Therefore, I have determined that the equipment at issue was 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. Physician 3: The patient is a 42-year-old male with low back pain who was treated with physical therapy without relief. In August 2004, the patient began using the Saunders lumbar traction unit. The patient indicates he has benefited from use of this equipment. The patient has requested reimbursement for the equipment at issue. The Health Plan indicates the efficacy of the Saunders lumbar traction unit has not been established in peer-reviewed literature. Review of the current medical literature reveals the efficacy of lumbar traction for treatment of low back pain has not been established. There is no randomized, placebo-controlled, peer-reviewed literature to support the use of the Saunders lumbar traction unit for treatment of this patients pain. The patient would have been more likely to benefit from a proactive physical rehabilitation program. Therefore, I have determined that the equipment at issue was 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

A seventy-nine year-old male with a history of congestive heart failure and progressive shortness of breath is requesting reimbursement for out-of-network inpatient hospital services.Reviewers Findings:  The reviewing physician found that post-stabilization transfer to a Health Plan hospital would have been medically reasonable and appropriate.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of an eight-year-old male with a history of escalating disruptive, defiant behavior is requesting authorization of inpatient psychiatric treatment services.Reviewers Findings:  The reviewing physician found that there is no objective evidence that the patient required inpatient psychiatric treatment services.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 44-year-old female who has requested authorization and coverage for the medication Allegra. The patient has a history of allergic rhinitis, asthma, and recurrent sinusitis. The patients provider notes the patient has tried and failed numerous medications for treatment of her allergic rhinitis including Claritin, Actifed, Clarinex, Zyrtec, Sudafed, and Phenergan. The Health Plan has denied coverage for Allegra indicating that the requested medication is not medically necessary for treatment of the patients medical condition. No objective documentation has been provided demonstrating that Allegra is medically necessary at this time. The patient has chronic rhinitis despite use of antihistamines, intranasal steroids, and Singulair. As such, an allergy referral for consideration of immunotherapy or other medical treatment alternatives is medically indicated. There is no evidence that another antihistamine would prove any more efficacious than those previously tried. 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 three-year-old female with a history of speech delay who has been receiving speech therapy for articulation problems. The patients developmental pediatrician also documents errors of pragmatic speech, lack of development of age appropriate peer relationships, and lack of social reciprocity. The patient lacks repetitive stereotypical behavior or preoccupation with parts of objects, which is needed for a diagnosis of Asperger's syndrome. A request has been made for reimbursement for speech therapy services the patient received from November 2003 to May 2004. The Health Plan has denied this request indicating the therapy at issue was not medically necessary. The Health Plans denial should be upheld. The patients speech therapist documents the patients primary problem as an issue with articulation. Based upon the information provided, it does not appear the patients speech and articulation errors are aligned with the symptoms associated with the concerns outlined by her developmental pediatrician (i.e., symptoms placing this patient on the autism spectrum). Since the patients primary issues involve articulation, speech therapy was not medically warranted for this patient. Therefore, I have determined that the therapy 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: Upheld Decision of Health Plan

The patient is a 59-year-old female with plantar fasciitis. She has undergone a number of treatments without success. Her provider is now recommending extracorporeal shock wave therapy (ESWT). The Health Plan has denied authorization because of a lack of established efficacy. The Health Plans denial should be upheld. The therapy in question, ESWT, has yet to be shown as effective in the treatment of plantar fasciitis in any long-term, prospective studies. In addition, there are studies showing that it is, in fact, ineffective. Furthermore, the long-term risks and complications of the therapy are unknown. Because there is no established efficacy, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 24-year-old female with a body mass index (BMI) of 67.8. The patient also indicates she has a number of comorbid conditions.  She has requested authorization for Lap-Band surgery. The Health Plan has denied this request on the basis that Lap-Band surgery is not medically necessary for treatment of the patients medical condition. Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not indicated in this case. 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 51-year-old male who injured his knee while out of state. He was evaluated in the emergency room and an evaluation by an orthopedist was recommended. A few days later the enrollee was evaluated by an orthopedist and an MRI was recommended. The patient remains out of state and the Health Plan has denied authorization for the MRI on the basis that it is not considered an emergent or urgent service. The Health Plans denial should be upheld. Although an MRI appears indicated for this patient it is neither emergent nor urgent in nature. The documentation submitted demonstrates the evaluating orthopedist did not consider the MRI emergent or urgent in nature. The Health Plan indicates it will provide an MRI to the patient when he returns to his state of residence. There is no indication in the information provided that the requested MRI needs to be provided on an emergent or urgent basis. Therefore, I have determined the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 12-year-old male with a history of developmental delays including significant speech delay. There is also a reported history of otitis media with effusion. The patient has been receiving speech therapy. Periodic reevaluations have reflected some improvement in speech. A request has been made for additional speech therapy services. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition. While the submitted information indicates the patient has been diagnosed with Aspergers syndrome and otitis media with effusion, no supporting documentation has been provided. Formal developmental testing results are not available. In addition, the patients hearing is reported to be normal. Thus, there is insufficient evidence that speech therapy is medically warranted. As such, 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 74-year-old male who was hospitalized in July 2004 for dysphagia. At that time he was found to have perforation of his esophagus. He also had a past history of chronic lymphocytic leukemia for which he was not on any specific treatment. He was apparently transfused and started on Epogen, though his hemoglobin was 12.3. It appears Epogen was continued while the patient was in an extended care facility. It was noted that a hemoglobin on 8/2/04 was 12.5. The patient is seeking reimbursement for the doses of Epogen he received. The Health Plan has denied the patients request on the basis that Epogen was not medically necessary for treatment of the patients medical condition. Epogen is a bone marrow stimulant, which can increase hemoglobin and correct anemia. The Health Plan indicates hemoglobin must be below 11 and/or the patient must be receiving chemotherapy to qualify for Epogen use. The patient met neither of these criteria and in fact it does not appear he was anemic during the period at issue. The Health Plans criteria are medically reasonable and appropriate and consistent with community standards. As such, 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: Upheld Decision of Health Plan

The patient is a 61-year-old male with a history of night sweats and fever. The patient has undergone extensive workup, which included a physical exam, chemistries, blood counts, chest x-ray and colonoscopy. All of the results were normal. The patient wishes to undergo a PET scan to rule out a tumor. The Health Plan has denied the patients request on the basis that a PET scan is not medically necessary. The Health Plans denial should be upheld. There is no established role for PET scanning in this setting. There is no medical indication or justification for PET scanning in the treatment of this patient. In addition, there is no evidence to suggest that PET scanning is indicated for this patient. Therefore, I have determined that the requested PET scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.