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

Review of the patients records demonstrates the patient has multiple medical problems including obesity, congestive heart failure, ischemic disease, hypertension, and angina. The patient also has diabetes with related neuropathy and foot ulcers. The patient currently utilizes a manual wheelchair for in-home mobility, but complains it is becoming more difficult to operate a manual wheelchair. The patient is seeking authorization for a power-operated vehicle (POV).The patients primary care provider believes a POV would be counterproductive, as it would contribute to the patients deconditioning. In addition, a note indicates as of May 2004 the patients upper extremity strength was normal and there is no indication her condition has changed to the point where she can no longer operate a manual wheelchair. Based upon the patients condition, I concur with her provider that a POV would be counterproductive and contribute to deconditioning. Furthermore, there is no clinical evidence demonstrating a POV is medically necessary. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old man with hepatitis C genotype 1 and cirrhosis. He has failed treatment with interferon and ribavirin due to side effects including bone marrow and psychiatric effects. He has a long list of complicating diagnoses including hypertension and cholelithiasis. The patients provider has recommended the patient begin treatment with ribavirin monotherapy. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients medical condition.The issue of treatment failure and the benefit of ongoing therapy with interferon or ribavirin as a method to suppress inflammation has been addressed in the published guidelines of the American Association for the Study of Liver Disease. The guidelines state, although these are interesting and suggestive data, the hypothesis that treatment will delay disease progression even if it does not eradicate the actual hepatitis C virus has not been tested in well-controlled trials. Such studies are in progress, but until they are completed and the treatment regimen established, no recommendation can be offered with regard to the value of maintenance therapy.The subject of ribavirin monotherapy in the treatment of hepatitis C is the subject of a current review. The review includes three additional studies of ribavirin monotherapy in hepatitis C and states overall, these data suggest that ribavirin monotherapy is associated with a decline in serum aminotransferases levels during therapy and may lead to histologic improvement in those in whom the aminotransferases become normal. However, ribavirin is ineffective in eliminating HCV RNA, although it may reduce HCV RNA levels in some patients. Furthermore, aminotransferases rarely remain normal after therapy is discontinued, and histologic improvement associated with ribavirin among those who normalize serum aminotransferases is generally modest. The absence of a virological response to ribavirin monotherapy suggests that it has a limited, if any, primary role in the treatment of chronic hepatitis C. Its use in specialized situations, as in liver transplantation, continues to be studied. A small controlled trial suggested that ribavirin monotherapy might sustain biochemical and histologic improvement in patients who failed to respond to combination therapy with interferon plus ribavirin. Further studies are needed to determine the clinical significance of this observation. At this time, the efficacy of ribavirin monotherapy for patients such as this patient remains unproven.Based upon the information set forth above, 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 48-year-old male with degenerative changes, curve alteration, and persisting pain of the neck. Symptoms extending to the upper extremities are now relieved, but neck pain persists. The patient has a history of extensive examination and medical treatment including plain x-rays and MRI, treatment by epidural injections times three, medications, and chiropractic care. Six chiropractic treatments have been authorized. The patients extremity complaints have been relieved and his neck pain has eased with chiropractic treatment. The patients primary care physician has written a letter of support for the chiropractic treatment. The patients treating chiropractor has stated complicating factors are present; as such, he has recommended 14 more treatments over a period of two months. Authorization and coverage for the additional care has been denied by the Health Plan on the basis it is not medically necessary for treatment of the patients neck and shoulder pain.This patient has had extensive diagnostic and medical treatments. The record reveals complications of degenerative joint and disc disease with disc extrusion at C7-T1 supported objectively with MRI and plain x-ray studies. Chiropractic care is supported by the patients primary care physician and has helped this patient by diminishing his pain and allowing him to decrease his use of pain medication. The Health Plan has not offered a specific alternative service to chiropractic care and the disputed care is as or more clinically appropriate than the treatments received before chiropractic care. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. Additional chiropractic treatment should be authorized at least twice a week for three weeks with a decrease to once per week for three weeks concurrent to a developed and practiced home program for self-reliance. Exacerbations may dictate treatment beyond this recommendation, but should not be an intensive as the initial course of care.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old woman with multiple problems who requests growth hormone (GH) therapy based on nonspecific symptoms, low GH concentrations, and a sub-optimal response to a GH releasing hormone stimulation test. She has also been given the diagnoses of chronic fatigue syndrome, sleep apnea, chronic pain syndrome, and leaky gut syndrome. She takes a multiplicity of medications and amino acid supplements, many of which could affect GH and GH stimulation. The patients provider has recommended the patient receive GH injections. The Health Plan has denied authorization and coverage for growth hormone therapy on the basis it is not medically necessary for treatment of the patients medical condition.The diagnosis of adult growth hormone deficiency (AGHD) is based on the clinical context, which is suggestive of some disorder of the hypothalamic pituitary axis. Other causes for the patients symptoms could be her depression, chronic fatigue syndrome, perimenopause, obesity, chronic pain, and sleep apnea. These must be considered before undertaking a course of testing for isolated AGHD. With the exception of a low ACTH level associated with a normal cortisol level the rest of the tested pituitary hormones appear normal. The patients head MRI, IGF-1s (which are decreased in 70% of patients with AGHD), ILGF-1, and IGFBP3 concentrations were all normal. Her low GH levels and inadequate response to the GH releasing stimulation test in this context could also be caused by any of her other conditions. As such, it has not been established that GH therapy is medically indicated in this patient.Based upon the information set forth above, I have determined that 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 45-year-old female who is post reconstruction of mastectomy utilizing a TRAM flap. The patient has had reconstruction of the nipple/areolar complex and mastopexy of the contralateral breast as well as some body contouring as part of her program. The patient is presently seeking authorization for further body contouring of the posterior/lateral trunk bilaterally. The Health Plan has denied the patients request on the basis that the requested procedure is cosmetic in nature and therefore, not medically necessary.Review of the submitted records reveals no medical indication for the requested procedure. The submitted documentation of the patients surgical progress demonstrates appropriate results. The patients provider has indicated that the requested liposuction procedure is not part of the patients breast reconstruction. There is no evidence of medical necessity for liposuction of the patients trunk. 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 has had long-standing migraine headaches that respond to Imitrex. She is using 50mg tablets and indicates she needs more than one tablet per attack. Attacks remain frequent and may last days per the submitted records. Several prior preventatives have been used, apparently without much success. The patient has requested authorization and coverage for 27 Imitrex tablets per month. The Health Plan has determined the requested prescription is not medically necessary for treatment of the patients migraine headaches.The patients migraines are disabling and acute abortive therapy has been effective for this patient. However, she continues to have frequent headaches and does not appear to have been on any anti-convulsant category of prevention, such as Depakote, Topamax or Neurontin. Further preventive care is indicated with ongoing neurologic input. In addition, the patient is on hormonal medication that sometimes worsens headaches and its discontinuation should be considered. Moreover, she is using 50mg tablets of Imitrex and may have a better headache free response to 100mg tablets, which may reduce the number of times she needs to be retreated and the number of tablets needed per month. In any event, there is no medical justification for 27 Imitrex tablets per month. 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 53-year-old male with a long history of neck pain from anterior cervical degenerative joint disease, and chest pain in 2003 from pericarditis, requesting coverage for Bextra 20mg twice daily. The patient also has a history of diverticulitis and chronic gastritis for which he is on Prevacid. The patients provider states that Cox II inhibitors have not helped relieve the patients chest pain, and Bextra has been very effective in providing relief of his chest pain.I find that the requested dosage of Bextra is higher than the manufacturers recommended dosage. Since NSAIDs have adverse side effects that are dose related, the patient should not exceed the manufacturers recommended dosage. As such, the use of Bextra at the requested dosage is not medically indicated. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient presents with a complaint of nasal congestion, which has been present for almost two years. The medical records indicate the patient was evaluated for this condition two years ago. A CT scan was performed and surgery was recommended. Because of the patients fear of surgery he deferred treatment, but now returns for care. The patient states that he has been using nasal sprays, which have been somewhat effective. However, the patient reports the nasal sprays have begun to lose their effectiveness. The medical records state the patient has been given numerous antibiotics for his condition, but they have failed to clear the problem. The physical exam documents a severely deviated septum and a hyponasal voice. A CT scan from August 2004 revealed extensive sinus disease, which had not improved from a prior study of May 2002. A chart note from June 2002 recommended nasal sprays, allergy screening, and four weeks of antibiotics with a repeat of the CT scan. The patient now wishes to proceed with nasal surgery. The Health Plan has denied the request on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.The patient has a nasal obstruction with both physical and CT evidence of a mechanical cause for this obstruction. Though he may have had some previous issues with compliance, the patient has made a reasonable effort with conservative management. The patient continues to be symptomatic. Though management of allergy and soft tissue swelling can reverse some cases of rhinosinusitis, the physical findings indicate the patient has a severely deviated septum with no improvement in his condition over the past two years. As such, the patients condition needs to be treated surgically. Therefore, I have determined the requested surgery 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 71-year-old woman who has eye irritation and pain in her left eye. She underwent bilateral cataract surgery in 1997. She has requested authorization and coverage for eye surgery. The Health Plan has determined the requested surgery is not medically necessary.The Health Plans denial should be upheld. There is no medical indication for eye surgery in this patient. The submitted records indicate the patient has been examined by several providers. None of the patients providers have recommended eye surgery. There is no evidence the patients eye irritation will be relieved by surgery. Thus, there is no medical justification for surgical intervention. Therefore, I have determined that the requested surgery 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 14-year-old female with a monosome chromosome 10-P translocation with a history of speech delay (receptive greater than expressive), cognitive delays, and seizures. The patient has been receiving speech therapy since 1996. At issue is whether continued speech therapy is medically necessary.Review of the submitted clinical records indicates there is a lack of objective documentation demonstrating the patient has made significant gains with speech therapy. The patients deficient language skills are life-long deficits and are educational rather than medical in nature. As such, continued speech therapy in a medical setting is not warranted. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be uphe
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 54-year-old female with a history of documented right atrial tachycardia, tachycardia induced cardiomyopathy and status post atrial ablation in February 2004. The patient has reported continued symptomatic palpitations during follow-up evaluation. The patient was not offered repeat ablation at that time. Thereafter, the patient underwent repeat Holter monitoring demonstrating recurrent symptomatic supraventricular tachycardia at 127-130 bpm. Despite these findings, there is no report from the patients treating electrophysiologist of any new recommendations or plans for additional therapy. The patient has sought a second opinion from another electrophysiologist. The second opinion has recommended attempting a repeat ablation. The patient is requesting authorization for a repeat electrophysiologic study and catheter ablation.Treating atrial tachycardia is challenging. This patient has had an abnormal Holter monitor and was not offered any additional therapy other than a follow up visit. Based upon the patients history and abnormal testing the repeat electrophysiologic study and catheter ablation are medically indicated and within the standard of care for this patients condition. Therefore, I have determined that the requested services are medically necessary for the 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 31-year-old female who reports a long-standing history of panic attacks, anxiety disorder, and minor depression. Since the birth of her child, the patient reports her panic attacks, anxiety disorder, and depression have increased. She reports experiencing approximately three episodes a day. The patients physician attributes the increase in part to increased hormone levels as well as low-level depression. The patient has requested authorization and coverage for acupuncture as an alternative to medications as she is breast-feeding her child and also plans on becoming pregnant in the near future.This patient has requested acupuncture for treatment of her panic attacks, anxiety disorder, and minor depression. She states she has tried other types of treatments without any long-term benefit. Because the patient is a nursing mother and also plans on becoming pregnant again in the near future she does not at this time want to take any medication because of concerns the medication could have an adverse affect on the baby and also on her ability to become pregnant. Acupuncture is a medically reasonable and appropriate alternative for treatment of anxiety and depression and is commonly used for the treatment of these conditions. In light of the patients concerns regarding the use of medication, a trial of six acupuncture treatments is medically appropriate as an alternative to pharmacologic treatment. Therefore, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 60-year-old man who presented with a right supraclavicular node in mid- 2003. Biopsy revealed non-small cell lung carcinoma. At that time, he was also noted to have a large right upper lobe lung mass, along with extensive hilar and mediastinal adenopathy. The positive neck node classified the patient as stage IV and it was clear he was not operable. The patient was seen by radiation therapy and a PET scan was recommended, which most likely would have been followed by treatment with chemotherapy combined with radiation therapy. The patient instead chose an alternative route and received low dose chemotherapy at another institution, to no effect.The patient began a combination of hyperthermia and radiation therapy to his neck. The Health Plan has denied authorization and coverage for hyperthermia and radiation treatment on the basis the therapy is not medically necessary for treatment of the patients medical condition.Hyperthermia is the use of coils to generate high temperatures within a cancer mass. It has been studied for many years, both by itself and in combination with radiation and/or chemotherapy. Though there are certain situations where such therapy might be beneficial in terms of controlling a large specific mass, it is unclear how this would compare to more standard radiation, often combined with radiosensitizing chemotherapy. There is no evidence in the peer-reviewed literature demonstrating the superiority of hyperthermia and radiation treatment over standard radiation. 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 41-year-old male with a long-term history of chronic back pain. An MRI revealed degenerative changes in the patients spine. The patient is seeking authorization for a vertebroplasty. There is no evidence the patient has a compression fracture.The patient suffers from chronic lumbar pain with apparent arthritis of the lumbosacral spine. The patient does not have an acute compression fracture. In the absence of such a fracture there is no clinical indication for a vertebroplasty. The patients condition does not meet accepted criteria for consideration of a vertebroplasty. 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 34-year-old female with a history of right ankle fracture six years ago. She underwent hardware removal in February 2004. Since removal of the hardware she has been walking with an SPC and Cam Walker. She continues to have pain. X-rays have not demonstrated the etiology of her continued pain. She began physical therapy in August 2004 and therapy notes indicate the patient has difficulty standing for long periods of time. Her quadriceps strength was rated as 3+/5 with no abnormality in her upper extremity strength noted. In addition, there is no indication from the patients orthopedist that the patient is non-weight bearing. The patient is seeking authorization for a power-operated vehicle (POV). The patient does not meet nationally accepted medical necessity criteria for authorization of a POV. The patient is not bed or chair confined. In relation to her ankle fracture, there is no indication the patient is currently non-weight bearing. Furthermore, there is no indication the patient cannot operate a manual wheelchair. As such, there is no evidence a POV is medically necessary for this patient. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old female with a body mass index (BMI) of 32.7. She has a family history of diabetes mellitus and experiences shortness of breath. She has requested authorization for gastric bypass surgery. There is no evidence she has undergone a formal psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary for treatment of the patients obesity.With a BMI of 32.7 and no significant comorbidities, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. Furthermore, in light of this patients BMI, there is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the 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.