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

The patient is a 43-year-old female who presents with neck and back pain as well as right side upper extremity pain. No cause or incident for the pain is evident. Chiropractic care has been provided 18 times over several months. The patient indicates she is in constant pain and is unable to work despite a recent course of chiropractic care. The patient notes on the chiropractic intake forms that her complaints are all the time, extreme, and she has neck pain on swallowing. An x-ray exam has been requested by the chiropractor but the submitted documentation does not indicate if the exam was performed. The patient has requested authorization for continued chiropractic care. The Health Plan has denied the patients request on the basis that continued chiropractic care is not medically necessary for treatment of the patients medical condition.Upon review of the patients records it appears she has made little progress with chiropractic care. Additionally, the submitted records do not demonstrate that other causes for the patients arm complaints have been ruled out or that referrals have been made. Chiropractic care has been given an adequate opportunity to cure or relieve the patients pain. Continued chiropractic care is not likely to be clinically beneficial to this patients current complaints. The patient should receive a referral to her primary care physician for further workup or a referral to rule out other causation or to suggest possible curative care approaches. Based upon the information set forth above, 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 upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 63-year-old woman with a several year history of migraine headaches. She wishes to receive 18 Axert tablets per month. The submitted notes indicate the patient is currently taking a long list of medications for treatment of migraine headaches. The patient uses Axert as a recovery medication. She has requested authorization for 18 tablets of Axert per month to treat her migraines. The Health Plan has denied the patients request on the basis that the requested prescription is not medically necessary.Acute migraine headaches are generally treated with a variety of medications with triptans being the most effective. For patients who experience frequent migraine attacks, prophylactic medication is essential. Medications such as atenolol are very effective in the prophylactic treatment of migraine. A note from the patients provider in December 2003 indicates that atenolol reduced the patients headaches. Triptans such as Axert should only be used for occasional acute episodes. Upon review of the submitted information, it appears the patients use of multiple medications may be precipitating headaches. Thus, the requested prescription is not medically indicated since it is likely to cause rebound headaches. The patients long list of medications should be reviewed by her provider to determine which medications are essential.Based upon the information set forth above, 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: Upheld Decision of Health Plan

A 40-year-old female patient has requested authorization and coverage for endovenous laser therapy for treatment of varicose veins. The patient is status post ligation of perforators and varices in the left leg. The patient indicates her symptoms include aching pain in her legs, swelling, restless legs, and throbbing. The Health Plan has denied authorization for endovenous laser therapy on the basis that it is not medically necessary.Based upon the submitted documentation, it has not been established that any intervention is medically indicated. The patients venous pathology and efforts at conservative management appear vague and contradictory. Thus, it has not been demonstrated that standard treatment modalities are not likely to be effective.  Furthermore, the efficacy of endovenous laser therapy remains unproven in long-term trials compared to radiofrequency ablation and stripping. 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 16-year-old female status post a motor scooter accident in 2001 in which she sustained ligament and tendon damage to the wrist requiring repair. The patient sustained a humeral fracture, which was undiagnosed. She has been treated with improvement in muscle strength, but without much improvement in symptomatology. The patients orthopedic surgeon recommended a referral to a shoulder specialist orthopedic surgeon for consideration of surgery to correct hyperlaxity and impingement of the shoulder. The patients mother has requested authorization for additional physical therapy visits prior to referral to a shoulder specialist to see if further therapy will resolve the issue.At issue is whether additional physical therapy is medically necessary for treatment of the patients condition. The Health Plan has authorized four visits with the possibility of further sessions if progress is documented. Given the documentation by the patients physical therapist and orthopedic surgeon, which indicates that little improvement in symptoms has occurred with the initial six physical therapy sessions, it is probable that further sessions will not be of great benefit in reducing the patients symptoms. This is particularly true in light of the patients compliance with a home-exercise program. The Health Plans authorization of four additional physical therapy visits followed by reevaluation is medically reasonable and appropriate. 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 16-year-old male with a diagnosis of allergic rhinitis. The submitted information indicates the patient has taken Allegra in the past for seasonal allergy problems with successful results. The patients provider indicates the patient is not contraindicated to Alavert or Claritin, and may use Claritin 10mg daily. There is no history of failure or intolerance to over-the-counter alternatives such as Alavert, Claritin, or generic loratadine.A request has been made for authorization and coverage for Allegra. The Health Plan has denied the request on the basis that Allegra is not medically necessary for treatment of the patients allergic rhinitis.The submitted records do not document the medical necessity of Allegra for treatment of the patients seasonal allergic rhinitis. The patients provider has indicated that Claritin may be used. Furthermore, there is no documented history of failure of over-the-counter alternatives. Although the patient has obtained good results from Allegra, there is no indication the over-the-counter alternatives will be ineffective. 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: Overturned Decision of Health Plan

HOLD    HOLD      HOLD            HOLD   The patient is a 38-year-old woman with severe maxillary alveolar atrophy. She has been edentulous in the maxilla since the age of 21 and wears a full maxillary denture prosthesis, which occludes with natural dentition in the mandible. The maxillary denture now has poor retention and poor stability because of atrophy of the supporting maxillary alveolar process resulting in discomfort and inability to masticate a wide variety of foods. The patients treating providers have recommended augmentation of the maxillary alveolar bone with bone grafting in the floor of the maxillary sinuses to allow eventual placement of endosseous dental implants. The goals of the recommended treatment are to provide retention and stability to an upper denture prosthesis, stem further resorption of the maxillary alveolar process, and restore normal masticatory function. The Health Plan has denied authorization for the requested procedures on the basis that the procedures were not covered benefits.The recommended maxillary bone grafting and placement of dental implants are medically necessary for treatment of the patients medical condition. The patients described bone atrophy is an abnormal structure of the body. It is caused by chronic trauma to the maxillary alveolar process. Bone grafting and placement of dental implants are needed to improve function and to create a normal appearance to the extent possible. The requested procedures have been sought in order to treat a condition directly affecting the upper jawbone. Failure to authorize these procedures in this case would result in a failure to provide medically necessary health care services to this patient. Therefore, I have determined that the requested procedures are 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

This is an unusual case of a 28-year-old male with cystic fibrosis who is status post living lobar lung transplantation eight years ago. The transplant was bilateral from a living donor of one lobe each side. Apparently the patient has done well in the interval and is now working. The patient has recently developed an episode of sinusitis. The patient has requested authorization and coverage for a referral to a pulmonary specialist with experience and affiliation with a lung transplant center. The submitted documentation indicates the patient has been treated by the same providers at a transplant center for the past eight years. Because of the unusual circumstances of this case the patient should continue to be followed by a pulmonary specialist at a lung transplant center. Furthermore, continuity of care at a single center with the same team of physicians is in the patients best interest. The complexity and complications of the patients treatment are best remembered and best understood by the physicians who administered the treatment and who were there for the complications. Moreover, in cases where the patient is receiving treatment for a chronic illness, care is better in patients who have a consistent provider of care. In light of these factors, continued care from the patients treating providers at the lung transplant center from which he received his transplant is medically indicated. Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 43-year-old woman with chronic constipation who has been treated for irritable bowel syndrome with several medications including Elavil, Synthroid, Protonix, and Zelnorm. Zelnorm was initiated in October 2003 with an apparent reduction in the patients symptoms. The patient was continued on Zelnorm for up to 24 weeks of therapy. A request has been made for further treatment with Zelnorm. The Health Plan has denied authorization for the requested medication on the basis that it is not medically indicated for treatment of the patients condition.Zelnorm has been approved by the Food and Drug Administration (FDA) on the basis of clinical trials involving treatment up to 12 weeks. Although the drug has limited efficacy and has not been shown to be superior to conventional treatment it is superior to placebo and has had some use in the gastroenterology community. Furthermore, it has only been studied for use over longer periods in an open label study (see citation above). In that study, almost 50% of patients dropped out and there was a 4.4% incidence of serious adverse effects. The patient has received twice the duration of Zelnorm treatment approved by the FDA. To date, there is no evidence that the drug is efficacious over a longer period of time. Furthermore the safety of long-term use of Zelnorm has not been documented in extensive peer-reviewed clinical trials. As such, further treatment with Zelnorm is not medically indicated at this time.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 37-year-old woman who has had cystic acne for several years. Topical acne medications, oral minocycline, and orthotricyclen have been prescribed by the patients primary care physician with variable results. The patients primary care physician has requested a referral to a dermatologist, which has been denied by the Health Plan.Analysis and Findings:Inflammatory acne vulgaris and cystic acne vulgaris are medical conditions, which can lead to significant to severe disfigurement secondary to scarring. Dermatologists are experts in treating cystic acne vulgaris. After attempting treatment of the patients cystic acne the patients primary care physician recommended the patient consult with a dermatologist. As such, it is medically necessary to refer the patient to a dermatologist for assistance in treating this potentially debilitating medical condition. 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 21-year-old female with cystic fibrosis. The patients provider indicates the patient has benefited from use of the Vest Airway Clearance System (the Vest system) and has had only two hospitalizations while using the device. The patients provider also notes the patient has used both a Flutter device and chest physiotherapy (CPT) with minimal success. A hospital discharge summary from June 2004 states the patient was admitted for 48 hours of hemoptysis. The patient was discharged on intravenous antibiotics for cystic fibrosis exacerbation. The record also shows the patient had a baby in March 2004 and that she is the primary caregiver for her child. A request has been made for continued use of the Vest system. The Health Plan has determined that the requested equipment is not medically necessary for treatment of the patients cystic fibrosis.There are many studies to support the contention that enhancing mucous clearance in patients with bronchiectasis, (specifically cystic fibrosis) results in a benefit in disease control and symptoms. These include the use of chest physiotherapy, postural drainage, and mucolytics. The submitted literature reviewed the high frequency chest compression (HFCC) devices with other mucous clearance methods such as the Flutter device and chest physiotherapy. Overall, the methods appear to be equivalent in terms of secretion clearance. The patient is concurrently using various methods of secretion clearance including bronchodilators, inhaled recombinant DNase (Pulmozyme), and Flutter device. Secretion clearance is paramount in the management of cystic fibrosis as it prevents infections and improves symptoms. The patient is an adult who recently had a baby and is the primary caregiver for the child. She would greatly benefit from a method of self-administered secretion clearance. The submitted documentation indicates the patient has used the Vest system since 1999 and has had few hospitalizations and exacerbations. HFCC devices such as the Vest system are widely accepted and are standard therapy for patients with cystic fibrosis. Thus, continued use of the Vest system is medically appropriate and indicated for continued management of the patients cystic fibrosis.Based upon the information set forth above, I have determined the requested equipment 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 an 11-year-old female with sleep apnea symptoms that date back to age five. She underwent a tonsillectomy and adenoidectomy in August 2001. She continues with obstructive breathing symptoms. A complete sleep study was performed in September 2003. The sleep study documents a respiratory disturbance index (RDI) of 5.7. Nadir oxygen desaturation was 93%. The patients provider prescribed bi-level positive airway pressure (BIPAP) medical therapy since further surgery was not an option at the time. The patient has proceeded with a BIPAP trial, which she has tolerated well (compliance of 87%), and demonstrates significant persistent improvement.The patient also has severe scoliosis and will require spinal fusion surgery in the near future. The patients mother has requested authorization for a BIPAP machine until the patient recovers from her spinal surgery and until further palate surgery can be considered to surgically address her persistent obstructive sleep apnea.The Health Plan has denied authorization for a BIPAP machine on the basis that it is not medically necessary for treatment of the patients medical condition.Childhood obstructive sleep apnea is common (estimated prevalence of 1-3% in preschool children) and can result in significant morbidity. Childhood obstructive sleep apnea syndrome differs significantly from adult obstructive sleep apnea syndrome. Polysomnographic results in the pediatric age group differ from the adult population.On the basis of normative data, an obstructive apnea index of 1 is often chosen as the cutoff for normality. Multiple normative studies have been performed in children and adolescents. The consensus across these studies supports the diagnosis of obstructive sleep apnea in children with a RDI or apnea hypopnea index (AHI) of 1.5 or greater. An RDI of 5 in children and adolescents is considered moderate obstructive sleep apnea. This differs from adult normative data that support the diagnosis of obstructive sleep apnea with a RDI or AHI of 15 or greater.This patient has a RDI of 5.7 after tonsillectomy and adenoidectomy. This indicates moderate obstructive sleep apnea using current normative guidelines in children. As such, use of a BIPAP machine is medically appropriate and indicated. Therefore, I have determined that the requested equipment 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 27-year-old female with a body mass index (BMI) of 46. The patient has undergone a psychological evaluation and has been deemed an appropriate candidate for weight loss surgery. She wishes to undergo a gastric bypass procedure. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary for treatment of the patients medical condition.With a BMI of 46, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Furthermore a psychological evaluation has determined the patient is an appropriate candidate for weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence demonstrates that once a morbidly obese patient has been identified as an appropriate candidate for weight loss surgery from a medical and psychological standpoint, further conservative attempts at weight loss are not necessary. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old female with a history of endometrial cancer. The patient was initially diagnosed in 1999. Since her surgery, the patient has been followed with CT scans and serum markers. The CT scans have been negative for recurrence with the last exam performed in October 2002. The serum 19-9 has increased from 63 to 74.4. The patients provider has recommended a positron emission tomography (PET) scan to rule out active metastases. The Health Plan has denied authorization for the requested PET scan on the basis that it is not medically necessary for evaluation of the patients medical condition.The Centers for Medicare and Medicaid Services (CMS) does not list endometrial cancer as an approved indication for PET scanning. Though some studies evaluating PET scanning and endometrial cancer have shown the PET scan can be of value in detecting recurrent disease, the number of patients in these studies has been relatively small. At this time, PET scanning for endometrial cancer is not a standard imaging exam. Follow-up CT scan of the chest/abdomen/pelvis is the exam of choice. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 37-year-old female with a body mass index (BMI) of 44.9. She has obesity-related comorbidities including urinary stress incontinence and gastroesophageal reflux disease. She wishes to undergo gastric bypass. It does not appear that she has undergone a psychological evaluation to assist in determining 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.With a BMI of 44.9 and comorbid conditions the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. Weight loss surgery is medically indicated and necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence demonstrates that once a morbidly obese patient has been identified as an appropriate candidate for weight loss surgery, further conservative attempts at weight loss are not necessary. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not undergone a formal psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. Such evaluations are considered standard of care prior to authorization of weight loss surgery. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. If the evaluation indicates the patient is an appropriate candidate for weight loss surgery, the requested surgery should be authorized. If the evaluation indicates the patient is not a candidate for weight loss surgery, the requested surgery should not be authorized.