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

The patient is a 60-year-old male who had progressive symptoms of sore throat, right ear and neck pain, dysphagia, and right-sided jaw pain for over a year. Many forms of therapy were unsuccessful. Eventually, a barium swallow led him to have a direct laryngoscopy and biopsy in October 2003. The right tonsil was larger and firmer than the left; it was excised. The right and left bases of the tongue were biopsied and were positive for adenoid cystic carcinoma. Chest and neck CT scans were negative for cancer. In November 2003, an MRI scan revealed a 3cm diameter mass in the right base of the tongue with invasion of the left. The patients provider recommended surgical resection with or without flap reconstruction, followed by external beam irradiation. The patient consulted another provider for a second opinion who recommended that the patient undergo neutron beam radiotherapy. The patient decided to undergo neutron beam radiotherapy and has requested reimbursement for the therapy. The Health Plan had denied the patients request indicating that neutron beam radiotherapy was not medically necessary for treatment of the patients medical condition.The patient is a 60-year-old lawyer who needs his voice to continue working in his profession. He was diagnosed with adenoid cystic carcinoma in the base of the tongue, which does not respond to conventional forms of radiation therapy. The Health Plan recommended resection of the tumor followed by radiation therapy. This would have significantly impacted the patients quality of life. Fast neutron is a particle form of radiation as opposed to photon, which is electromagnetic wave. The submitted literature documents the efficacy of neutron beam radiotherapy for treatment of adenoid cystic carcinoma. Furthermore, an MRI scan at six months showed absence of the 3cm tumor present on the November 2003 MRI scan. Thus, neutron beam radiotherapy appears to have been effective for this patient and was medically indicated given the medical needs of the patient.Based upon the information set forth above, I have determined that the therapy at issue was 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 37-year-old female enrollee with a body mass index (BMI) of 42. In addition, the patient has comorbid conditions including sleep apnea and degenerative joint disease. The patient has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery. The patient wishes to undergo gastric bypass surgery. With a BMI of 42 and documented sleep apnea, gastric bypass surgery is medically indicated and necessary for this patient as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.Based upon the information set forth above, I have determined that 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 15-year-old male who has been diagnosed with Perthes disease and adolescent avascular necrosis. After discussing treatment options with the patients providers, the patients family decided to pursue the distraction procedure (external fixation) to treat the disorder. On 11/25/03, the patient underwent application of external fixation to the right hemipelvis and femur for hip joint distraction, which was performed by an out-of-plan provider. On 4/26/04, the patient returned to the out-of-plan provider for an arthrogram, external fixation removal, percutaneous adductor tenotomy and hip injection of growth hormone. A request has been made for reimbursement for the services at issue. The Health Plan has denied the request on the basis that the services at issue were not medically necessary.The patient is a 15-year-old male with Perthes disease and adolescent avascular necrosis. Standard surgical therapy for patients in the patients age group results in mixed outcomes. Furthermore, conservative management was not likely to be of benefit to the patient. The distraction procedure is a medically reasonable and appropriate option for patients such as this patient. Since the distraction procedure is only available at a few centers throughout the country, it was medically necessary for the patient to receive the treatment from an out-of-plan provider. However, follow-up care including external fixation removal could have been performed by an in-plan physician. There is no evidence that the patients in-plan physician did not have sufficient expertise to provide follow-up care. As such, the follow-up services at issue were not medically indicated for treatment of the patients condition.Based upon the information set forth above, I have determined that although distraction surgery was medically necessary for treatment of the patients medical condition, it was not medically necessary for the patient to receive follow-up care from the patients out-of-plan provider. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 17-year-old female patient have requested authorization and coverage for a plastic surgery consultation for possible otoplasty. The Health Plan has denied this request indicating that the requested consultation is not medically necessary for treatment of the patients protruding ears. The submitted materials include photographs of the patients ears. No measurements have been provided in the submitted records. The submitted materials also include a letter from the patients therapist describing the patients concerns regarding her ears.The Health Plans denial should be upheld. There is no evidence that the requested consultation is medically indicated. The submitted photographic evidence demonstrates normal appearing ears with slight to moderate protrusion from the patients head. There is no evidence of any functional deformity of the ears. The submitted information does not establish that an otoplasty would be reconstructive in nature. Therefore, I have determined that the requested consultation is not medically necessary for the 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 has a history of idiopathic hypersomnolence with excessive daytime sleepiness. In addition, it appears the patient may have an established diagnosis of hypothyroidism. The patients daytime sleepiness is interfering with her ability to drive safely and her job performance. The submitted information indicates the patient has failed traditional alternative treatments. The patient indicates that she has tried stimulants in the past but experienced side effects. A request has been made for authorization and coverage for Provigil. The Health Plan has denied this request on the basis that Provigil is not medically indicated for treatment of the patients clinical condition.The submitted information documents that the patient has been tried on Provigil and it has been effective for treatment of her excessive daytime sleepiness. The submitted records also document that traditional alternative treatments have not been effective or have caused intolerable side effects. In light of these factors, continued treatment with Provigil is medically reasonable and appropriate. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 49-year-old woman with a history of low back pain, neck pain, and fibromyalgia. The submitted records indicate the patient has undergone an extensive workup by her primary care physician and a rheumatologist. In addition, the patient has been treated by a sports medicine physician, podiatrist, and physical therapist. The patient has requested authorization and coverage for Celebrex for pain control. The Health Plan has denied the request indicating that Celebrex is not medically necessary.Review of the submitted clinical information demonstrates that the patient has extensive pain control issues. There is documented evidence that older NSAIDs have not been effective for the patient. In addition, the submitted information indicates the patient has been on Protonix for over a year for gastroesophageal reflux disease and acid reflux. Furthermore, the clinical evidence shows that the patient receives better relief from symptoms with Celebrex than with Vicodin. Due to the addictive potential of Vicodin, Celebrex is a more appropriate choice for ongoing management of the patients pain. Based upon the information set forth above, I have determined that 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 59-year-old man with a T1c adenocarcinoma of the prostate, Gleason 4+5=9 and a PSA of 8.7. Seven of the 10 biopsies contained tumor, which indicates a relatively large percentage of the volume of the prostate is involved. Based upon Partins Tables the probability that the patients tumor is confined to the prostate only is 37% with 13% chance of involvement of the seminal vesicle, 48% chance of involvement of the capsule and 3% chance of involvement of the lymph nodes. The patient has received three months of hormonal therapy. A request has been made for brachytherapy. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary.Brachytherapy is a very effective therapy for a smaller volume of prostate cancer. Proton beam therapy is a better option for patients such as this patient because it can provide a higher dose uniformly to the prostate, the capsule, and the seminal vesicles. Proton beam therapy in combination with external proton radiation to the pelvis will offer the patient a better outcome since it will encompass more of his disease than brachytherapy. 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 upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 66-year-old man with cirrhosis and a single hepatocellular carcinoma of the left lobe of the liver. He has a history of severe portal hypertension secondary to his cirrhosis and has had esophageal variceal bleeding. The patient underwent two banding procedures for his esophageal varices without recurrent upper gastrointestinal bleeding. In November 2003, the patient was found to have two hepatic masses on CT scan. By report, a biopsy was performed that documented hepatocellular carcinoma. An MRI was performed on 2/4/04 that revealed only a single lesion in the left lateral segment, cirrhosis, and evidence of portal hypertension. There was no ascites noted.In March 2004, the patients surgeon recommended a transjugular intrahepatic portosystemic shunt (TIPS) procedure prior to surgical resection of the isolated hepatoma. Based upon the information provided, it appears the TIPS procedure has been requested as a preoperative measure to control the patients portal hypertension and is not directed at management of the esophageal varices or any potential ascites. The Health Plan had denied authorization and coverage for the requested TIPS procedure.Hepatic resection in patients with portal hypertension can be quite difficult with complications related to bleeding from the liver surface. It has been clearly demonstrated that combined portal decompression procedures (i.e., portosystemic shunts) with hepatic resections reduce operative complications. However, these reports primarily used operative shunts. There are case reports that have been published using TIPS preoperatively rather than surgical decompressive shunts in patients undergoing major upper abdominal surgery or liver resection. The ability of TIPS to decompress the portal system in patients with portal hypertension from cirrhosis has clearly been established. Therefore, it is medically appropriate to use the TIPS procedure preoperatively in those patients who have portal hypertension and are to undergo major hepatic or upper abdominal surgery. This preoperative maneuver is expected to decompress the portal venous system and therefore, reduce intraoperative and postoperative bleeding complications.Based upon the information set forth above, I have determined that the requested procedure is 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 50-year-old man with a history of nasal fracture from boxing. There is documentation of several severe episodes of epistaxis in the providers treatment notes. In addition, the submitted treatment notes document a severe, acute angled, septal deviation, which is consistent with a nasal fracture. The patients provider has recommended nasal surgery to repair the deviated septum. The Health Plan indicates that the requested procedure is not medically necessary.The American Academy of Otolaryngology (AAO) recommends a septoplasty to repair severe nasal obstruction; recurrent epistaxis; atypical facial pain/recurrent sinusitis; or to allow surgical access to other intranasal/sinus structures. Upon review of the submitted clinical information, there is documentation that the patient has a severe nasal obstruction and recurrent epistaxis. In light of the fact that the patient meets AAO clinical indications for nasal surgery, the requested procedure is medically indicated. 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 31-year-old woman who underwent bariatric surgery and experienced massive weight loss. The submitted records indicate the patient underwent abdominoplasty and was seen in consultation by a plastic surgeon for ptotic breasts. The patient wishes to undergo mastopexy with augmentation and has requested authorization and coverage for the mastopexy. The Health Plan has denied the patients request on the basis that the requested procedure is not medically necessary.The information provided does not provide documentation of symptoms related to massive mammary hypertrophy. The submitted copies of photographs demonstrate the described ptotic breasts with an immature incisional scar in the medial left breast. However, there is no photographic documentation of intertrigo. In the absence of documentation of intertrigo, the requested procedure is not medically indicated. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if documented evidence of intertrigo is provided, the patients request for mastopexy should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 38-year-old female with dyspepsia and heartburn. She has been taking antacids for relief of her symptoms. The submitted records reveal no objective clinical evidence of weight loss, dysphagia, abdominal pain or anemia. On 6/22/02, the patients provider indicated the patients family history was negative for colon cancer or other gastrointestinal malignancies. The patients physical exam was negative. The patient has requested reimbursement for an endoscopy and colonoscopy that were performed in June 2002. The Health Plan has denied the patients request on the basis that the procedures at issue were not medically necessary.The Health Plans denial should be upheld. The submitted evidence does not demonstrate that the procedures at issue were medically indicated. There is no documentation of symptomatology that would warrant an endoscopy. In addition, there is no evidence that the patient received a trial of any H2 blockers or proton pump inhibitors prior to the endoscopy at issue. Furthermore, at the time the patient underwent the endoscopy and colonoscopy there was no objective evidence of any of the accepted clinical indications for the procedures at issue. Therefore, I have determined that the procedures at issue were 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

This patient is a 62-year-old male with PSA of 4.4 on 12/16/2003. He underwent prostate biopsy on 1/23/2004 showing Gleason 3+3 adenocarcinoma of the prostate in the right side of the prostate, laterally in the mid prostate and base. The patient is seeking authorization for laparoscopic prostatectomy. The Health Plan has denied this request and approved the open radical prostatectomy for treatment of the patients condition.The patient is a 62-year-old male with a biopsy proven Gleason 3+3 stage T2a adenocarcinoma of the prostate, with a Partins table probability of 51 to 66% that the cancer is organ confined. The patient is requesting authorization for laparoscopic prostatectomy. Accepted appropriate alternative treatments for this patients condition include open radical retropubic prostatectomy. The open surgical approach is well established with good long-standing results in terms of survival and complications. The laparoscopic approach is newer with good short-term results in terms of survival and complications, but long-term results are not yet available. Complications rates of the laparoscopic approach appear to be comparable to the open approach; however, it is not yet known if long-term survival results will be comparable to the results of the open surgery. By recommending open radical retropubic prostatectomy, the Health Plan is offering an acceptable, appropriate and effective therapy for treatment of the patients medical condition. Laparoscopic prostatectomy has not been established as a more effective treatment for this patients condition Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 56-year-old female with a history of breast cancer. The patient has undergone bilateral salpingo-oophorectomy and mastectomy. Both the patients mother and daughter died of breast cancer under the age of 50. A request has been made for BRCA 1 and BRCA 2 genetic testing. The Health Plan has denied the request indicating that BRCA genetic testing is not medically indicated for the patient.The Health Plans denial should be upheld. Although the patient has a family history of breast cancer the patient has already been diagnosed with breast cancer and has undergone bilateral mastectomy and bilateral salpingo-oophorectomy. Thus, BRCA testing will not alter her future treatment. While BRCA genetic testing may be indicated for the patients daughter, it is not medically indicated for the patient herself. Therefore, I have determined that the requested services are 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 62-year-old woman with allergic bronchopulmonary aspergillosis (ABPA). The patient has been treated with steroids and Sporanox. When Sporanox was discontinued the patients condition became worse. The patient wishes to continue treatment with Sporanox. The Health Plan indicates that Sporanox is not medically indicated for treatment of the patients ABPA.Review of the submitted information demonstrates that Sporanox is medically necessary for this patient. ABPA is an allergic manifestation of a bronchopulmonary aspergillosis infection. The typical treatment of ABPA is steroids, and at times, antifungal medications are added. However, in the case of this patient, the patients discontinuation of Sporanox led to a documented deterioration in her condition. Sporanox is an antifungal agent that has been approved by the Food and Drug Administration for the treatment of aspergillus pulmonary infection. Therefore, the patients use of Sporanox is medically appropriate and indicated.Based upon the information set forth above, I have determined that 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: Overturned Decision of Health Plan

The patient is a 62-year-old woman with multiple significant risk factors for coronary artery disease including hyperlipidemia, obesity, previous stroke at age 59, and hypertension. The patient presented to her primary care physician and complained of chest pain, which was described as 5 to 6 out of 10 and as lasting for a few seconds. The patient has also experienced a recent onset of fatigue and shortness of breath. She wishes to be evaluated by a cardiologist. The Health Plan has denied authorization and coverage for a referral to a cardiologist on the basis that the requested referral is not medically necessary for treatment of the patients medical condition.The patient has multiple risk factors for coronary artery disease and has a significantly higher pretest probability of having coronary artery disease based upon her risk factors and an earlier than expected presumed cerebral atherosclerotic event. This patient has been referred by her primary care physician to cardiology services, which is an appropriate referral given the patients symptoms and significant risk factors. Based upon the submitted information, a cardiology consultation for evaluation of chest discomfort to rule out significant coronary artery disease is medically reasonable and constitutes an appropriate use of cardiology services. 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.