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

The patient is a 47-year-old female who has requested authorization and coverage for Crinone 8% gel. The patient states that she has irregular menses, is perimenopausal, is depressed, has mood swings, and has a hormonal imbalance. The submitted notes indicated the patient was given a refill of Lo-Orval (oral contraceptives) and a testosterone gel. There is also a report of her having normal hormonal levels, which indicate that she is not menopausal. There is some indication that the irregular menses might be due to breakthrough bleeding from the oral contraceptives. The Health Plan has denied the patients request for Crinone gel on the basis that it is not medically necessary for treatment of her menopausal symptoms.Crinone gel is not medically necessary. Crinone gel is progesterone and there is no indication for its use in this patient. Progesterone is commonly used in patients of this age to control abnormal bleeding but not depression and mood swings. If progesterone were needed, oral progesterone would be preferable. Birth control pills are the equivalent, and indeed, provide a higher dose of hormonal replacement therapy. To the extent that any of the patients symptoms were due to menopausal or hormonal factors, her use of birth control pills should have helped to alleviate her symptoms. An evaluation should be performed to determine if there is any abnormal bleeding. If so, further diagnostic testing should be performed.  Based upon the information set forth above, I have determined that the requested gel 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 20-year-old female with apparent irritable bowel syndrome. It appears the patient attempted conservative treatment with fiber and stool softeners without success. The patients provider has recommended Zelnorm 6mg twice a day. The Health Plan has denied authorization and coverage for Zelnorm on the basis that it is not medically necessary at this time.The Health Plans denial should be upheld. Upon review of the information provided it does not appear the patient has undergone a complete gastrointestinal workup. The submitted information does not demonstrate the basis for the patients diagnosis. There is no evidence of any imaging studies or laboratory results. Thus, the gastroenterology consultation recommended by the Health Plan is medically reasonable and appropriate. The patient should undergo evaluation by a gastroenterologist with a complete gastrointestinal workup to determine the etiology of her symptoms.Based upon the information set forth above, I have determined that the requested medication is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old man with hepatitis C, which was non-responsive to treatment with interferon. A liver biopsy in December 1997 showed grade two inflammation and stage two fibrosis. In December 2003, the patients provider recommended treatment with PEGASYS. The Health Plan has denied authorization for the requested therapy indicating that the patient was previously non-responsive to interferon therapy.According to the Food and Drug Administration approval, PEGASYS is indicated for treatment of hepatitis C patients who are interferon naive. Typically, the chance of sustained viral response with PEGASYS in patients who have been non-responsive to traditional interferon is quite low. The HALT-C study is currently looking at this issue; however, the results are not yet known. Thus, as of this time there is insufficient evidence that PEGASYS is likely to benefit the patient. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 36-year-old woman with intractable chronic pain using escalating doses of injectable opiates. She has apparently seen many neurologists and pain specialists without relief. She is moderately well controlled with her current medication regimen. A request has been made for authorization of home injectable hydrocodone, hydroxyzine, and Phenergan. The Health Plan has denied the request on the basis that the requested medications are not medically indicated.Though the requested medications are potent narcotics the patient is under the care of a pain management specialist who has prescribed these medications. The patient has documented severe intractable pain. It has been documented that the patient has failed conservative management efforts. There is also documentation that the requested medication regimen has been successful in relieving the patients pain. Continuation of the requested medications is medically indicated and necessary. A referral to a comprehensive pain management center with expertise in headache should be considered. Based upon the information set forth above, I have determined that the requested medications 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

The patient is a 46-year-old man with bilateral symptomatic varicose veins with documented greater saphenous vein reflux refractory to use of compression stockings. This is an indication for surgical removal or ablation of the greater saphenous vein and removal of painful veins. The patient has requested authorization for thermal endovenous ablation, which has been denied by the Health Plan. There is now sufficient, peer-reviewed, randomized, controlled clinical trials with long-term follow-up to support the use of thermal endovenous ablation in the treatment of greater saphenous vein incompetence of symptomatic varicose veins. Thermal endovenous ablation has been approved by the Food and Drug Administration and has been widely used with well-documented safety and efficacy, and with less morbidity and recovery time. It is as effective as standard surgical therapy and is associated with significantly less rehabilitation and long-term morbidity. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 17-year-old male patient seen and evaluated for nasal obstruction symptoms. This evaluation resulted in the recommendation and authorization for a septoplasty to relieve the obstructive symptoms. The patients mother initiated a request for a rhinoplasty in addition to the authorized septoplasty. The Health Plan has denied the rhinoplasty request as not medically necessary.The Health Plans denial should be upheld. The records submitted do not document any findings that would constitute medical necessity for a rhinoplasty. The patients nasal obstruction symptoms should be alleviated by the proposed septoplasty. The rhinoplasty procedure has not been proposed to correct a functional impairment. Furthermore, there is insufficient evidence that the patient experienced a trauma that resulted in an abnormal structure. Therefore, I have determined that the requested procedure 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 53-year-old man with a long-standing history of knee pain. The patients symptoms persist and he wishes to undergo further surgery. The patient has seen several orthopedics for his condition. He has requested authorization for another orthopedic consultation. The Health Plan has denied the request on the basis that the requested consultation is not medically necessary.The Health Plans denial should be upheld. There is no evidence another orthopedic consultation is medically indicated. Upon review of the patients history and the submitted records, it appears the patient has received appropriate care for his condition. There is no evidence that removal of the Bakers cyst is medically necessary or is likely to resolve the patients pain. It appears the patient will eventually require knee replacement surgery. In addition, a weight loss program is indicated. At this time, there is no medical justification for another orthopedic consultation. 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: Upheld Decision of Health Plan

The patient is a 40-year-old woman with diabetes mellitus with a history of onychomycosis. The patients primary care physician prescribed Lamisil 250mg daily for a period of three months to treat her onychomycosis. It appears the patient began treatment with Lamisil in December 2003. Laboratory results after 12/4/03 have not been provided. The patients provider has recommended continuation of treatment with Lamisil. The Health Plan indicates that the requested medication is not medically necessary.It is medically necessary for diabetics with onychomycosis to be treated with systemic medication. However, given the lack of recent clinical data provided it is not known if the patient still has documented onychomycosis. The patient should be evaluated and treated by a dermatologist to determine whether the clinical and fungus culture criteria for onychomycosis are present. If upon physical examination, history, and fungus culture it is determined that onychomycosis is present then another three-month course of Lamisil would be medically indicated.  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 at this time. Therefore the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 42-year-old woman who is status post gastric bypass. The patient has lost approximately 150 pounds since the surgery, resulting in excess skin. She has requested authorization and coverage for an abdominoplasty with panniculectomy. The Health Plan has denied the patients request on the basis that the requested procedure is not medically necessary.Based upon the available medical data, the procedure of abdominoplasty and panniculectomy is not medically necessary. The submitted medical records include no mention of intertrigo, skin ulcerations or cellulitis that has been refractive to conservative medical management. Furthermore, there is no documentation in the submitted medical records that the patients activities of daily living have been affected due to her condition. Therefore, I have determined that the requested procedure 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 35-year-old female three years post gastric bypass for morbid obesity. She underwent an abdominoplasty with rectus plication in 2003. The patient wishes to undergo revision of the abdominal wall in the upper portion where there remains excess tissue. The Health Plan has denied authorization for the requested procedure on the basis that it is cosmetic in nature and not medically necessary.Clinical information from the operating surgeon and photographs of the patient show an obese female with scars from a prior procedure. These materials fail to indicate evidence of medical necessity for the proposed procedure. There is no evidence of a functional impairment. Based upon the information provided, it appears the requested procedure is cosmetic and not reconstructive in nature. Therefore, I have determined that the requested procedure 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 13-year-old male with cystic fibrosis diagnosed at the age of eight months. The patients mother indicates that the patients pulmonary lung function has decreased over the last three years. It does not appear that the patient is receiving treatment from a cystic fibrosis center. According to the submitted information, the patient has not seen a pulmonologist since 1998. The patient has been using The Vest for over a year. The Health Plan has denied authorization and coverage for the Vest on the basis that it is not medically necessary for treatment of the patients medical condition.Cystic fibrosis is an overwhelming disease in terms of family commitment and stress. The information submitted demonstrates that the ABI Vest has been beneficial for the patient. Experience at many cystic fibrosis centers is that the ABI Vest allows for more uniform chest treatment and increased compliance. Furthermore, there is sufficient scientific evidence demonstrating that the ABI Vest is safe and effective for patients with cystic fibrosis. Moreover, the Health Plan indicates the patient is unable to utilize a Flutter Valve effectively and the patients parents are unable to perform effective chest physical therapy 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: Upheld Decision of Health Plan

This patient is a 28-year-old female who has requested bilateral breast reduction surgery. The submitted records indicate the patient is 411 and weighs 126 pounds. Her bra size is 36DD. The notes of the patients provider note shoulder, back, and neck pain. The patients provider has recommended bilateral breast reduction surgery to alleviate the patients pain. The Health Plan has denied authorization for the procedure on the basis that it is cosmetic in nature and is not medically necessary.Based upon the submitted clinical information, which includes photographs, the requested procedure is not medically indicated. The submitted photographs do not show evidence of intertrigo, shoulder grooving, ulceration, or hyperpigmentation. While there is documentation of back and neck pain, the various reports allude to other possible causes of the pain. The procedure of bilateral breast reduction is not medically indicated and is cosmetic in nature. Therefore, I have determined that the requested procedure 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

This patient is a 53-year-old woman who has worn maxillary and mandibular full denture prostheses for 38 years. She has severe mandibular atrophy resulting in loss of stability and retention of the lower denture. She has pain from denture pressure on the terminal branches of the mandibular nerves (cranial nerve V, division III) bilaterally. She also has bilateral temporomandibular joint pain. The patient has difficulty masticating her food. The patient has requested authorization for hip cartilage grafting, specifically iliac crest onlay graft to mandible. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary.Iliac crest onlay graft to mandible is not medically necessary to treat the patients medical condition. Cortical-cancellous bone grafts and cancellous bone grafts for vertical augmentation of the mandible have poor long-term results and are not considered standard of care for this problem. The standard method of treatment, even in extreme cases with unfavorable oral mucosal health, consists of placement of dental implants for stability and retention of the denture. Iliac crest onlay grafts have not been shown to be necessary or beneficial in the long-term for patients such as this patient. 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: Overturned Decision of Health Plan

The patient is a three-year-old female with a history of multiple emergency room visits due to seizures. The patients provider has documented episodes of seizures lasting 45 to 60 minutes associated with perioral cyanosis lasting 10 to 15 minutes. In-home oxygen has been recommended by the patients provider. The Health Plan has denied authorization and coverage for the requested equipment on the basis that it is not medically necessary.The Health Plans denial should be overturned. A three-year-old female who has up to 60-minute seizures with perioral cyanosis is a reasonable candidate for supplemental oxygen. The patient has a history of multiple emergency room visits. An in-home oxygen tank is medically reasonable and appropriate and is indicated given the duration and frequency of the patients seizures. 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 38-year-old female with a history of chronic pain due to costochondritis. The patient indicates that she has been treated by a pain management specialist for the past few years. It appears the patients medications include trazadone, Duragesic, and Vicodin. The notes from the patients pain management specialist indicate that the patients primary care physician is uncomfortable with prescribing triplicates. The patient has requested authorization and coverage for continuation of her pain management treatment plan.Based upon the submitted records, it appears the patients pain has been under control with medication. Generally when this is accomplished the pain management specialist can discharge the patient back to the primary care physician. It is typically within a primary care physicians scope of practice to continue writing prescriptions for these medications once the patient is stable. However, in this case it appears the patients primary care physician does not feel it is within the scope of her practice as she is not comfortable with prescribing triplicates. In any event, the patients pain management treatment plan has been successful and continuation of the treatment plan is medically indicated. 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: Overturned Decision of Health Plan

The patient is a 44-year-old male who has a body mass index (BMI) of 45.6. In addition, the patient has several comorbid conditions including sleep apnea, degenerative arthritis, and gastroesophageal reflux disease. There is no evidence that the patient has undergone a psychiatric consultation. A request has been made for gastric bypass surgery. The Health Plan has denied the request on the basis that gastric bypass surgery is not medically necessary.With a BMI of 45.6 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. 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, there is no evidence that the patient has undergone a psychological evaluation to determine whether he is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 37-year-old woman with breast implants. She states that she was involved in a motor vehicle accident in November 2002. The enrollee indicates that her left breast implant was displaced by a shoulder belt during the accident. A breast exam in March 2003 was unremarkable for significant abnormalities. It appears the patient underwent a procedure several years ago to reposition her left breast implantation more laterally. The submitted photographs show lateral distortion of the left nipple. The Health Plan indicates the requested procedure is cosmetic in nature and is not medically necessary.The Health Plans denial should be upheld. The patient indicates that her condition was caused by a seat belt during a motor vehicle accident in which she was a passenger but there is not sufficient evidence that the patients problem is related to a seat beat injury. In addition, the submitted records indicate the patient had previously undergone a secondary augmentation of the right breast so it appears she has had prior problems, which necessitated cosmetic revision surgery prior to her motor vehicle accident. Furthermore, the requested procedure has been proposed to correct a breast implant, which is not a structure of the body. Moreover, removal of the implants has been offered by the Health Plan.Based upon the information set forth above, I have determined that the requested procedure is cosmetic in nature and is not medically necessary. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 45-year-old male who has facial, hand, and feet hyperhidrosis. The patient has requested authorization and coverage for a bilateral thoracoscopic sympathectomy. The Health Plan has denied the patients request on the basis that thoracoscopic sympathectomy is not medically necessary.The medical necessity of the requested procedure has not been established. There is no evidence that the patient has experienced skin maceration. In addition, the risk of Horners syndrome is high for this patient. As such, the risks of the requested procedure outweigh the potential benefits. Therefore, I have determined that the requested procedure is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.