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

The patient is a 53-year-old female with type I diabetes. Her comorbidities include retinopathy, very mild neuropathy, peripheral vascular disease and hypertension. She uses Humalog, Lantus and Novolog to manage her blood glucose levels. She has also been prescribed Adipex, Celexa, Diovan, L-Arginine, Levoxyl, Lexapro, Vicodin, Xanax, Singulair and Zonegran.  The patients provider noted that the patients fasting glucose and hemoglobin A1C were inappropriately high, apparently based on a review of her home-glucose monitoring. There is no data available for her home-glucose monitoring or hemoglobin A1c laboratory analysis.  CGMS data are available for eighteen hours in July 2005 as well as the results of her sensory testing. The patient has requested reimbursement for the procedures. The Health Plan denied the request based on a determination that the procedures were not medically necessary.Continuous glucose monitoring is typically an adjunct to home-glucose monitoring to assist in the insulin management of a patient. It may also be useful in detecting nocturnal hypoglycemia and elevated postprandial blood glucose levels. However, in many cases similar information can be obtained by consistent daily monitoring and recording of pre-and postprandial and nocturnal blood glucose levels. There are no blood glucose records available for this patient, but based on her providers notes there was no record of unexplained hypoglycemia. Similarly, it did not appear to be a situation where the patient demonstrated accurate frequent blood glucose testing and there was no correlation with her hemoglobin A1C or blood glucose levels performed by laboratories.  Based on the records provided, there was no clear medical indication for CGMS for this patient.This patients quantitative sensory testing showed very mild peripheral neuropathy. Monofilament, vibrations or pinprick testing may provide similar information. This test is considered investigational as long-term clinical outcome data are not available and it should not replace conventional nerve testing.Based upon the information set forth above, I have determined 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: Overturned Decision of Health Plan

The patient is a 51-year-old female diagnosed with Adjustment Disorder - mixed anxiety and depression, and Generalized Anxiety Disorder.  She has been seen in psychotherapy for about one year, due in part to family stressors. The stressors include parenting three teenage children, a husband who is depressed and drinking excessively, and a former spouse, the biological father of her children, who is deaf, brain damaged, and now homeless. The patients therapist notes that she is making excellent use of psychotherapy and tends to typically downplay the extent of her symptoms. The patient has indicated that therapy has allowed her to face her life challenges by understanding them more clearly, without the use of medication, alcohol, or other destructive means. The patients request for authorization of additional therapy sessions was denied based upon the Health Plans determination that continued therapy is not medically necessary.While the enclosed notes are fairly topical in some areas, others review the pertinent issues with which the patient is struggling. Though it is unclear to what extent there are acute stressors, there are clearly significant chronic ones that persist. The patients diagnoses of Adjustment Disorder and Generalized Anxiety Disorder appear valid and are not disputed by the Health Plan.  The literature cited supports the need for therapy with adjustment disorder alone, and it follows logically that therapy for adjustment disorder combined with anxiety disorder is at least equally important. Therefore, I have determined that the requested therapy 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 17-year-old male diagnosed with ADHD.  He was treated with Concerta, Adderall and Wellbutrin and appeared to respond well to the medications.  The patients mother noted that he became less tolerant of his medications after a time and she concluded that he had become depressed.  The patients parents believed that his depression was caused by the medications and that the medications were harmful to him.  The parents elected to discontinue the medications and seek alternative evaluation and treatment of the patients ADHD. The patient underwent a neurobehavioral evaluation that included an EEG and neuromuscular testing followed by neurofeedback treatments.  The Health Plan denied coverage and the family now requests reimbursement for the procedures.  It appears that the initial diagnosis of ADHD was accurate and the choice of medications appropriate. The patient responded in a positive manner as exemplified by the parents report of improvement in his academic performance. The severity of the later depressive symptoms is not known and no record of a psychiatric evaluation was submitted. Despite the informality of the diagnosis, the appearance of concurrent mood and attention deficit disorders is common. When depression is also diagnosed, an antidepressant medication can resolve the depressive symptoms in over 80% of the cases. On the other hand, without a psychiatric evaluation describing the nature of the depression and the severity of the patients symptoms, it is difficult to even validate this diagnosis. The decision to discontinue the medications appears to be one made by the parents because of their belief that the depression was caused by the medications and was harmful to their son.The literature documents the utilization of biofeedback in situations where stress is a factor such as: pilots, individuals who cannot take medication due to a neurological contraindication, stress reduction to improve blood pressure, etc. The utilization of biofeedback to decrease the symptoms of an attention deficit disorder is described in the literature as a secondary treatment if medication and/or behavior modification do not decrease the symptoms of ADHD. There is no reference in the literature to biofeedback as a treatment for clinical depression.  Neurofeedback would not appear to be the most appropriate treatment in this clinical situation. Additionally, in the absence of neurological findings suggesting neurological or neuromuscular dysfunction, there is no indication for an EEG or neuromuscular testing.  In summary, the procedures at issue are not the standard of care for the described symptoms and diagnoses of this patient. There are safe and effective treatments for ADHD and co-morbid depression. There is no documentation of the exploration of these services and the alternative evaluation/treatment chosen was not a medical necessity.  Therefore, I have determined 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 was referred for physical therapy (PT) in March 2004. At that time she was experiencing left hip abductor strain and scapulothoracic upper back pain. She continued to receive PT through July 2004. The Health Plan has denied coverage for PT as of June 2004 on the basis that continued PT was not medically necessary for treatment of the patients condition.Review of the records from June 2004 through July 2004 shows resolution of pain with keyboarding on July 2004. PT notes from July 2004 show increased pain with bike riding. In June 2004 a 75% overall improvement was documented compared to 50% in April 2004. In July 2004 it was noted the patient tried playing tennis and experienced tightness but no pain. Notes from July 204 show no complaints of pain. The patient continued to be pain free through July 2004. The focus of therapy as of June 2004 was strengthening. The patient made some gains in trapezius and external rotation strength. The submitted notes show ongoing improvement with attainment of goals by July 2004. The patient was pain free in mid-July 2004 and was appropriate for discharge from PT at that time. Based upon the information set forth above, I have determined that physical therapy was medically necessary for treatment of the patients medical condition through July 2004. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 15-year-old male with several years of difficulty in organization and attention, who was referred for SPECT and CT scans. The scans were proposed for further evaluation and determination of his diagnoses and to devise a recommended treatment plan. The patient was described as carrying everything in his backpack, avoiding things he did not like, forgetting to write down assignments or turn in his homework, frequently feeling bored, and having difficulty finishing tasks. It was also noted he had problems with listening, requiring his mother having to repeat things several times before he hears her. The patient reportedly struggled with writing and getting his thoughts onto paper at times. Alternatively, he was also noted to hyper focus and to become an expert in the things he enjoyed doing. He was characterized as set in his ways, liking routine, and focusing on cleanliness. The patient was previously diagnosed with ADHD and in the spring of 2003, began taking Ritalin and was later switched to Adderall. The medications were initially thought to be beneficial, but his parents later determined them to be the cause of a subsequent lethargy and therefore discontinued the medications completely. Notably, the patients energy level did not improve until sometime later. As part of his psychiatric evaluation, the patient underwent SPECT and CT scans and findings consistent with ADHD, mood disorder  not otherwise specified, and generalized anxiety disorder were identified by his provider. The patients provider recommended that the parents consider treatments involving Trileptal, Omega 3 fatty acids, Neurontin, and Adderall or Strattera. The patients parents are requesting reimbursement for the SPECT and CT scans. The Health Plan denied this request based upon a determination that the diagnostic procedures were not medically necessary.The patients prior history was unquestionably clear about his diagnosis of ADHD. He could also be suffering from a depressive syndrome given his lethargy. However, one does not need a scan of any sort, SPECT or CT, in order to make this psychiatric diagnosis and recommend appropriate treatment. The SPECT and CT scans did not add any clinical value in this setting. Therefore, I have determined the diagnostic 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

The patient is a 17-year-old male with an extensive history of mental illness, behavioral problems, and chemical dependence. He has had two acute inpatient psychiatric admissions. He had intensive outpatient treatment, partial hospitalization treatment, outpatient therapy, and has been diagnosed as having depression, polysubstance dependence, and possible post-traumatic stress disorder (PTSD). He was admitted to a residential treatment facility in August 2005 due to combative behavior at home, running away, and failing outpatient treatment. The primary goals to be addressed were his family conflict, chemical dependence, and self-isolating, self-destructive behavior. The patient was evaluated at the residential treatment facility, received family therapy, medical management, and individual treatment. The patient adjusted well to the structure of the facility, and was engaged and involved in his treatment. The patient has not been suicidal, homicidal, psychotic, aggressive or out of control.At issue in this case is whether residential treatment services after August 2005 were/are medically necessary for treatment of the patients behavioral health problems.After a detailed review of the submitted clinical records there is no documentation in the patients progress notes, session notes, call logs, and notes by the psychiatrist, demonstrating that the patient was aggressive or not in control of his behavior as of August 2005. There is no evidence that the patient was psychotic or unable to care for himself as of that time. Furthermore, the patient was not actively suicidal or homicidal or at any imminent or immediate risk of harming himself or others.The session notes as well as progress notes are devoid of any information that would support the need for continued stay in the residential treatment facility beyond August 2005. The patient could have been treated at a less intensive level of care as of that date. Therefore, I have determined the services at issue were/are 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 35-year-old male who has had back pain following a motor vehicle accident. A request has been made for an MRI. The Health Plan has denied this request indicating the requested MRI is not medically necessary for evaluation of the patients medical condition.Review of the submitted clinical information does not demonstrate an MRI is medically indicated at this time. Although it appears the patient consulted an orthopedist in October 2005, the consultation notes are difficult to read. There does not appear to be any documentation of radicular findings. Furthermore, there is no evidence the patient has been experiencing lumbar pain for a prolonged period of time. If the patient is still experiencing lumbar pain he should follow-up with an orthopedist or neurosurgeon who should perform a complete workup and document any indications for an MRI of the lumbar spine. Based upon the information available at this time, there is insufficient evidence to warrant an MRI study.Accordingly, I have determined the requested MRI is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an eight-year-old male with apraxia of speech are requesting coverage of SPECT scan and doppler vasodilators.  Reviewers Findings:  The reviewing physician found that SPECT scans and vasodilators are not standard treatment for apraxia of speech or developmental delay.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 10-month-old male with positional plagiocephaly diagnosed in September 2005. His provider also detected an associated torticollis, noting a loss of range of motion in the neck when turning to the left. The patients provider recommended a Dynamic Orthotic Cranioplasty (DOC) band. The Health Plan denied coverage for the DOC band based on their determination that it was not medically necessary, and the patients parents are now seeking reimbursement.Early review articles were indifferent as to the superiority of one treatment option for plagiocephaly over another. Recent research however, supports the superior benefit of orthotics such as the DOC band when compared to alternative treatment modalities. In this case, physical therapy was not performed, but the neurosurgeon clearly documented significant plagiocephaly and the patients mothers attempts at repositioning, without avail. Thus, the use of a DOC band was a medically reasonable and appropriate approach in the treatment of this patients plagiocephaly. Accordingly, I have determined the device at issue was 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 an eight-year-old female diagnosed with attention deficit hyperactivity disorder (ADHD) who has recently been treated with EEG biofeedback therapy. The parents request for reimbursement for the biofeedback therapy has been denied on the basis that the therapy was not medically necessary for treatment of the patients ADHD.To date, there is insufficient evidence supporting the use of biofeedback therapy for the treatment of ADHD. Randomized controlled group studies are needed in order to provide an accurate estimate of the percentage of patients who demonstrate gains. Convincing, statistical results of such studies have not been published to date. Meanwhile, pharmacological treatment is quite successful for most patients. Though children would be better served with non-pharmacological methods, until statistically valid results supporting the efficacy of biofeedback therapy are obtained from large numbers of patients, accepted pharmacological treatment should be utilized. Therefore, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old female with a history of low back and leg pain who has been diagnosed with grade I anterior spondylolisthesis at L5-S1.  She has tried conservative treatment with chiropractic therapy but does not wish to pursue any other conservative treatment modalities. The patients provider recommends lumbar fusion at L5-S1, which was denied by the Health Plan based upon a determination that the procedure is not medically necessary.The patient has not had a formal trial of physical therapy and therefore does not yet meet criteria for lumbar fusion surgery. She may be a candidate for surgery in the future if physical therapy does not resolve her problem, but conservative options should be exhausted before surgical intervention. Surgery for spondylolisthesis is generally effective in patients who have tried and failed physical therapy. Therefore, if the patient fails to obtain relief from a trial of physical therapy her request for lumbar fusion should be reconsidered. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 52-year-old female with persistent left shoulder pain and limited range of motion. The pain began when she wrenched her shoulder over one year ago.  There is apparently also a possibility of rheumatoid arthritis.  The patient has undergone conservative treatment including pain medication and a cortisone injection.  Her provider ordered an MRI of the left shoulder but authorization was denied by the Health Plan based upon a determination that it was not medically necessary.The patient gives a history of trauma to her shoulder and now has limited range of motion. While she does exhibit signs of a frozen shoulder, she could also have a rotator cuff tear. An MRI would be beneficial to rule out a torn ligament as the cause of her problems. As such, the requested MRI is medically appropriate and indicated in this setting. Therefore, I have determined the requested MRI is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This is a 61-year-old male patient who was diagnosed with type II diabetes in 2004. He is obese and has hypertension and dyslipidemia. His current medications are metformin 500mg twice per day, glipizide 10mg daily, lisinopril 20mg daily, Plendil 10mg daily, Coreg 25mg twice per day, Aldactazide 25/25 daily and Lipitor 10mg daily.The patients endocrinologist started him on oral antidiabetic medications. His first medication was metformin; subsequently glipizide and Actos were added. His blood glucose still was not well controlled with all three medications despite an appropriate diet. Finally, Lantus insulin was added. The dose was titrated up to 70 units per day but the patients morning blood glucose levels remained between 150-200mg/dl. The patient gained 35 pounds during this time and developed edema. In October 2005 Actos was discontinued. His hemoglobin A1C in April 2005 was 9.3% and dropped to 7.3% in October 2005.The patient was started on Byetta 5mcg twice per day and then the dose was increased to 10mcg twice per day. His insulin was reduced to 35 units per day. The patients morning blood glucose level improved to a range of 120mg/dl-150mg/dl.  The patient is requesting authorization of Byetta and his Health Plan had denied this request based upon a determination that it is not medically necessary.This is a 61-year-old male patient with type II diabetes who gained 35 pounds on a regimen of insulin and oral antidiabetic medications but failed to attain blood glucose levels in the desired range. After starting Byetta, he was able to reduce his insulin dose by one half and has started to lose weight.This patient has severe insulin resistance. He is still able to make insulin and most likely has high insulin levels. Even with additional insulin he was not able to overcome his insulin resistance. Byetta, like insulin, is the synthetic version of a natural gastrointestinal hormone. It slows down digestion, stimulates insulin production when needed and decreases postprandial glucagon levels. The results are better blood glucose control, lower postprandial blood sugars, decreased appetite, and weight loss. The only side effect of Byetta is initial nausea, which generally subsides.   The FDA approved Byetta for the management of type II diabetes where there is typically an insulin reserve. Many endocrinologists are using Byetta in type II patients like this patient. He has responded well and Byetta has been effective for him where other approaches to diabetic management have failed. There has been an overall improvement in the patients health since Byetta was initiated. As such, Byetta is medically appropriate and indicated for treatment of the patients diabetes.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.