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

The patient is 61-year-old female who is requesting coverage for a bilateral surgical brow lift. The submitted information includes a color image of the patient and limited medical records. The provider notes that the patient is concerned about occasional changes in visual acuity, but there are not records of visual testing. The Health Plan does not find that surgical correction of the brow ptosis is medically necessary, and has denied authorization for the procedure.The patient is requesting authorization and coverage for a brow lift.  There is no objective evidence of visual impairment and the photographs do not reveal brow ptosis that could cause a functional defect. The patients brow ptosis in this case is a cosmetic concern.  Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a three-year-old female with a history of prematurity at age 36 weeks complicated by oligohydramnios and fetal bradycardia. She has persistent hypotonia and gross motor delays. She has been receiving physical and occupational therapy to address these issues and her parent has requested authorization for continued physical and occupational therapy. At issue is whether these therapies were/are medically necessary for treatment of the patients condition.With regard to physical therapy services, it appears that although treatment goals have not been well established or outlined, there have been documented functional gains. The physical therapist continues to document difficulty with ascending and descending stairs while alternating legs; the patient also has difficulty with hopping and standing on a single extremity, which is required for higher level dressing skills. While the patient has received benefit from physical therapy services she received in the past, she still has functional difficulties and therefore requires continued physical therapy. The patients physical therapist should outline functional goals using a more formal standardized method and her physician should monitor her progress. Regarding coverage for occupational therapy, the treatment goals set forth by the patients provider primarily outline gross motor skills and appear to overlap the physical therapy goals. Although the provider outlines fine motor deficiencies in holding a pencil and scissors as well as difficulties with coloring, cutting and use of a Lite-Brite and Play Doh, these are educational issues and should be addressed with early intervention through an IEP. Overall, goals are poorly outlined and no measures are used to document improvement in these goals. Given this, as well as the fact that the therapy overlaps with the physical therapy services the patient has been receiving, occupational therapy was/is not medically necessary for treatment of the patients condition. Based upon the information set forth above, I have determined that physical therapy was/is medically necessary for treatment of the patients medical condition; however, occupational therapy was/is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 28-year-old female who has a history of neck, shoulder and back pain apparently related to an injury three years ago. She also experiences headaches and stress and anxiety possibly related to the injury. Furthermore, the patient has complaints of pre-menstrual syndrome and menstrual symptoms. It is also noted from the submitted records that the patient experiences digestive problems, e.g., bloating after eating. It appears from the records provided that she is taking prescribed medications for the anxiety and stress symptoms. The patient began acupuncture treatments in May 2005 and has had treatment up to and including August 2005. The patient feels her symptoms have improved since she began to receive acupuncture treatments.At issue is whether acupuncture is medically necessary for treatment of the patients condition.Acupuncture is beneficial in pain cases, whether the pain is myofascial in nature, results from sprain/strain injuries, or is secondary to menstrual cramping/dysmenorrhea. The patient was treated with acupuncture from May through August 2005. The submitted acupuncture notes indicate that there has been improvement in the patients presenting complaints and that based on the improvement, the plan is for the patient to be able to reduce the frequency of treatment. The acupuncture treatment rendered has been appropriate and has been of some benefit to the patient. As such, continued therapy (8 to 10 treatments) at a decreasing frequency is medically reasonable and appropriate for this patient. Therefore, I have determined 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 45-year-old male with a history of anemia, hepatic encephalopathy and cirrhosis. He was admitted to acute care in October 2005 with acute alcohol intoxication. He was admitted to a skilled care facility (SNF) in October 2005. A physical therapy evaluation performed in October 2005 found the patient was alert and able to ambulate independently. The patients provider switched the patient from intravenous antibiotics to oral antibiotics and recommended discontinuation of skilled therapy. The Health Plan denied coverage for continued SNF services as of October 2005. At issue is whether continued SNF services are medically necessary for treatment of the patients medical condition.Based upon the evidence provided, the patient does not meet medical necessity criteria for continued SNF services. The submitted records indicate the patient was alert and oriented in October 2005 and was independent with mobility and ambulation. The patient does not require physical or occupational therapy and has no need for daily skilled nursing services. Though it appears the patient would benefit from treatment of his alcohol dependence, there is no indication for continued SNF services. Therefore, I have determined the requested services are 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 50-year-old woman who presented with an explosive course of bronchoalveolar adenocarcinoma and respiratory failure. She had a dramatic response to treatment with Iressa. When she later reached a plateau on Iressa, she was switched to Tarceva.  The Health Plan indicates it will not authorize Tarceva because it is not considered medically necessary unless it follows failed treatment with a platinum-based chemotherapy.When this patient initially presented, she was too sick for chemotherapy.  She was treated with Iressa, an EGFR-targeted treatment, and had a remarkable response. Although Tarcevas current indication is for second line treatment, it is another EGFR-targeted treatment that is routinely being used for subsets of patients with a high likelihood of benefit.  This patients response to Iressa indicates the expected benefit of Tarceva is far greater than that of a platinum-based chemotherapy.  The Health Plans guidelines would require a failed trial of platinum-based chemotherapy before the patient could continue with Tarceva, the treatment most likely to produce a positive result. Uninterrupted treatment with Tarceva is a more prudent course of treatment for this patient.  Therefore, I have determined 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 51-year-old male with a history of hepatitis C. Despite 12 weeks of Peg-Intron and ribavirin therapy the patients viral count did not drop by two logs. The patient has requested authorization for continued therapy. The Health Plan has denied this request on the basis that the requested therapy is not likely to be of benefit and therefore, is not medically necessary.The Health Plans denial should be upheld. The submitted records indicate the patients viral count did not drop by two logs after 12 weeks of Peg-Intron and ribavirin therapy. There is no prospective, peer-reviewed study demonstrating that continued therapy is beneficial in this group of patients. The article cited above by Fried shows that patients who do not experience a two log drop after 12 weeks of therapy only have a 3% chance of clearing the virus after a full course of therapy. Thus, continuation of Peg-Intron and ribavirin is not likely to benefit the patient and is not medically warranted. Based upon the information set forth above, I have determined 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 59-year-old female with a body mass index (BMI) of 52.4. She has multiple comorbidities including asthma and peripheral vascular disease. The patient has outlined failed attempts at weight loss with both supervised and unsupervised programs. She has requested authorization for a bariatric surgery consultation. The Health Plan has denied this request citing a lack of documented evidence the patient has participated in a medically supervised nutrition and exercise program.With a BMI of 52 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. 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.The patient needs to be evaluated by a bariatric surgeon to determine whether she should proceed with weight loss surgery. Thus, a consultation with a bariatric surgeon is medically indicated and necessary for treatment of this patients morbid obesity.Based upon the information set forth above, I have determined that the requested consultation is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. In addition, if upon consultation with a bariatric surgeon weight loss surgery is recommended and the patient undergoes a formal psychological evaluation and is found to be an appropriate surgical candidate, weight loss surgery should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old woman who has had lifting of the left first toenail with resultant pain for at least 1.5 years. In June 2004, Lamisil was prescribed, after which improvement was noted. Treatment was discontinued because the patient indicated she was having a reaction to Lamisil. The painful toenail problem has persisted. In August 2005, Lamisil was again prescribed, but the Health Plan denied authorization on the basis that the drug is no longer a formulary medication. Fungus cultures were negative. The patient was offered surgical removal of the toenail, which she refused. At issue is whether Lamisil is medically necessary for treatment of the patients condition.The submitted information indicates the patient has been receiving treatment for her nail condition from her primary care physician. Given that the patient continues to experience separation of the toenail, a referral to a dermatologist would be medically appropriate. Although fungus cultures were negative, it is possible to have a false negative fungus culture. The dermatologist should take nail scrapings and clippings and immediately plant them on culture medium rather than send the specimens in a container to the lab. If based upon the patients history, physical exam and laboratory results, the dermatologist prescribes Lamisil, the medication should be authorized. 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. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old male with significant knee osteoarthritis who has failed treatment with NSAIDs due to renal complication, Tylenol, physical therapy and arthroscopic debridement. He is requesting authorization for Supartz injections with the hope of putting off knee replacement surgery. The Health Plan has denied authorization for the requested injections on the basis they are not medically necessary for treatment of the patients medical condition.Upon review of the submitted clinical records, it does not appear steroid injections have been attempted.  One of the pre-requisites for administration of Supartz injections is the failure of steroid injections.  If steroid injections fail to resolve the patients symptoms, then Supartz might be considered. However, at this time the use of Supartz injections is not medically warranted. Therefore, I have determined the requested injections are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 35-year-old female with a history of degenerative disc disease at L5-S1. A discogram performed in April 2005 showed diffuse contrast material throughout the disc at L5-S1 and posterior extravastion of contrast material. The patients provider believes the L5-S1 disc is responsible for the patients pain and is recommending artificial disc replacement with the Charite disc. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 35-year-old female with degenerative disc disease. She is seeking authorization for single disc replacement utilizing the Charite disc. The Health Plan has denied this request because it considers the Charite disc experimental.The current clinical evidence regarding the Charite disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial, the Charite disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 35-year-old female with degenerative disc disease. The patient has failed multiple conservative measures. Single level artificial disc replacement has been recommended by the patients provider. The Health Plan indicates there is insufficient peer-reviewed evidence demonstrating the efficacy of the proposed procedure.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 59-year-old male who is requesting reimbursement for a continuous positive airway pressure (CPAP) machine. The patient previously had a diagnosis of obstructive sleep apnea based on a polysomnography with an apnea index of 7. The submitted records indicate the patient had a polysomnography study with a full-face mask CPAP at pressure of 5 to 9 cm in December 2004. The patient had an apnea index of 0 with CPAP at 9 cm H2O. The submitted documentation does not include the patients preceding symptoms and/or signs that led to the polysomnography. There are no comorbidities noted in the submitted records. At issue is whether a CPAP machine was medically necessary for treatment of the patients medical condition.Upon review of the submitted clinical documentation, the patient did not meet medical necessity criteria for CPAP therapy. There is no mention in the submitted documentation of the patients preceding symptoms and/or signs that led to the polysomnography. Furthermore, there is no documentation of symptomatic improvement after intervention with CPAP. In fact, there is no evidence of any associated comorbidities. Though the subsequent titration study suggests an ablation of the apneic events, there was no clinical indication for CPAP therapy based on the information provided. Moreover, there is no evidence of a trial and failure of conservative sleep hygiene therapy prior to the initiation of CPAP therapy. Therefore, I have determined the equipment 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: Overturned Decision of Health Plan

The patient is a 53-year-old female who is status post gastric bypass for morbid obesity. The patient reports having lost 150 pounds. She underwent bilateral reduction mammaplasty for symptoms of back, neck, and shoulder pain in 2004 but she still requires narcotics three to four times per day. The patient has apparently sought authorization from her Health Plan for a panniculectomy and lipectomy of the axillary tails resulting from her previous mammaplasty. The Health Plan had denied authorization for both procedures on the basis they are cosmetic in nature.In reviewing the provided materials, which include office notes from the patients primary care physician and her plastic surgeon as well as photocopied photographs of the patient, it is noted that the patients weight has been constant at 180 pounds since January 2004. The submitted photographic evidence clearly demonstrates a pannus well below the pubic syphilis. Given a pannus of such size, functional impairments are likely including severe unrelenting intertrigo. Thus, the patient meets medical necessity criteria for authorization of a panniculectomy. However, based upon the evidence provided there is no medical justification for removal of the residual axillary tails secondary to the patients mammaplasty. As such, the requested axillary lipectomy is cosmetic in nature and not medically warranted.Based upon the information set forth above, I have determined that although the requested panniculectomy is medically necessary for treatment of the patients medical condition, the requested axillary lipectomy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 47-year-old female with a body mass index (BMI) of 41.7. She has multiple comorbid conditions. The patient wishes to undergo gastric bypass surgery. The Health Plan has denied this request indicating the patient has had a rapid weight gain over the past two years without any documented objective evidence of attempts at non-surgical weight management. At issue is whether gastric bypass surgery is medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The submitted documentation indicates the patient experienced a rapid rise in her weight over the past two years. It appears further workup is in order to investigate the etiology of the patients rapid weight gain. Furthermore, based upon the evidence provided, further attempts at non-surgical weight management should be attempted prior to consideration of gastric bypass surgery. Therefore, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 42-year-old female who was diagnosed with breast cancer in 2004. In November 2004, she underwent a right mastectomy. The pathology revealed multifocal invasive and in situ ductal carcinomas  high grade. Eight of fifteen axillary nodes were positive. Estrogen and progesterone receptors were positive and HER2 was negative. Various scans were negative for metastatic disease. Thereafter, the patient elected to undergo Light Beam Generator therapy, intravenous immune support therapy, and sauna treatments. All of these treatments were denied by the Health Plan.Light Beam Generator therapy is allegedly utilized for restoring lymph flow. There is no scientific evidence demonstrating its effectiveness in any cancer-related situation. Similarly, intravenous immune therapy and sauna treatments are of no known clinical benefit in the treatment of breast cancer. Scientific evidence supports adjuvant chemotherapy for this patient. Because there is no evidence supporting the use of the therapy at issue for treatment of the patients condition, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.