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

The patient is a 50-year-old postmenopausal woman who was diagnosed with osteoporosis of the lumbar spine and osteopenia of the hips following a DEXA scan seven months ago. The etiology of the low bone density is unknown. She has no documented fragility fractures and no apparent risk factors beyond her T scores.  Based upon the extension study of a recent study of combination therapy in postmenopausal women, the patients provider wishes to begin a two-year course of Forteo (parathyroid hormone) followed by bisphosphonate. The Health Plan has denied the request for Forteo based upon their determination that treatment with Forteo is not medically necessary absent an intolerance or failure of a bisphosphonate agent.The current standard is to treat with parathyroid hormone either in combination with or before a bisphosphonate regimen for those women who have failed other treatments or have very severe osteoporosis.  Failure in the treatment of osteoporosis is defined as statistically/clinically significant decreases in bone mineral density or the occurrence or recurrence of fragility fractures while on treatment, or an intolerance to the first line treatment regimen.  Very severe osteoporosis is typically defined as T-scores greater than -4.0 standard deviations below the mean for young adult women or a combination of other risk factors such as old age, a family history of hip fractures, smoking or a high risk of fracture as assessed by standard risk indices.  This patient has not failed a bisphosphonate treatment regimen, nor does she meet the generally accepted definitions of severe osteoporosis.   The patients provider cited an extension study by Black, et al. that showed women who were treated with bisphosphonates after either a combination regimen of parathyroid hormone and bisphosphonate or parathyroid hormone alone had better outcomes with regard to the maintenance of bone mineral density gains achieved in the initial study. This study contained no clinical fracture data. Based on the scientific evidence currently available, the use of Forteo in this patient is not medically warranted.For the reasons set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a 47-year-old female with chronic Hepatitis C that has either not completely responded or relapsed following two prior one-year treatments with interferon-ribavirin therapy.  Her previous therapy was continued until October 2004 and she had detectable viral load in January 2005; three months later.  End-of-treatment titers were not provided.  The patient is requesting a third treatment with a third different interferon. Her symptoms are minimal according to her chart notes, hepatic enzymes are only slightly elevated, hepatic synthetic function is preserved and a biopsy performed in April 2005 shows minimal hepatic disease.  The Health Plan denied authorization for the Infergen and Copegus therapy on the basis that it is not medically necessary or likely to be effective.The patient has failed two standard therapies for Hepatitis C and should not receive further therapy until there is a therapy available that offers a reasonable likelihood of success for previous non-responders or early relapsers.  As yet, no such therapy has been discovered or adequately tested in carefully controlled trials.  The patients minimal symptoms, hepatic enzyme abnormalities and histological changes indicate that either she may not need treatment or that she has the ability to wait for further therapy until a one with proven efficacy for patients such as herself is available. Therefore, 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: Upheld Decision of Health Plan

The patient is a 50-year-old female who had spinal fusion and instrumentation in 2001 for severe scoliosis. She experienced neck and shoulder pain in November 2004 and was treated by her primary care physician with Toradol, tramadol, and Medrol dose pack. She now complains of increased pain and sensory deficits. Spinal x-rays were negative for any acute abnormality. The patient believes she should only be treated by her previous surgeon (or his associate) and is requesting an immediate spinal CT.  The Health Plan denied both of these requests based upon their determination that neither an out-of-network physician referral nor a spinal CT are medically necessary at this time.  The patient would clearly benefit from an orthopedic surgery consultation. The Health Plan indicates the services of an orthopedic surgeon are available within the Health Plans provider network. As long as the orthopedist specializes in spinal disorders and performs the type of surgery the patient underwent years ago, the patient can be appropriately treated by the in-network provider. No evidence has been provided that demonstrates a need for the patient to be seen by her previous surgical group.  As such, it is not necessary that she see the requested out-of-network physician. With regard to the CT scan, the evaluating physician can order this test if it is deemed necessary. It is not indicated at this time.Based upon the information set forth above, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 27-year-old male with back pain dating to January 2005. A request has been made for a two-level artificial disc replacement. The Health Plan has denied this request on the basis that artificial disc replacement remains experimental.Artificial disc replacement remains an unproven procedure at this time. There are no long-term prospective studies to support a two-level disc replacement. The patient is young in age and his pain started less than a year ago. There is no record of a trial of conservative measures. A two-level disc replacement is drastic step without documented long-term benefit. Furthermore, the risks of the procedure are unknown. Therefore, 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. The Health Plans denial should be upheld.Physician 2: The patient is a 27-year-old male with degenerative disc disease. He has had a positive discogram at L4-5 and L5-S1. His provider is recommending two-level artificial disc replacement at these levels. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. There is no evidence supporting the safety and efficacy of a two-level disc replacement. 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 27-year-old man who has degenerative disc disease at L4-5 and L5-S1. His physician has recommended multi-level artificial disc replacement surgery. The Health Plan has denied authorization for the requested procedure citing the lack of proven efficacy.The proposed procedure is experimental without established long-term safety and efficacy particularly when a multi-level procedure is involved. 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 the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Accordingly, 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 stage III primary peritoneal cancer who most likely received first line paclitaxel and carboplatin prior to 2003.  She has also received the following treatments: Doxil, gemcitabine, carboplatin, cisplatin and Navelbine. There is no record that she has received topotecan or etoposide. There is no mention of palpable tumor or CT results in the record. The patient was not able to tolerate high-dose paclitaxel due to peripheral neuropathy, and her physician initiated treatment with Abraxane. Apparently the status of her disease is being monitored by CA-125 levels (alone), and her CA-125 level has decreased since treatment with Abraxane began. The Health Plan has denied authorization for Abraxane on the basis that it is not medically necessary.Considering the patients history of neuropathy and her heavy platin use, Abraxane is a reasonable, clinically appropriate choice of drug that appears to be effective for her. The NCI-GOG study included for review related to patients clinically without evidence of disease after first-line therapy and is not strictly applicable to this patient. The Nyman study however is relevant; it includes three subjects with partial response to Abraxane and supports the position that Abraxane is clinically appropriate for this patient. If the patients CA-125 levels become elevated it would be appropriate to stop the Abraxane as the patients provider has done with the other agents that were not helpful.  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 58-year-old woman who has psoriasis of her scalp, ears, torso and upper extremities. Treatment with appropriate topicals is painful and severely itchy because of the psoriasis. Methotrexate therapy was stopped because of an abnormal liver function test. The patient indicates the nearest ultraviolet treatment facility is not practical because of the long travel time that would be involved, many times per week. It has been stated that the psoriasis covers 15% of the patients body surface. A request has been made for authorization for Raptiva. The Health Plan has denied this request indicating Raptiva is not medically necessary for treatment of the patients condition.Ultraviolet treatment for this patient is impractical, unless a treatment center near the patient is located. Topicals were ineffective. In addition, methotrexate, cyclosporine and Soriatane are contraindicated because of the patients abnormal liver function tests. According to medically accepted guidelines, it appears the body surface area involved in this case is at least 50%, the scalp at least 67%, and the trunk at least 30%. Thus, the patients psoriasis requires further treatment. However, given the respective safety profiles of Enbrel and Raptiva, Enbrel would be the medically appropriate next step in the patients regimen. Thus, the use of Raptiva is not medically warranted at this time. Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld. However, if treatment with Enbrel is requested by the patient and her provider, it would be medically appropriate and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a three-year-old female with diagnoses of cerebral palsy with spastic quadriplegia and microcephaly.  She was born at full term and delivery was complicated by meconium aspiration requiring two days of ventilatory support.  The patient has been receiving traditional physical therapy (PT) since her diagnosis of cerebral palsy approximately three years ago.  The record did not include progress notes from the earlier PT.  The patient has been receiving intensive physical therapy based upon a model that includes the TheraSuit and Spider therapy since June 2005.  The Health Plan has denied coverage and prospective authorization for the intensive physical therapy program based upon their determination that it is not medically necessary or medically appropriate.In reviewing the literature, there was no documented evidence that intensive therapy of this type is better than standard therapy. The only literature available was one small study from Japan using a different type of intensive therapy. The consensus in the scientific community is that little functional benefit is realized from these programs.Based upon the information set forth above, I have determined the therapy at issue was/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 52-year-old female with chronic back and neck pain.  In 2003 she had an MRI that demonstrated mild disc bulging at C5-6 and C6-7 with some vertebral spurring. The patient tried physical therapy and chiropractic in 2003 and 2004 respectively.  When her pain reoccurred in 2005 she apparently chose this particular PT provider because she wanted a more holistic approach to her PT.  The patient participated in two extended sessions of therapy in August and November of 2004 and found them helpful.  The Health Plan denied coverage for this therapy based upon their determination that it was not medically necessary.The information provided was reviewed and it appears the primary intervention was integration therapy.  Although there is an indication that manual therapy was provided, there is no clinical documentation confirming this.  It appears the patient was also treated with ice packs, but her condition was chronic and there was no medical necessity for that treatment.  As sensory integration is an investigational modality without proven benefit, it has not been established that the therapy provided was medically necessary.  Based upon the information set forth above, 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: Overturned Decision of Health Plan

The patient is a 44-year-old female with refractory migraine and has been treated with several preventative regimens without sufficient success. She is currently on combination therapy with Lyrica as a preventative and Zomig and Amerge as abortive medications. The patient apparently requires daily to near daily therapy with one of the triptans to adequately manage her headaches.  The Health Plan has denied authorization for 36 Amerge tablets per month based upon their determination that more than 18 tablets per month is not medically necessary.The patient has migraine headaches and has been managed with preventative and acute therapies. Although daily triptan use has the potential for inducing rebound or medication-overuse headaches, several clinical trials have found them safe for daily use.  Transitional therapy with a triptan on a daily basis is a logical approach while awaiting response from a preventative that may take some time to show a benefit.  The higher quantity of Amerge tablets should be approved for an interval of 2-3 months to allow for titration and reassessment of the patients preventative regimen.  Patient follow-up is essential with a review of her headache diary, the tolerability of the regimen, her compliance, and her successes and failures in managing her migraines.Based upon the information set forth above, I have determined the requested prescription is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 21-year-old woman with chronic migraine headaches with a recent worsening in her headache pattern. Her primary care physician, an internist, ordered an MRI and an MRA of the brain, which were both performed.  The studies were normal and there is no information about the current status of the patient.  The Health Plan determined the MRA was not medically necessary and has denied coverage.The patient had a recent change in her headache pattern, with progression to daily headaches. An imaging study is standard of care in these situations, with MRI being the preferred study. MRA is also a reasonable study in patients with new chronic daily headache, specifically to look for aneurysm.  There are no standard published guidelines that address the utility of MRA in the evaluation of chronic headache. However, MRA does have a role in the evaluation of chronic headache as many headache specialists, if not the majority, utilize MRA for diagnostic evaluation for patients with a recent change in their headache pattern. Given the patients clinical condition at the time, an MRA was medically reasonable and appropriate.Based upon the information set forth above, I have determined the diagnostic procedure at issue was 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

The patient is a 61-year-old male with refractory daily migraine or tension headaches.  His diagnostic workup included lumbar puncture with measurement of opening pressures, but the source of his headaches has not been identified. The patient has tried acupuncture, Botox, and an exhaustive list of preventive and abortive medications. A treatment trial of Lyrica was prescribed by his neurologist. The Health Plan has denied authorization for the medication as not medically necessary for treatment of migraine headaches.The patients headaches are unquestionably refractory to standard treatments as numerous preventive medications have been tried and failed.  The safety of Lyrica has been sufficiently tested in other clinical applications. Lyrica should be approved on an interim basis. The patient should be titrated up to either therapeutic success or failure monitoring for side effects over a one to two month span.  He should then be reassessed, with a review of his headache diary as well as desirability measures such as drowsiness or dizziness.  If treatment with Lyrica is beneficial authorization should be continued.Based upon the information set forth above, I have determined 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 26-year-old male who was hospitalized for depression in 1997 and has been diagnosed with depression since that time. He has been treated with Effexor 150mg per day for the past five years with apparently good results. The patient saw his primary care provider (PCP) in 2003 for purposes of a referral to psychiatry to obtain a refill for the Effexor, although it appears this was handled by the PCP. The patient more recently noted problems with concentration and energy level that he did not believe were symptoms of his depression per se.  His PCP deemed his mental status exam WNL (within normal limits). The patients provider then prescribed Provigil 200 mg and the patient felt substantially improved from the standpoints of alertness and concentration. He was not referred to psychiatry.  The Health Plan denied authorization and coverage for the Provigil on the basis that the patient did not meet their medical necessity criteria for that medication.It is difficult to know what to make of the patients complaints of poor concentration and energy level because the exact nature of his depressive illness is obscure and it appears he has not been formally referred to psychiatry for at least the past several years. His symptoms may represent side effects from Effexor, or just as likely, they could represent components of his depressive illness. For example, his dosage of Effexor is not particularly robust. The patients mental status was noted as within normal limits and a detailed psychiatric history is not included. It appears the patients depression has not been optimally evaluated. As such, it has not been established that Provigil is medically warranted in this case. Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a 24-year-old female who is two years post bilateral subcutaneous mastectomy with immediate saline breast implant reconstruction for mastodynia associated with benign fibrocystic disease of the breasts.  Recently, the patient had a consultation with an out-of-plan plastic surgeon that identified some asymmetry of the breasts and some degree of capsulation.  She was re-evaluated by an in-plan plastic surgeon who opined that the asymmetry was minimal and therefore the proposed procedure would not be medically necessary. There remains an apparent difference in assessments as to the degree of capsular contracture.  The patient is seeking authorization from her Health Plan for surgical correction of the perceived breast asymmetry.  The Health Plan has denied authorization based upon their determination that the surgery is cosmetic in nature, and not medically necessary.I have reviewed the records and both the pre and postoperative photographic evidence of the patient. Though the degree of capsular contracture cannot be observed without physical examination of the patient, the degree of asymmetry is minimal and within the normal range. Furthermore, two examining physicians took measurements and concluded the asymmetry was within the normal range.  The Health Plans recommendation that the patient be reevaluated for possible capsule procedures is medically appropriate. The proposed surgery by the out-of-plan surgeon is essentially an augmentation and a cosmetic procedure.  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: Upheld Decision of Health Plan

A male patient of 37 years of age has had chiropractic care over the span of a year for neck and back pain. The patient states the chiropractic care provides relief of his pain and requests continued authorization and coverage. The Health Plan denied future chiropractic services citing a lack of medical necessity.The medical records reviewed consisted of progress notes and a single page request for treatment authorization. The information provided did not include a detailed case history, initial examination or patient intake forms. The patient does feel the chiropractic care benefits him, but a review of the record does not have supporting documentation illustrating medical necessity for continuing chiropractic care. The actual clinical condition and status of the patient relative to the treatment received cannot be ascertained from the existing record. As such, the effectiveness of treatment is uncertain and the need for continued care is not substantiated.  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.