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

The patient is a 51-year-old male who is requesting authorization for Provigil to treat daytime somnolence. He has an established diagnosis of failed back syndrome with chronic pain. He has taken narcotics and benzodiazepines for pain management. Most recently he has been taking methadone. His daytime somnolence has been attributed to narcotic and benzodiazepine therapy. The Health Plan notes no polysomnography data is available for this patient. The submitted documentation indicates the patient has had 15 office visits for pain management over the last 12 months; five different narcotics have been dispensed, frequently overlapping with different benzodiazepines.Additionally, the patient has taken multiple other medications including Ambien from August 2004 to July 2005 plus overlapping Restoril in March 2005. Physical findings include variable weight from 220-250 pounds over a 12-month period. There is no record of the patients height.The medical records include no reference to the patients sleep habits, including any snoring history. According to the patients provider, Provigil has been clinically effective for treatment of the patients daytime somnolence. The Health Plan has denied coverage for Provigil on the basis the patient does not meet medical necessity criteria for the medication.The medical necessity of Provigil to counter act somnolence due to the effects of other drugs has not been established. Currently, the Food and Drug Administration (FDA) has approved Provigil for the treatment of obstructive sleep apnea, narcolepsy, and shift work disorder. This case involves polypharmacy necessitated by the patients failed back. Review of the patients medications indicate that in addition to the requested Provigil the patient takes sedatives and hypnotics to facilitate his sleep. It appears the patient may be obese but there is no documented evidence of a sleep study and/or polysomnography. The patient may have hypersomnolence secondary to obstructive sleep apnea. Certainly, the degree of polypharmacy involved in this case could facilitate obstructive sleep apnea. As such, a more appropriate therapy may be medication reduction, specifically narcotics and sedatives. If medication reduction is not possible, CPAP and/or BIPAP therapy is a more appropriate alternative than the addition of Provigil to the patients regimen. 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: Overturned Decision of Health Plan

The patient is a 62-year-old female who is 49. She was formerly morbidly obese. She underwent a gastric bypass procedure with a resultant weight loss that has caused excess abdominal wall skin and fatty tissue. The patients history is also significant for neurological symptoms and anticoagulation. The patient has requested authorization and coverage for panniculectomy and abdominoplasty. The Health Plan has denied authorization and coverage for the requested surgery on the basis it is not medically necessary for treatment of the patients medical condition.Massive weight loss following gastric bypass results in significant redundant tissue. Most commonly, the dependent skin develops symptoms related to moisture, friction and intertrigo. In the case of this patient, she has a large hanging pannus over the mons pubis. The submitted photographs suggest intertriginous skin changes beneath the pannus. As such, the patient meets ASPS criteria for the requested surgery. Therefore, I have determined the requested surgery 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 14-year-old male with a history of Arnold-Chiari malformation. He underwent neurosurgical intervention in November 2004.  The patient has had persistent headaches since the surgery. He was evaluated by an optometrist and diagnosed with accommodative dysfunction and binocular dysfunction. A request has been made for authorization and coverage for vision therapy with an optometrist. The Health Plan has denied this request.The patients optometrist indicates the patients diagnoses of accommodative dysfunction and binocular dysfunction are indications for vision therapy. No clinical notes have been provided demonstrating the patient has undergone a complete eye exam. There are no references to the patients visual acuity, refractive error, motility or neuro-ophthalmologic exam in the submitted materials.The above notwithstanding, the medical literature does not support the effectiveness of vision therapy. This therapy has not been proven to be effective for treatment of visual dysfunction. Thus, there is no evidence vision therapy is likely to have any clinical value in this case. 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 54-year-old female who is approximately 100 pounds over her ideal weight. Her comorbidities are mild. She has been approved for gastric bypass with duodenal switch. The patient is requesting authorization for an immediate laparoscopic duodenal switch procedure. The Health Plan has denied authorization for the requested technique and timeframe citing a lack of medically necessity.The Health Plans denial should be upheld. There is no situation in which bariatric surgery needs to be performed on an emergent basis. Furthermore, there has been extensive literature demonstrating morbidity and mortality rates are excellent with the open duodenal switch procedure. Moreover, long-term results of the laparoscopic procedure are similar to the open procedure. Thus, as both the open and laparoscopic approaches are appropriate for the bariatric patient, it is not medically necessary for the patient to have the duodenal switch procedure performed laparoscopically.Based upon the information set forth above, I have determined the requested technique and timeframe 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 44-year-old male with chronic low back pain. He is status post a right hemi-laminectomy. The patient recently completed four weeks of physical therapy and has requested authorization and coverage for a Saunders traction unit for continued treatment of his remaining symptoms. The Health Plan has denied this request on the basis that the requested device is not medically necessary for treatment of the patients condition.This patient received physical therapy in a program that included traction with 80% relief in his back pain. The therapist instructed him in a home program. The Health Plan indicates the patients medical group is able to provide a standard traction device. Review of the clinical literature does not demonstrate that use of the requested Saunders traction unit results in a superior outcome over standard traction devices. As such, there is no medical justification for use of the requested device in this case. Therefore, I have determined the requested device 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 38-year-old female who has muscular myopathy. She has been using a power wheelchair for 10 years. The patients current power wheelchair is broken and requires repair. Her physician completed an authorization request for repairs to the patients wheelchair in June 2005 stating the patient is unable to ambulate and needs the wheelchair to continue independent living. The patient is requesting authorization for repair or replacement of her current power wheelchair. The Health Plan has denied this request on the basis that a power wheelchair is not medically necessary based on the documentation provided.The patient has been diagnosed with muscular myopathy. She indicates she requires a power wheelchair for ambulation. There is no evidence in the submitted documentation of any consultations, office visits or physical examination reports from any provider. The patients primary care provider indicates she has not seen the patient since December 2003. There is no evidence in the submitted materials that the patient has undergone a recent neurological work-up. It appears the patient should be evaluated by a neurologist or physiatrist is in order to determine her current level of functioning. In light of the absence of any recent clinical findings regarding the patients functional status, it has not been established that the patient requires the use of a power wheelchair at this time. Based upon the information set forth above, I have determined that repair or replacement of the patients power wheelchair is not medically necessary. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 58-year-old male who was diagnosed with moderate sleep apnea in January 2005 and more recently diagnosed with mitral valve prolapse and regurgitation. A follow-up sleep study completed in May 2005 showed his arousal index decreased from 22.5 to 17.9 and his respiratory disturbance index (RDI) decreased from 18.4 to 3.6 with nasal CPAP at pressures of six to eight cm/H2O. His physician has recommended continued CPAP use. The Health Plan had denied the patients request for the CPAP device on the basis it is not medically necessary.The patient has documented obstructive sleep apnea (OSA), moderately-scored. The patients provider recommended a trial of CPAP therapy. The patient utilized a CPAP device with good results as supported by a second sleep study. As such, CPAP therapy is the treatment of choice for this patient. Therefore, I have determined the requested device 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 40-year-old female with a history of migraines, worse with menstruation, for at least six years. In January 2005, the patients physician recommended an MRI of the brain due to an increase in the frequency of headaches. The MRI was unremarkable. The submitted status reports indicate that while the patient may have had a favorable response to various medications, it was only for a short duration. The patient started receiving acupuncture in February 2005. In addition, she changed her eating habits and began exercising regularly. The patient reports this regimen has helped reduce the frequency of her migraines and that she has lost weight and is generally feeling better with acupuncture treatment. The patient further indicates she has been able to reduce her medication dosage.  At issue is whether acupuncture is medically necessary for treatment of the patients medical condition.Because of the patients poor response to prescribed medications and her more favorable response to acupuncture treatment, continued acupuncture is more appropriate for treatment of the patients medical condition than pharmacotherapy. Since the patients symptoms appear to worsen during her menstrual period, one or two acupuncture treatments at that time are indicated for relief of migraines associated with her period. In addition, the patient should continue her exercise program and improved eating habits. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 37-year-old female with a body mass index (BMI) of 36.6. In addition, the patient had multiple comorbid conditions including sleep apnea, proteinuria, and urinary stress incontinence. The patient indicated she had tried supervised and unsupervised weight loss programs without success. In August 2005, the patient underwent gastric bypass with duodenal switch. The Health Plan has denied reimbursement for the surgery on the basis it was not medically necessary for treatment of the patients medical condition.The patient was an appropriate candidate for surgical intervention to treat her morbid obesity. There is more than substantial data in the literature to support the use of the duodenal switch procedure to accomplish this goal. The literature shows that duodenal switch is a safe and effective form of weight loss surgery. Consequently, duodenal switch was a medically appropriate and indicated procedure for this patient. Based upon the information set forth above, I have determined the surgery at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 46-year-old female who has been using CPAP in the treatment of obstructive sleep apnea. A polysomonography performed in March 2005 revealed mild obstructive sleep apnea (OSA) with an AHI of 10 and an oxygen saturation nadir of 87%. It was also noted at that time that the patients Epworth Sleepiness Scale score was 8/24. The patients height is stated to be 55 with a weight of 208 pounds. It would appear that the patient is not tolerating or satisfied with the use of CPAP since surgical consultation was sought for treatment of OSA. She was noted on examination in July 2005 to have inferior turbinate hypertrophy, a light tongue tie, large base of tongue and a long low slung palate. Inferior turbinate reduction and release of ankyloglossia were performed in August 2005. The treatment plan was to follow these procedures with UPPP and tongue base reduction. There was evidently a follow-up evaluation of the patients symptoms performed in September 2005. Repeat Epworth Sleepiness Scale was performed with a score of 14/24. The patient reports that she is tired during the day, frequently has headaches, has difficulty concentrating, has fallen asleep while driving, has experienced excessive weight gain and has been depressed. Her medications are noted to include Wellbutrin, Cymbalta, Vivactil, Restasis, Soma and Norco. At issue in this case is whether laser-assisted UPPP and radiofrequency ablation of the base of the tongue are medically necessary for treatment of the patients medical condition.Though the patient meets medical necessity criteria for a UPPP procedure, it is not medically necessary for the procedure to be performed with laser assistance. The use of laser assistance is not likely to result in a superior clinical outcome. With regard to the other requested procedure, although multi-level surgeries for OSA have been found to be more efficacious than addressing only a single site, tongue base ablation with radiofrequency is not yet standard of care. The patient does meet medical necessity criteria for tongue base reduction without radiofrequency ablation. However, there is insufficient evidence demonstrating that radiofrequency ablation of the base of the tongue is more effective than traditional tongue base reduction. As such, the use of radiofrequency ablation in this clinical setting is not medically warranted.Based upon the information set forth above, I have determined that the requested procedures are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 31-year-old woman who had gastric bypass surgery approximately 18 months ago and has lost over 100 pounds.  She is bothered by redundant skin on her arms, breasts and abdomen. The patient has experienced neck and back pain in the past and was recently referred to a dermatologist for a rash under her breasts.  Her plastic surgeon requested authorization for a panniculectomy, which the Health Plan has denied.Based upon review of the medical records and the photographs provided, the proposed panniculectomy is a cosmetic procedure and does not satisfy the criteria for medical necessity.  Medical therapy for the rash under the patients breasts is ongoing and not related to the requested panniculectomy. The photographs of the patient do not support the premise that her back and neck pain are caused by the excess abdominal skin. As such, there is no evidence a panniculectomy is medically warranted in this case. Therefore, I have determined that 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: Overturned Decision of Health Plan

This patient is a 59-year-old woman with long-standing knee pain due to osteoarthritis. She received a series of Synvisc injections in October 2004 with good results. In July 2005, the patient underwent a repeat course of Synvisc injections. The patient has requested coverage for these injections. The Health Plan indicates a repeat course of Synvisc was not medically necessary for treatment of the patients condition.Synvisc injections have been proven to be helpful for this patient in obliterating the pain caused by her osteoarthritis. Given the positive results of the first series one year ago, it was medically reasonable to provide a second series to treat her pain. The only other alternative for this patient would be knee-replacement surgery. As such, a repeat course of Synvisc injections was medically appropriate and indicated in this case. Therefore, I have determined the injections at issue were 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 76-year-old female who has a history of multiple eye surgeries. The surgeries performed on the left eye in 1988 and 1989 resulted in right eye exotropia and strabismus. The patient now has 20/200 vision in her right eye and does not experience any double vision. The patient is requesting coverage for strabismus surgery to correct a large angle exotropia in the right eye. The Health Plan has denied this request on the basis the requested surgery is not medically necessary for treatment of the patients condition.The patients exotropia is due in part to prior surgeries, but is primarily the result of a sensory loss of vision in the right eye. The patients condition is characterized as sensory exotropia. Her vision is very poor in the right eye so there is no potential for binocular fusion in this patient. Binocular depth perception is not possible when one eye has such poor vision. Surgical correction of the strabismus would not lead to functional improvement and is thus a cosmetic procedure.  Therefore, I have determined the requested eye surgery 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 male who has end-stage COPD requiring continuous supplemental oxygen. He is receiving long-term treatment with steroids and frequent treatment with oral antibiotics. The patient is also Hepatitis C positive.  The record indicates the patient has been evaluated for a single lung transplant at two transplant centers and both determined he was not a candidate due to his Hepatitis C status. The patient then consulted with the Cleveland Clinic, which apparently has accepted him as a single lung transplant candidate. This is a patient with end stage lung disease who also has hepatitis C. At issue is whether the patient is a candidate for a lung transplant.  Three reasons were stated as to why the patient may not be a candidate despite meeting all other criteria to be listed as a candidate.  The prime reason is the presence of Hepatitis C in the patient.  A secondary reason, related to the Hepatitis C is a question raised regarding the patients status to receive immunosuppressive therapy. The third was a specific reason at the Cleveland Clinic, that being a lack of social support.The mere presence of Hepatitis C is not a contraindication for receiving a lung transplant.  As described by the enclosed information from the Cleveland Clinic, they have performed lung transplants in more than ten patients with Hepatitis C and have reported their favorable results.   In a survey of UNOS lung transplantation facilities published in 1999, 72% of programs considered Hepatitis C seropositive patients for transplantation.  55% of the programs then accepted lungs from seropositive donors (Cotler, Jensen, and Kesten).  In a more recent publication, Hartwig, et. al. recommended that more programs use Hepatitis B and C positive donors as a means to increase the available organs for lung transplantation.There is no evidence in the record presented that provides a concern regarding immunosuppressive therapy. Patients with Hepatitis B, Hepatitis C, HIV and liver diseases receive transplants. Modulating the dose of immunotherapy may be required. Patients who have liver disease including Hepatitis C are currently receiving kidney, liver, and heart transplants.  The patient has stated, and it would be true if the patient has been listed, that the concern about social support is no longer valid. The decision of whether a given patient is a candidate is determined by the individual transplant center and their specific protocols.  The patient has been accepted by one such transplant center. The transplantation of lungs to patients with Hepatitis C is not experimental or investigational in general and not for the Cleveland Clinic. The experience of the Cleveland Clinic has been reported and is positive for lung transplantation in patients such as this patient.  Based upon the information set forth above, I have determined that the requested procedure is medically necessary and appropriate for treatment of the patients condition. The Health Plans denial should be overturned.