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

The patient is a 40-year-old male with a reported history of diabetes, neuropathy, congestive heart failure, degenerative joint disease of the lumbar spine, asthma, sleep apnea and lower extremity edema. His cardiologist has recommended a power-operated vehicle (POV). The Health Plan has denied coverage for the requested POV on the basis that it is not medically necessary. The submitted clinical information does not support the medical necessity of a POV at this time. The patients cardiologist requested the POV for severe neuropathy rather than a cardiac condition. Furthermore, the cardiology notes do not objectively document an exam assessing the degree of neuropathy. In contrast, the physiatrist evaluation states sensation is intact and documents the patient walking into the exam room with a four-wheeled walker with normal blood pressure and respirations. The physiatrist states further information would be required such as an EMG to verify the need for a POV. Moreover, there is no documentation of the severity of the patients osteoarthritis or report of orthopedic exam findings. Hence, there is no objective evidence supporting the need for a POV.For the reasons stated above, I have determined the requested POV is not medically necessary the patients mobility. 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 who has been experiencing fasciculations in his arms and hand for approximately one year. He also has pain and numbness in his left-sided extremities.  Diagnostically, he had an EMG, NCV studies and an MRI. The differential diagnoses include polyradiculopathy, multifocal motor neuropathy or early ALS.  The patients provider has requested authorization for IVIG therapy.  The Health Plan denied the request based upon a determination that the therapy is not medically necessary.There is no definitive diagnosis for this patient at this time. He has some neuropathological features on the nerve conduction study, but a diagnosis of multifocal motor neuropathy is not yet sustainable. The patient may have elements of radiculopathy or symptoms of early ALS.  Given the lack of a more definitive diagnosis, a trial of IVIG is speculative and not medically justified. 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: Overturned Decision of Health Plan

The patient is a 41-year-old female who has a body mass index (BMI) of 46. She has requested authorization for bariatric surgery.  She reports the following comorbid conditions: hypertension, osteoarthritis, COPD and asthma.  The patient has completed a psychological evaluation and was approved for bariatric surgery pending a weight loss of approximately 10% of her total body weight. The Health Plan indicates a 10% weight loss requirement is a prerequisite to approval for weight loss surgery. With a BMI of 46 and comorbid conditions the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that bariatric surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. 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. 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 68-year-old female who underwent lower extremity bypass for a non-healing foot ulcer.  Postoperatively, the wound did not heal and her provider prescribed an ArtAssist compression device.  The wound reportedly healed completely with the use of the device.  The patient now requests reimbursement for the ArtAssist device.  The Health Plan does not consider the device medically necessary and has denied coverage.A review of the current literature, including the articles cited at the manufacturers website, reveals numerous case studies, case series, and basic science studies regarding the use of the ArtAssist device. These studies show that the device may increase blood flow to the lower leg. The case series reports instances of wound healing after application of the device. However, there are no randomized, prospective studies that show the ArtAssist device produces a greater benefit than standard therapies in cases of ischemic wounds.  The only two randomized, prospective studies that exist concerning this device show some benefit for patients with claudication. Although claudication is also a result of chronic limb ischemia, the patterns of disease and pathophysiology of patients with tissue loss and patients with claudication are not directly comparable. Therefore, the two randomized studies showing benefit in claudicants cannot be directly applied to patients with tissue loss. Until randomized, prospective trials show benefit in patients with ischemic wounds, the technology should be considered experimental/investigational for this indication. Experimental/investigational measures may be appropriate only when other non-experimental treatments have failed. In this case, hyperbaric oxygen (HBO) therapy is a treatment that is considered non-investigational for this patients condition, and it was not tried prior to the application of the ArtAssist device. Therefore, I have determined the device 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 45-year-old male who underwent an ACL reconstruction. Postoperatively he utilized a CPM device as prescribed by his orthopedic surgeon.  He is requesting reimbursement for the rental cost of the device. The Health Plan denied coverage based upon their determination that the CPM device was not medically necessary following the patients surgery. A CPM device is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. Patient compliance is generally good and many surgeons find that patients regain their range of motion faster and have better pain control with the device.  Physical therapy cannot usually be started immediately after surgery secondary to postoperative pain. The orthopedic community has recognized the benefit of early range of motion following this type of surgery and the use of the device for 12 to 14 days postoperatively is medically appropriate. Therefore, 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 a 38-year-old female who is 57 tall and weighs 165 pounds. She had a gastric bypass in November 2003 with preoperative weight at 298 pounds. She lost 130 pounds subsequent to the surgery and her weight is now stable. The patients provider indicates the patient is concerned about excess skin at her abdomen, especially on the hypogastrium. This is occasionally associated with the sweating and rashes, especially in the summer months. She also dislikes the excess skin at her inner thighs. She also notes that she has had significant buttock pain since losing a lot of weight and notes that she gets soreness on the ischial bones when sitting on poorly cushioned seats. The patient was evaluated by a plastic surgeon for these complaints in December 2005. The surgeon noted no hernia and no active rashes. He found ptosis of the lateral thighs and both buttocks and upper and lower abdominal aprons of fat with excess vertical and horizontal skin. He recommended circumferential torsoplasty, abdominoplasty or simple panniculectomy.  A medial thigh lift was also discussed.  The office notes from the patients primary care provider span the time period of September 2005 through January 2006 and do not mention any patient complaints related to the above abdominal/torso issues.   The patients request for authorization of the torsoplasty was denied by the Health Plan based upon a determination that the procedure is not medically necessary.The photos provided do demonstrate a hanging pannus. However, there is no documentation of a chronic or recurrent skin condition associated with the pannus. The providers notes do not show a chronicity of skin complaints or outline any medical therapies prescribed for such a condition.  The photographs provided do not illustrate the skin conditions described by the patient.  The record does not include documentation of any medical condition sufficiently significant to require medical treatment. The requested procedure falls within the definition of cosmetic surgery, and would be an alteration of a normal body structure to improve appearance.Based upon the information set forth above, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: A 55-year-old female patient has requested reimbursement for insulin-potentiation therapy for treatment of metastatic advanced large-cell lung cancer involving the left femur and possibly the left kidney, and associated with new onset of back pain.  She completed her radiation therapy and her insulin potentiation therapy in May 2005. The Health Plan has denied this request on the basis that the therapy at issue is considered experimental. The use of insulin-potentiation therapy in combination with chemotherapy for any tumor is currently very early in its clinical investigation phase. There are no randomized, controlled studies that support the use of the therapy in lung cancer such as this case.  Thus, currently there is insufficient data to indicate that use of insulin-potentiation therapy in this tumor setting was likely to be of clinical benefit. Therefore, I have determined that the therapy at issue was 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 55-year-old with metastatic large-cell lung cancer. She elected to pursue alternative therapy in Mexico and insulin-potentiation therapy with a local provider.  The patient completed radiation therapy and insulin-potentiation therapy in May 2005. She has requested reimbursement for the therapy from the Health Plan. At issue is whether insulin-potentiation therapy was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Insulin-potentiation chemotherapy is based on the theory that cancer cells need more sugar than normal cells. The insulin is given to lower the blood sugar, theoretically making the cancer cells more susceptible to the lethal effects of low-dose chemotherapy. There is, however, no reliable scientific data to support this treatment approach. Given that there is no known medical benefit associated with insulin-potentiation therapy, I have determined that it was 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 55-year-old woman with metastatic large-cell lung cancer. The patient pursued alternative treatment involving insulin-potentiation therapy. The Health Plan has denied reimbursement for the therapy indicating that its efficacy has not been established.There is insufficient data in support of insulin-potentiation therapy. The proposed treatment was not part of a clinical trial in a Food and Drug Administration-approved protocol. This therapy has not been tested in rigorous trials with favorable results and was not likely to result in any improvement in the patients condition. Therefore, I have determined that the therapy at issue was 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old woman who developed breast cancer at a relatively young age. She has a family history of breast cancer. She is requesting authorization for BRCA1 and BRCA2 genetic testing. The Health Plan has denied this request on the basis that genetic testing is not medically necessary in this case.BRCA testing is a means of determining whether a patient carries a gene mutation. Carriers of a mutation have an extremely high risk of developing both breast cancer and ovarian cancer. Patients found to have such a mutation often consider preventive surgical removal of ovaries and/or breasts. This patient who developed breast cancer at a young age also has a significant family history of breast cancer. BRCA testing would provide additional information as to whether she is at increased risk of ovarian cancer, a disease that lacks good screening tools. Given that she has multiple family members with a history of breast cancer, BRCA 1 and BRCA 2 genetic testing is medically appropriate and indicated. Therefore, I have determined the requested genetic testing is medically necessary for evaluation 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 54-year-old male who worked as a roofer. He had surgery on his cervical spine and his lumbar spine. Post-operatively he continued to have severe pain that was not associated with loss of bowel, loss of bladder or other neurological findings. He was prescribed multiple pain medications with no significant reported improvement. He had injections in the facets of his lower spine but there was no reported improvement. After failure of Duragesic patches and Vicodin he was placed on methadone. He reportedly gave some of his medication to another individual and also had a urine analysis documenting his use of other opiates. Prior to being prescribed other opiates the patient was told that he had to attend a program offered by the Health Plan for chemical dependency. He was not compliant with this request. The Health Plan denied his request to start methadone again.The patient has chronic pain and is dependent on opiates. He was unable to follow the guidelines of methadone treatment and was discontinued from the program because of his escalation in the use of other opiates. The discontinuation of a long-acting opiate because of non-compliance is not unusual.It is clear that the patient experiences overwhelming pain from his orthopedic condition. His participation in the chemical dependency program remains a prerequisite for his receiving other opiates. Without his participation in this program, other treatments will not be effective.The denial of the request for methadone is medically appropriate. The need to offer a support program prior to starting other pain medications is customary and appropriate to the needs of the patient. Alternative pain management and the possibility of continuing opiates in a measured and controlled manner is an option after the patient shows full participation and compliance with the chemical dependency program offered by the Health Plan.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

The patient is a 52-year-old male who has a long history of low back pain. He was previously seen by a neurosurgeon in April 2005, and his symptoms improved with conservative therapy.  The patient had an MRI of the lumbar spine in April 2005, which showed degenerative disc disease at L4-5, and grade l spondylolisthesis at L5 with a disc bulge and neuroforaminal narrowing.A clinical note dated March 2006 states that the patient has pain in his upper back that radiates to his right shoulder.  The note states the pain is chronic, but the exact duration is not documented.  It is stated that the patient has had physical therapy, but the duration is not documented. No other conservative therapeutic measures are documented.  A follow-up appointment with the neurosurgeon was made and MRIs of the cervical and thoracic spine was ordered.  Follow-up MRI of the lumbar spine is also being requested but it is unclear from the notes by whom.At issue is whether MRIs of the cervical, thoracic and lumbar spine are medically necessary for evaluation of the patients back pain.According to the notes provided, a follow-up appointment with a neurosurgeon has been scheduled. It has been clearly established that the information gained from MRI of the spine is vital in evaluating complicated back pain. The patient has had a prior MRI of the lumbar spine, which is important for comparison to any subsequent exams. However, the next appropriate step in the diagnosis and treatment of the patients back pain would be a follow-up evaluation with a neurosurgeon. The neurosurgeon can then determine the precise diagnostic studies that are indicated based upon the patients history and a physical examination of the patient. As such, the requested MRIs are not medically warranted at this time.Based upon the information set forth above, I have determined the requested MRIs are 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 58-year-old male with organic erectile dysfunction on a vascular basis due to arteriosclerosis, diabetes mellitus and hypercholesterolemia.  According to the December 2005 urology report, he is taking Nitrostat, a nitroglycerin preparation.  The patients previous treatment with Viagra, an oral PDE-5 inhibiting medication, was unsuccessful as was treatment with Caverject intra-cavernosal injection therapy.  Surgical treatment with the placement of a multi-component penile prosthesis has been recommended by his urologist. The Health Plan denied authorization for this procedure based upon a determination that it is not medically necessary.The medical records presented indicate that this patient has erectile dysfunction on an organic basis, due to diabetes mellitus and vascular disease. Three worthwhile alternative treatments are available to him, and should be tried in the order of presentation.  Typically, first line treatment is with oral PDE-5 inhibiting medications such as Viagra, Levitra and Cialis. The record did not include the details of this treatment with Viagra and the patient has not yet tried Levitra or Cialis. In this case, the medical records submitted document treatment with Nitrostat for his arteriosclerotic cardiovascular disease, therefore treatment with oral PDE-5 inhibiting medications is contraindicated and not a viable treatment option. The second treatment option is intra-cavernosal injection therapy. The record indicates the patient tried Caverject without a good response.  However, the record did not indicate when or how many times this medication has been used, nor is there a reference to the dosage of medication used.  The dosage range is from 2.5mcg to 60mcg, or more, and the response tends to be dose related. There is no evidence the patient has been treated with the Tri-mix combination injections.  The appropriate next step in the treatment of his erectile dysfunction would be an adequate trial of intra-cavernosal injection therapy - adequate dosages of either Caverject or Tri-mix, or both, providing he is able to carry out and tolerate the injections. If all non-operative treatments fail, surgical treatment such as placement of a penile prosthesis device is appropriate.  It involves all the risks of surgery and anesthesia, may be complicated by infection, may require further surgeries to correct problems and/or to remove the device, and will forever alter the appearance of the penis. That is why non-operative options should be fully exhausted before the surgery is undertaken, and that has not yet been done.  Based upon the information set forth above, 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 57-year-old female who was diagnosed with pancreatic cancer in 2004 and underwent a whipple procedure. The tumor was a poorly differentiated adenocarcinoma. Eleven nodes were negative and the closest margin was 1mm.  Perineural invasion was present. The patient underwent chemotherapy and radiation therapy. She has been followed regularly and a CT scan dated March 2006 revealed borderline enlarged periaortic and mesenteric lymph nodes. The patients oncologist has requested a PET scan for further evaluation. The question is whether the PET scan is medically necessary.Prior Centers for Medicare and Medicaid Services (CMS) reimbursement standards did not include pancreatic cancer as one of the listed indications for PET scan.  However, the National Oncologic PET Registry (NOPR) was developed in response to the CMS proposal to expand coverage for PET scans to include cancers and indications that were not previously eligible for Medicare reimbursement. Pancreatic cancer is listed by NOPR for diagnosis, staging, restaging, and monitoring. NOPR is implementing this registry for CMS and the registry has recently opened.The sensitivity of PET in the detection of pancreatic adenocarcinoma ranges from 85% to 100%. A study by Kalra, et. al. concluded PET offers a reliable method of differentiating recurrent or residual tumor from inflammatory or scar tissue, detecting unsuspected metastases, and evaluating pancreatic masses with equivocal CT diagnosis. The information from the PET scan will be helpful to the treating oncologist in planning the patients future management and as such, is medically appropriate and necessary.For the reasons set forth above, I have determined the requested PET scan is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.