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

The patient is a 53-year-old man who has had two surgeries and radiation for a recurrent pituitary macroadenoma. He has requested growth hormone (GH) for presumed adult GH deficiency (AGHD) based on non-specific symptoms and a low IGF-1 concentration. The patient is on replacement therapy for presumed deficiencies of LH/FSH and TSH with testosterone and thyroxine. The symptoms are a generalized sense of loss of well-being and difficulty maintaining muscle mass despite full replacement of the other hormones.Based upon the information provided, it is likely this patient has AGHD. The diagnosis is usually made based on the clinical context, which is suggestive of some disorder of the hypothalamic-pituitary axis. In this case the patient has a structural reason for suspecting AGHD based on his recurrent pituitary tumor and its treatment. The low IGF-1 level is also suggestive of AGHD. However, he has very little in the way of clinical symptoms of GH deficiency. It appears the patient has not had a GH stimulation test. The diagnosis of AGHD should be based on the results of a dynamic GH stimulation test. The possibility that a patient with a low IGF-1 and two trophic hormone deficiencies, (TSH and gonadotrophin (LH/FSH)) will fail the test, has a positive predictive value of 83% in one large series of patients collected by the US Hypopituitary Control and Complications Study Group. If the patient fails a dynamic GH stimulation test, GH therapy would be medically indicated.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, if the patient fails a dynamic GH stimulation test, GH therapy should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 47-year-old female who is 411 and weighs 123 pounds. She has large pendulous breasts. The submitted chart notes indicate the patient has been experiencing cervical/thoracic pain secondary to large breasts for four years. The patients physician has recommended the patient undergo bilateral breast reduction surgery. The Health Plan has denied this request indicating the requested procedure is not medically necessary.The patient meets medical necessity criteria for authorization of breast reduction surgery.  The consulting breast surgeon anticipates removal of at least 300 grams of breast tissue. In addition, the patient has lower cervical and thoracic back pain that has been present for more than one year, and etiology other than breast weight has been reasonably ruled out.Furthermore, the patients pain has been of such severity that she has sought medical treatment. For these reasons, bilateral breast reduction is medically appropriate and indicated for this patient. Accordingly, I have determined that the requested procedure 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 41-year-old female who has requested LDL apheresis treatment for familial hyperlipidemia. The patients physician indicates the patients LDL cholesterol remains greater than 200 on diet and exercise programs. The patient is reported to be intolerant to Niacin, Zetia and statins. There is no record of the patient being treated with bile acid sequestrates or fibric acid derivatives. A stress myocardial perfusion study was negative for exercise-induced ischemia. A coronary calcium study showed no coronary calcium, but significant aorta calcium.The Health Plan has denied coverage for LDL apheresis treatments indicating the patient does not meet medical necessity criteria for authorization of the requested therapy. The patient does not have evidence of coronary artery disease as determined by stress myocardial perfusion study and coronary calcium measurements. As such, she does not meet medical necessity criteria for LDL apheresis. The presence of aortic calcification suggests atherosclerosis is present as a systemic condition, which may affect the coronary arteries. A trial of bile acid sequestrates, fibric acid derivatives or combination of these agents and low doses of previous failed medications needs to be documented before apheresis therapy should be pursued. Therefore, I have determined that 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 an 11-year-old female who is short (-3.25 SD), did not screen positive for GH deficiency (normal IGF-1 and IGFBP-3 levels) or thyroid disease, and had a normal bone age for chronological age. The patient had a predicted adult height of from 46 to 48 which is akin to the heights seen in untreated Turners syndrome. Thus, this patient would fall into the idiopathic short stature group. DNA analysis of the short stature homeobox or SHOX gene showed a probable deletion of a whole gene and a partial deletion of the other. The patients provider recommended growth hormone therapy. The Health Plan has determined continued use of growth hormone therapy is not medically necessary for treatment of the patients medical condition.The Food and Drug Administration has approved the use of growth hormone therapy for the diagnosis of idiopathic short stature. SHOX gene mutations have been estimated to be present in about 2% of idiopathic short stature cases. Whereas the patient had a normal karyotype ruling out Turners syndrome, she in effect does have a similar genetic lesion affecting the Xpter-p22.32 chromosomal region. Furthermore, the submitted records indicate the patients rate of growth has improved from 3 cm per year to 10 cm per year. For these reasons, continued growth hormone therapy is medically appropriate and indicated.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 56-year-old right-handed woman who underwent right wrist surgery in March 2005. She developed an infection, which led to persistent swelling and stiffness in the fingers and wrist. She was unable to participate in therapy due to the ongoing infection. A request has been made for authorization for a continuous passive motion (CPM) machine. The Health Plan has denied coverage for the requested equipment on the basis it is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be overturned. The patient is right-hand dominant with significant stiffness and edema postoperatively. A CPM machine would be useful along with therapy to help the patient regain strength and motion. Use of a CPM machine for a three-week period is medically appropriate and indicated based upon the patients current condition. Therefore, I have determined the requested equipment is medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 14-year-old male with short stature. His pre-GH height was 144 cm on 8/30/04, which was less than the third percentile and his pre-GH treatment height velocity was 5 cm a year. His bone age was reported as not delayed, being read at 13 years 8 months at a chronological age of 13 years 6 months. The IGF-1 result was 218. The patient had a peak GH level of 14 after clonidine and 9.8 after arginine. He was found to have testicular enlargement and to have entered puberty. His adult height prediction at 13 years 6 months approximates almost 52 to 53 at his then growth rate, according to the table in the Greulich and Pyle Hand Atlas.The patient began GH therapy in November 2004 at 0.4 mg/kg/week and showed an increased growth velocity of 7.44 cm per year. He had been seen by a pediatric endocrinologist who considered him to be GH deficient in that only one GH level exceeded 10 in one of the two stimulation tests (albeit he had a peak of 9.8 on the other), while his IGF-1 was considered low for pubertal stage (though this was not given).In regard to the diagnosis, it appears idiopathic short stature would be a better descriptor, assuming that other non-growth hormone related causes had been ruled out. The FDA supports the use of GH therapy for treatment of idiopathic short stature. Since the patient is pubertal and without delayed bone age, he is clearly destined to be a short adult without treatment as mentioned above. He thus fulfills the FDA criteria for idiopathic short stature and therefore, GH therapy is medically appropriate and indicated. For the reasons set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old female with rheumatoid arthritis. She has significant ankle and subtalar involvement. The patients surgeon recommended subtalar fusion and total ankle arthroplasty. The patients surgeon is no longer with the patients medical group and is unable to perform the surgery as proposed. The patient is requesting a referral to have the proposed surgery performed by an out-of-network surgeon. The patient has a complex disease and has had multiple joint replacements including knees, shoulders, and hips. She has been referred to an in-network surgeon for a consultation. The in-network surgeon is an orthopedic foot and ankle specialist. There is no evidence that the patient requires the services of the out-of-network surgeon. Though the patient prefers to be treated by the out-of-network surgeon, there is no evidence that the in-network surgeon is unable to provide medically appropriate care. Therefore, I have determined that the requested referral 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 49-year-old female with paralysis due to transverse myelitis. She has requested authorization and coverage for an EasyStand 6000 Glider to help control lower extremity swelling, edema, and muscle atrophy. The Health Plan has denied the patients request on the basis the requested equipment is not medically necessary.The Health Plans denial should be upheld at this time. Review of the information provided demonstrates the patient requires additional follow-up in order to determine the most effective and appropriate treatment plan. As recommended by the Health Plan, the patient should consult with a physical medicine and rehabilitation physician, preferably one who is fellowship trained in spinal cord injury rehabilitation. The physical medicine and rehabilitation physician should perform a comprehensive consultation and recommend a rehabilitation plan for the maximum functional outcome. If the physician determines an EasyStand 6000 Glider is an integral part of a home rehabilitation program, the patients request should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old male with complaints of pelvic pain for over three years. He has requested coverage for out-of-plan treatment for his pelvic pain syndrome. It appears the patient has seen numerous urologists both in and out of plan and has received virtually all of the standard therapies including antibiotics, antispasmodics, alpha-blockers, and advice regarding diet and exercises. Appropriate x-rays were performed to rule out spine and joint problems. The patient sought consultation from an out-of-plan provider who prescribed external and internal myofascial release treatments. As part of his treatment with this provider, the patient participated in a six-day Pain Intensive Clinic, which was described as a new treatment protocol. The patient wishes to proceed with his treatments as directed by the out-of-the-plan provider. The Health Plan has denied coverage for these services citing a lack of medical necessity.Chronic prostatitis, chronic pelvic pain syndrome, prostadynia, and prostatosis are terms loosely applied to a variety of pelvic and genital pain symptoms. Standardization of terminology and exact clinical characteristics are not well defined. There is a confusing array of physical and psychological factors at work in producing these symptoms. This is not to discount the distress these patients are experiencing. After acute and chronic bacterial prostatitis with documented infection are excluded, the vast majority of these patients are treated and improved with a combination of empiric antibiotics, anti-inflammatories, alpha blockers, anticholinergics, sedatives, avoidance of irritants, physical therapy sitzbaths, and time. All of these therapies have been offered to the patient from in-plan providers.Myofascial release therapy has been used to treat a wide range of painful complaints in many areas of the body. Therefore, it is not unexpected that some practitioners have attempted to apply it to chronic pelvic pain syndromes. However, there is no commonly accepted body of literature or standard of practice in urology that recognizes chronically contracted pelvic floor muscles as a cause of pelvic pain or myofascial release therapy as scientifically validated treatment for male pelvic pain. Thus, there is insufficient evidence such therapy is medically warranted in this case.Based upon the information provided, the treatment services offered by the Health Plan are medically reasonable and appropriate. There was and is no clinical indication in this case for out-of-plan urological evaluation or out-of-plan physical therapy services including myofascial release therapy and prostatic massage. Therefore, I have determined that 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 25-year-old female who has a left axillary mass that is painful when exercising. The mass had reportedly developed over a three-year period. The patient sought assistance from her general surgeon who suggested that a plastic surgeon remove the tissue. The plastic surgeon recommended removal of the tissue and sent a request for authorization for removal and tissue rearrangement. The authorization request was subsequently amended to a limited resection of breast tissue, bilateral. The Health Plan denied coverage for the procedure on the basis it is not medically necessary.The Health Plans denial should be overturned. Review of the clinical evidence indicates the patient has abnormal tissue that is symptomatic. The patient has been examined by appropriate specialists who have recommended an excisional biopsy. It is medically reasonable and appropriate to perform an excisional biopsy to relieve the patients symptoms. Therefore, I have determined that the requested procedure 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 female with type II diabetes requiring multiple daily insulin injections for adequate control of her glycemia. In addition, she has a needle phobia, which prevents her giving adequate frequency of injections, resulting in suboptimal glycemia control (A1c in April 2005 of 7.2% with AACE recommended goal of less than 6.5%). The patient has requested authorization and coverage for a needle-free injection system. The Health Plan has denied the request on the basis the requested equipment is not medically necessary.The patients endocrinologist recommends multiple daily insulin injections for the patient. The patient has a needle phobia as documented by her psychotherapist, which has resulted in inadequate glycemia control. Based upon the information provided, it does not appear the patient has been tried on a pre-filled insulin pen system. The pre-filled system has a very small, barely visible needle with an almost painless insertion that may be acceptable to the patient. In addition, the pre-filled pen system is much more portable and convenient than either the needle-free system or a syringe and vial process. The patient should undergo an 8-12 week trial of a pre-filled insulin pen system. If this trial is unsuccessful, the needle-free injection system would be medically appropriate and indicated based on the 2000 ADA position statement on needle-free injection systems.Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for the treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patient should receive a trial of the pre-filled insulin pen system. If the trial is unsuccessful, the requested needle-free injection system should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 53-year-old female with documented multifocal motor neuropathy. She has responded well to IVIG and reports her condition has worsened since IVIG was suspended in February 2005. The patients neurologist has recommended the patient continue with IVIG therapy. The Health Plan has denied authorization and coverage for IVIG on the basis it is not medically necessary.The patient has multifocal motor neuropathy with a positive anti-GM, antibody. Four randomized, double-blinded placebo controlled studies have shown IVIG to be effective therapy for patients such as this patient. To date, there are no other effective therapies, though Rituxan shows some promise. The patient meets medical necessity criteria for IVIG therapy. There is no scientific evidence demonstrating IVIG therapy should be limited to a two-year period. In fact, the Vucic, et. al. article shows IVIG has continued efficacy greater than seven years. For these reasons, 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 42-year-old man with a history of bilateral ptosis. The patient is status post multiple eyelid procedures. The patient states he is concerned about the appearance of his right eyelid and wishes to undergo another surgical procedure to correct the defect. No evidence of visual field tests has been provided. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The submitted documentation does not demonstrate the requested procedure is medically necessary. There is no evidence of field loss or exposure keratitis. The submitted photographs show only a mild ptosis that would not interfere with vision. Furthermore, fine-tuning ptosis repair with a second or third procedure can be problematic. As such, 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

A 31-year-old male enrollee has requested authorization and coverage for a referral to a podiatrist for treatment of his plantar fasciitis. The patient has been treated by his primary care provider (PCP) with heel pads, over-the-counter arches, oral NSAID, ice, and rest, all with minimal relief of his symptoms. Review of the submitted records indicates the patients PCP has requested a referral to a podiatrist for further care, including custom orthotics. The Health Plan has denied this request indicating the patient can be appropriately managed by his PCP.The patients condition warrants a referral to a podiatrist. A podiatry referral is more clinically appropriate than follow-up treatment with the patients PCP. Review of the submitted documentation indicates conservative treatment with the patients PCP has not benefited his condition. It is medically necessary at this point for the patient to follow-up with a specialist who is familiar with the various options available to treat the patients condition. Accordingly, I have determined the requested referral 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 33-year-old male post gastric bypass with significant weight loss and development of excess hanging skin. He has previously had an abdominoplasty performed and is desirous of further body contouring procedures. His plastic surgeon has offered to perform skin removal procedures and has applied for authorization from the Health Plan. The Health Plan has determined that the requested procedures are not medically necessary.There is no documented objective evidence that the patient meets medical necessity criteria for consideration of the requested procedures. There is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. As such, I have determined the requested body contouring procedures are cosmetic in nature and therefore, 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 51-year-old female with a history of a pelvic floor dysfunction and pudendal neuropathy resulting in painful muscle spasms. She has been receiving physical therapy utilizing pelvic floor therapy. In addition, biofeedback was used by the patients provider who has requested coverage for physical therapy and for biofeedback testing for diagnostic purposes. The Health Plan has denied reimbursement for physical therapy and biofeedback testing indicating the services were not medically necessary for treatment of the patients condition.It is the standard of practice that a patient with a particular symptom complex be availed of the proper medical consultations that will optimize the diagnosis and subsequent treatment. The submitted records do not include evidence the patient has had a complete diagnostic workup. A consultation with a gynecologist, neurologist, and physiatrist appear to be in order. In addition, the submitted information indicates the patient is taking Wellbutrin and Lexapro for treatment of clinical depression. As such, consultation with a psychiatrist may be appropriate (to rule out psycho-social factors that may be contributing to the patients symptom complex). In any event, based upon the information provided, the physical therapy services and biofeedback testing the patient received do not appear to have been of demonstrable benefit to her medical problems. As such, there is insufficient evidence the services at issue were medically warranted. Based upon the information set forth above, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.