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

The patient is a 53-year-old male who has recently undergone resection of a T2N3 high-grade mucoepidermoid carcinoma of the tongue base. The procedure was performed by an out-of-plan provider. The patient was initially diagnosed by a biopsy performed in February 2005. A CT scan was also performed and the patient was referred for consultation to an in-plan radiation oncologist, medical oncologist and to a head and neck/microvascular surgeon. The patient consulted with an out-of-plan provider in February 2005 and was more comfortable with the information the out-of-plan surgeon provided regarding the planned procedure. Therefore, the patient chose to have the surgery performed by the out-of-plan provider. The patient was offered an additional in-plan consultation in March 2005, but declined this and underwent transhyoid approach to tongue base resection as well as right modified neck dissection in March 2005. Based upon the information provided, it appears the patient has not yet returned for follow-up with post-operative radiation therapy, which was scheduled to begin in April 2005. At issue is whether the surgical services performed by the out-of-plan provider in March 2005 were medically necessary for treatment of the patients condition.The patient decided to pursue surgery with an out-of-plan provider evidently because he was more agreeable to the surgery proposed by the out-of-plan provider than with the procedure discussed with him by the in-plan providers. Review of the submitted evidence does not demonstrate the procedure proposed by the in-plan providers was different than the procedure that was proposed by the out-of-plan provider. Nor, is there evidence the in-plan providers were incapable of performing the same surgery that was performed by the out-of-plan provider. While laryngectomy is generally avoided unless laryngeal structures are involved with the tumor margin, a decision regarding laryngectomy is often made at the time of surgery based on the extent of the tumor. If tumor margins extend further than expected, either partial or total laryngectomy may have to be performed for complete oncologic resection. In addition, reconstructive methods may include primary closure or the use of pedicled or free tissue transfer, again depending upon the extent of resection and surgical technique. The patient needed to be made aware of these possibilities preoperatively.Based upon the evidence provided, the surgical services received from the out-of-plan provider were available from the in-plan providers. As such, 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 47-year-old female who was assaulted resulting in amputation of her right index finger at the middle phalanx. She complains of pain and swelling and that her function is impaired. She is seeking authorization for a prosthetic finger. The Health Plan has denied authorization for the requested prosthesis.The Health Plans denial is correct. A digital prosthesis is neither functional nor intended for treatment of stump pain. A digital prosthesis is indicated for aesthetic purposes. Because the requested prosthesis will neither benefit the patients stump pain nor improve function, I have determined the requested prosthesis is 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 an 19-year-old female who was admitted to residential treatment because of anorexia nervosa and depressive disorder, not otherwise specified. She had been restricting her food intake for eight months prior to admission after she broke her foot. Although she reported feeling fat and uncomfortable in her own skin for some years, she had not restricted her food intake until the foot injury. In addition to restricting her intake, the patient grew increasingly depressed, performed poorly academically and returned to living at home with her family. She received outpatient therapy but was unable to maintain a healthy weight and continued to feel depressed, and anxious with low self-esteem and poor body image. She also noted sleep continuity disturbance and low energy. During residential treatment, she was involved in a number of therapies and received both Zyprexa as well as Lexapro. She was thought to have eventually improved with both such that she was taken off the Zyprexa and left on only the Lexapro and Synthroid. The final dose of Lexapro appears to have been 10 mg and the final dose of the Synthroid .05 mg.Based upon the information submitted, the patient was making progress with her residential treatment. She had nearly attained her ideal body weight, was compliant with her medications, and was not exercising excessively. Records from September 2004 support the fact the patient was ready for transition to a less intense level of care. The evidence submitted does not demonstrate as of September 2004 the patient required 24-hour supervision or was too unstable for transfer to a less intense level of care.Based upon the information set forth above, I have determined the services at issue were 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 64-year-old male who developed gynecomastia secondary to treatment with Proscar for benign prostatic hypertrophy. The patient has discontinued his use of Proscar. The submitted notes indicate the patient has A-cup gynecomastia with a 3 cm breast bud under each areola. The patients physician has recommended breast reduction surgery. The Health Plan has denied authorization for the requested procedure on the basis it is not medically necessary for treatment of the patients condition.While the patients photographs do display gynecomastia, the condition represents a cosmetic rather than a functional problem for this patient. Documentation from the patients provider does not establish that the requested procedure is reconstructive in nature. The medical records and photographs show that the patient has mild gynecomastia. Based on the American Society of Plastic Surgery Guidelines, the clinical findings do not support surgical intervention at this time. Therefore, I have determined that 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 49-year-old female who has a history of stroke with right-sided hemiplegia and dysphasia. The results of a physical therapy evaluation in April 2005 indicated the patients rehabilitation potential is poor. A speech evaluation also performed in April 2005 showed moderate receptive/expressive aphasia with some improvement noted over previous evaluations. It was further noted the patient required moderate assistance in communication with potential to reach minimum assistance. A request has been made for additional physical and speech therapy. The Health Plan indicates the requested therapies are not medically necessary for the patients condition.Review of the submitted physical therapy evaluation of April 2005 reveals the patients rehabilitation potential is poor. Additionally, it appears there was an absence of significant response to the patients prior therapy. As such, there is no evidence the patients condition is likely to improve with additional physical therapy. However, based on the results of the April 2005 speech therapy evaluation, there is potential for improvement with regard to the patients ability to communicate. As such, an additional 12 sessions of speech therapy is medically reasonable and appropriate and should be authorized. The patient should be re-evaluated after the 12 sessions to determine if further therapy is likely to be beneficial. Accordingly, I have determined that although the requested physical therapy is not medically necessary for treatment of the patients medical condition, the requested speech therapy is medically necessary for the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old male with a slightly elevated PSA at 4.23 who on ultrasound-guided prostate biopsy on 3/11/05 was found to have mid-grade (Gleason total 6 out of 10) adenocarcinoma in the left base of his prostate. The patient has requested surgical treatment of this cancer, specifically, a robotic-assisted laparoscopic radical retropubic prostatectomy. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The robotic-assisted laparoscopic procedure is relatively new, and while short-term results are comparable, long-term data especially with regard to survival is not yet available. While there is no medical objection to the robotic-assisted laparoscopic approach, to date there is insufficient data to demonstrate its superiority to other procedures. The open surgical approach is a well-established treatment with good long-term results regarding survival and complications and is considered standard of care for treatment of the patients prostate adenocarcinoma. Therefore, I have determined that 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 16-year-old female with a long-standing history of behavioral and depressive symptoms. She has had three suicide attempts, high anxiety, much family strife, and trichotillomania. She is also experiencing problems in school, is overweight, and has chronic migraines and many personality conflicts. She remains mildly to moderately depressed on Klonopin, Geodon, Prozac, Wellbutrin, Topamax, and Relpax. She also has many somatic problems.  The patient was admitted to a psychiatric residential treatment program on 1/24/05. The Health Plan indicates residential treatment services were not medically necessary as of 4/12/05. The patient has long-standing problems, has not done well in prior outpatient treatment, and resides in an area with a clear paucity of adolescent treatment facilities (e.g. a partial hospitalization program or appropriate range of skilled professionals).  While the patient seems to have gradually improved in her depression, clear Axis II issues remained as of 4/12/05 and the patient required further structured and intense treatment. Such treatment was best obtained in her current residential treatment center facility and the clinical evidence indicates the patient was beginning to improve. Though she does not appear to have been suicidal or psychotic as of 4/12/05, the patient was not appropriate for discharge at that time. Standard of care would be to ensure an appropriate transition to a less intense level of care. In light of the patients history and clinical condition as of 4/12/05, an additional six weeks of residential treatment beyond 4/12/05 is medically appropriate and indicated to ensure stabilization and appropriate transition to a less intense level of care. The patient should be fully re-evaluated at the end of the six-week period to determine if she has been stabilized and is appropriate for discharge.Based upon the information set forth above, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old female with a history of chronic low back pain, obesity, and behavioral health issues. An epidural injection was ordered by the patients pain management provider and has been scheduled for 5/27/05. The patient has requested authorization for a more immediate appointment for the epidural in order to relieve her pain. It appears the Health Plan recommends the patient comply with previously recommended therapies such as physical therapy, a home exercise program or participation in a weight reduction program prior to the patients scheduled epidural injection. The Health Plans denial should be upheld. The submitted records indicate there are other pain management modalities available to the patient prior to her scheduled appointment.  Furthermore, the Health Plans recommendation that the patient comply with a conservative treatment program prior to her scheduled epidural steroid injection is medically reasonable and appropriate. It appears the patient would also benefit from behavioral health services for treatment of her depression and other behavioral health issues. Based upon the information provided, a more immediate lumbar epidural steroid injection is 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 61-year-old female who is seeking authorization for continued outpatient therapy. The patients therapist has provided a list of the patients symptoms including hopelessness, social withdrawal, and increased anger. The patient has been receiving outpatient therapy for approximately three years. The Health Plan has denied authorization for continued therapy.Based upon the information provided, the Health Plan has approved 88 therapy sessions for the patient over the last three years. No physician records or progress notes have been submitted. The patients therapist has not indicated the patient is psychotic or suicidal or having difficulty with a medication regimen. In addition, it appears the patient is functional, employed, and able to work. No information has been submitted that demonstrates ongoing therapy is necessary. 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 male with complaints of excessive daytime somnolence. He reports that he falls asleep while driving and while at work. The patients medical history is significant for possible bronchial asthma as well as chronic back pain with analgesic pump implantation. He is on multiple medications including Soma, morphine, Neurontin, hydrocodone, Valium, Wellbutin, Flexeril, quinine, and melatonin. There is no history of hypertension, cardiovascular disease or stroke. The patient is 510 and weighs 260 pounds. Polysomnography was performed that revealed the presence of mild sleep disordered breathing with AHI of 8.7, baseline oxygen saturation of 92.7% and maximum desaturation to 80%. With CPAP titration, these numbers were 1/7, 94.7%, and 76% respectively. No Epworth Scale data has been provided. The patients provider has recommended a trial of CPAP therapy for the patient. The Health Plan has determined CPAP therapy is not medically necessary for the patient.The patient is an obese male who is being treated with multiple medications known to produce somnolence and impaired function. Review of the clinical information does not include Epworth Sleepiness Scale data. Furthermore, additional medical evaluation with nutritional/diet counseling and simplification of the patients drug regimen appears to be in order. Therefore, I have determined CPAP therapy is not medically necessary at this time. As such, the Health Plans denial should be upheld at this time. However, the patients Epworth Scale score should be obtained; if the patients score is greater than 10, his request for CPAP therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is an 18-year-old female who underwent surgery to correct a malocclusion. Post surgery the patient developed a tongue thrust. The patients oral surgeon has recommended myofunctional intervention (speech therapy) to improve the thrust and to prevent recurrence of the malocclusion post surgery. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is not medically necessary.Review of the scientific literature demonstrates myofunctional therapy is supported by the American Speech and Hearing Association. In addition, although there is no literature specifically involving post surgical cases, a report by Piyapattamin, et al. documented post-surgical tongue thrust improvement by correction of applied forces. Given that the requested therapy is considered an appropriate treatment for tongue thrust, and there is concern malocclusion may occur in this patient, the requested therapy is medically reasonable and appropriate and should be authorized. Accordingly, 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: Overturned Decision of Health Plan

The patient is a 39-year-old female who is currently without breast cancer, but has a strong family history for this disease. The patients mother at age 38, one maternal aunt at age 50, and one maternal great aunt were diagnosed with breast cancer and subsequently died of the disease. In addition, the patient has two other maternal aunts diagnosed with DCIS in their seventies. The patient has requested authorization and coverage for BRCA 1 and BRCA 2 genetic testing. The Health Plan has determined the requested genetic testing is not medically necessary.The issue here is the medical necessity of BRCA 1 and BRCA 2 genetic testing in this patient with a strong family history of cancer. Although the patients geneticist indicates the probable risk of the patient having this mutant gene is 6%, circumstances (i.e., the death of all of those family members of their malignant disease) mitigate the ASCO recommendation of 10% risk cut-off for testing. Furthermore, BRCA testing is medically appropriate in women with two or more affected first- or second-degree relatives on the same side of family. Therefore, the patient meets medically necessity criteria for BRCA testing, and coverage for such testing should be provided. Accordingly, I have determined that 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 59-year-old female with degenerative arthritis of the right knee. She has undergone two previous Synvisc injections with good pain relief. She is seeking authorization for another injection. The Health Plan has denied authorization for another Synvisc injection.The Health Plans denial should be upheld. There is no data to support the efficacy of another Synvisc injection for this patient. In addition, there are other modalities available for the patient with established efficacy. There is very good potential the patient will obtain benefit from such treatments as steroid injections with physical therapy and NSAID treatment. Because there is no data to support another Synvisc injection for this patient and there are other effective treatments available for this patient, I have determined the requested therapy is 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 32-year-old female who has been experiencing constipation, cramping and bloating. In November 2004, the patients physician recommended the patient use Zelnorm for irritable bowel syndrome (IBS). The Health Plan has denied authorization and coverage for Zelnorm indicating the submitted documentation does not support a diagnosis of IBS.Upon review of the information provided, it does not appear the patient has undergone a complete gastrointestinal workup. The submitted information does not demonstrate the etiology of the patients abdominal symptoms. A full evaluation by a gastroenterologist is needed to establish a diagnosis and to determine optimal therapy. Thus, use of Zelnorm is not medically indicated at this time. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 45-year-old female with low back pain. The patient underwent NSAIDs, chiropractic, and a conservative treatment program without relief. In June and July 2004, the patient underwent sacroiliac and lumbar facet joint injections. The Health Plan indicates these injections were not medically necessary for treatment of the patients medical condition. Facet joint injections were appropriate on a diagnostic and therapeutic basis in this case. The submitted clinical evidence demonstrates the patient failed conservative treatment including NSAIDs, and chiropractic. The injections at issue were medically appropriate and indicated in this patient who had failed multiple pain management modalities and was experiencing debilitating pain. Therefore, I have determined that 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 was diagnosed with positional plagiocephaly at the age of 3.5 months and underwent a course of DOC band therapy. The patient improved with this therapy and in September 2004 the provider noted the patients cranial measurements were within the norm for his age. The patients provider indicated some asymmetry remained. At the age of 15 months, the patient underwent a second course of DOC band therapy.Positional plagiocephaly is often a self-correcting condition, treated by meticulous head positioning and in selected cases by DOC banding. The patient underwent DOC band therapy for approximately 10 months with good results. There is no evidence or documentation to support retreatment with DOC banding. As such, there was no clinical indication for use of a second DOC band. Accordingly, I have determined the equipment at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.