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

The patient is a 34-year-old female who is requesting authorization for the medication Provigil for shift work disorder. The patient indicates she has trouble sleeping due to her random work schedule. Further, excess daytime sleepiness is evidenced by the patient inappropriately falling asleep during regular working hours as well as while driving. The patient has received a trial of Provigil with good results. The Health Plan has denied coverage for Provigil on the basis it is not medically necessary for treatment of the patients medical condition.The clinical findings of a patient falling asleep during working hours and while driving are sufficient to confirm excessive sleepiness. Based upon the evidence provided, it appears the cause in this case is due to the patients random work schedule. Excessive drowsiness resulting from shift work sleep disorder is an indication for Provigil. Though the patient has not undergone a polysomnography, formal sleep studies are rarely indicated in the initial evaluation of insomnia. Insomnia is primarily a clinical diagnosis, and the American Sleep Disorders Association Standards of Practice Committee Guidelines do not suggest polysomnography for the routine evaluation. The patients provider has provided the patient with a clinical trial of Provigil, and from all indications the medication has been effective in reducing the patients excessive sleepiness. Further, there is no clear clinical evidence of an alternative diagnosis. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old female with avascular necrosis of the left hip. The patient has been followed by a pain management specialist due to the associated pain. The patients provider recommended changing the patients medication regimen from MS Contin to Percocet with continued use of Duragesic patch. The patient indicates discontinuation of MS Contin led to significant withdrawal symptoms and Percocet was ineffective. The patient is now seeking authorization and coverage for continued treatment with MS Contin, which has been denied by the Health Plan.The Health Plans denial should be upheld. The patients provider has recommended that MS Contin be discontinued. Without a second opinion from another pain management specialist, continuation of MS Contin is not medically appropriate. The Health Plan has recommended the patient be evaluated by another pain management clinic to determine a treatment plan for the patient. The alternative services recommended by the Health Plan are medically reasonable and appropriate. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 54-year-old female with a diagnosis of hydrocephalus based on MRI results. The patient has cognitive complaints. She has been evaluated by multiple providers including two neurosurgeons who had divergent opinions regarding the potential benefits of VP shunt placement. The patient has requested authorization and coverage for a referral to another neurosurgeon for evaluation of the need for further testing prior to VP shunt placement. The Health Plan has denied this request indicating that the requested referral is not medically necessary for treatment of the patients enlarged ventricles.The patient has a complex medical history. One of the examining neurosurgeons has recommended the patient undergo surgical intervention. Based upon the information provided, it is not clear VP shunt placement will resolve the patients symptoms. Evaluation by another neurosurgeon is medically reasonable and appropriate prior to surgical intervention. Given the lack of objective evidence demonstrating VP shunt placement is the most appropriate treatment option for this patient, further consultation is required and should be authorized. Therefore, I have determined that 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 30-year-old female who has been diagnosed with chronic kidney disease as a result of lupus nephritis and anemia. The patients provider diagnosed the patient based on proteinuria over 2 grams. The patient is now anemic. The patients provider has recommended Procrit for treatment of the patients anemia. The Health Plan has denied authorization for the requested medication stating the patient does not meet Health Plan criteria for its use.The use of Procrit to treat the anemia of chronic renal failure is best documented to be successful when the glomerular filtration rate is low. Review of the relevant medical literature reveals the glomerular filtration rate is typically below 30, though sometimes anemia can improve with Procrit for glomerular filtration rates between 30 and 60. This patients glomerular filtration rate was greater than 60; thus, according to the usual indications for Procrit for anemia in chronic renal disease, this patient would not fit the approved criteria. Furthermore, it is unlikely that the presence of proteinuria as a marker of chronic kidney disease would be an adequate pathophysiologic reason for Procrit to be used. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 27-year-old woman who sustained a severe fracture to her elbow, which required surgical intervention. She was taken to surgery on 4/4/05 and discharged on 4/6/05. The submitted chart notes reveal that postoperatively the patient was in severe pain (as would be expected) and required a PCA. She was to be discharged on 4/5/05, but was noted to have pain and swelling. Therefore, the patient remained hospitalized until 4/6/05. The Health Plan indicates inpatient services were not medically necessary beyond 4/5/05.Given the type of significant injury sustained by the patient and the complicated surgery that was performed, it is not unreasonable or inappropriate for a patient to stay an extra day for pain control and observation. Significant swelling could lead to compartment syndrome or other serious complications. In the case of this patient, her provider had concerns regarding her pain and condition. The additional night stay was medically reasonable and appropriate. Therefore, I have determined the services 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 59-year old female who sustained a fracture of the fifth metatarsal on her left foot in May 2004. The patient also has a history of diabetes, rheumatoid arthritis, and carpel tunnel surgeries. The patient underwent an open reduction-internal fixation surgical procedure to assist in bone healing. The submitted information indicates the patient utilized a manual wheelchair and a power-operated vehicle (POV) until November 2004. The Health Plan has denied reimbursement for use of the POV on the basis a POV was not medically necessary.The use of a POV is necessary when a patient is unable to operate a manual wheelchair. There is no evidence the patient was unable to utilize a manual wheelchair during the period at issue. Based upon the information provided, a manual wheelchair was medically reasonable and appropriate for this patient. There was no medical indication for a POV. Therefore, I have determined that the equipment at issue was not medically necessary for the patients mobility. 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 with bronchiectasis who experiences numerous pseudomonas infections. The patients provider has recommended tobramycin inhalation solution (TOBI) to decrease the pseudomonas. The Health Plan indicates there is insufficient scientific evidence demonstrating TOBI is safe and effective for treatment of the patients condition. Therefore, the Health Plan has determined TOBI is not medically necessary for treatment of the patients medical condition.The patient who has bronchiectasis also apparently has numerous exacerbations. The inability of patients with bronchiectasis to effectively clear secretions results in frequent pulmonary infections. One of the more difficult organisms to treat is pseudomonas. In patients such as this patient, TOBI has been beneficial in decreasing exacerbations.  Alternative standard therapy has not been satisfactory in this case. The patient is likely to achieve better results with TOBI than with continued attempts at standard therapies. Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive a six-month trial of TOBI with re-evaluation at the end of the six-month period.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 56-year-old female who reports loss of hearing and tinnitus in her right ear since approximately August 2004. In addition, she has experienced dizziness, which appears to have since resolved, but the tinnitus is persisting and is constant. An MRI performed in 2004 revealed no evidence of an acoustic neuroma or other pathology in cerebellopontine angles. There was a small right frontal convexity meningioma noted. Based upon the information provided, it appears the patient has been seen by an ENT specialist and a hearing aid has been recommended.The patient has requested authorization and coverage for acupuncture. The Health Plan has denied this request on the basis the requested therapy is not medically necessary for treatment of the patients condition.Tinnitus is usually described as a constant buzzing or ringing in the earsin this patients case, affecting her right ear only. Some of the causes of tinnitus include but are not limited to ear disease, excessive noise or some cardiovascular conditions such as anemia or aneurysm. Additionally, severe menopausal symptoms can cause dizziness and tinnitus. No known cause or trauma is indicated. The patients medical records reveal no benefit from antibiotics, antihistamines or anti-inflammatories. MRI reveals no acoustic neuroma; only a small right frontal convexity meningioma was noted which was not felt to be the cause of the symptoms.Although there have been mixed results using acupuncture to relieve/reduce the symptoms of tinnitus (based on various studies in the acupuncture literature) there is sufficient evidence to support a trial of acupuncture in this patient. The patient has been tried on multiple therapies without benefit. As such, a trial of acupuncture is medically reasonable and appropriate.  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. The patient should undergo a trial of six acupuncture treatments at a frequency of twice a week for three weeks with re-evaluation at the end of that period.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old male who was diagnosed with prostate cancer in 2005. The disease was staged at T2c. The patients PSA was 16.7. His Gleason score was 4+3=7. He was placed on Lupron and intensity modulated radiation therapy (IMRT) was recommended. The Health Plan has denied authorization for IMRT on the basis that it is not more effective than 3D conformal radiation therapy. Based upon Partins tables, the patient has a 7% chance the disease is limited to the prostate, a 43% chance the disease involves the capsule only, a 10% chance the disease has extended to the seminal vesicles, and a 38% chance the disease has also extended to the pelvic lymph nodes. Based upon this information, IMRT is not recommended for this patient. IMRT will only address the prostate while it is expected there is equal volume of disease in the seminal vesicles and the pelvic lymph nodes. Androgen ablation therapy (which the patient is already receiving) and conformal radiation therapy are the most appropriate treatment options for this patient. Based upon the information set forth above, 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 56-year-old male with low back pain who has failed conservative treatments. He is requesting coverage for VAX-D therapy for treatment of his low back pain. The Health Plan has denied reimbursement of the therapy at issue indicating the therapy at issue was not medically necessary.The Health Plans denial should be upheld. VAX-D therapy is considered an unproven modality in the treatment of low back pain. There are no peer-reviewed, controlled trials demonstrating the efficacy of VAX-D therapy for low back pain. Furthermore, VAX-D therapy is not considered an acceptable, indicated intervention for low back pain by medical community standards. Therefore, I have determined that the therapy at issue was not medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 63-year-old male with lower back pain secondary to osteomyelitis who was admitted to a skilled nursing facility after a hospital admission.  The patient had a physical therapy evaluation in April 2005. At that time the patient required minimum assistance for bed mobility, moderate assistance with transfers, and minimum assistance with ambulation. In addition, the patient required minimum assistance with toilet hygiene and maximum assistance with lower back dressing and bathing. After seven days of therapy, the patient required contact guard assistance with bed mobility, contact guard assistance with transfers, and contact guard assistance with ambulation. At this time the patient had not completed his rehabilitation course and was expected to continue to progress. He had not reached his functional potential and he was not independent or safe to be alone. The patient continued to receive therapy until May 2005. The Health Plan has denied reimbursement for the services the patient received after 5/5/05.The patient was denied continued rehabilitation therapy after seven sessions of physical and occupational therapy without achieving safe independent function. The patients coverage was denied before he completed his rehabilitation course. The clinical evidence demonstrates the patient was progressing with therapy and that there was an expectation he would continue to progress towards independence with continued therapy. The skilled therapy the patient received until 5/18/05 was medically necessary and appropriate. There is no indication this patient was at a custodial level of care during the dates of service in question.Based upon the information set forth above, I have determined the services at issue were 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 an 18-year-old male with chronic inflammatory demylinating polyneuropathy (CIDP). Previous treatment with IVIG has been beneficial for his condition. The patient is seeking further treatment with IVIG. The Health Plan has denied this request because there is a shortage of IVIG and the Health Plan is reserving IVIG for patients with life-threatening illnesses. The patient did not tolerate treatment with plasmapheresis. IVIG is a valid and accepted treatment for CIDP. This patient has responded positively to IVIG. The information provided demonstrates IVIG is the indicated therapy for this patient. Furthermore, records provided demonstrate plasmapheresis is not indicated for this patient. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients CIDP. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is 48-year-old female with a history of low back pain who previously found lumbar traction not helpful. The patient has been using an inversion table, which she reports has been beneficial. The patient has requested authorization and coverage for a home inversion table for pain control. The Health Plan has denied this request at this time. The Health Plan recommends the patient attempt a one-month trial of inversion traction in a clinic setting and upon completion of that trial authorization of an inversion table would be considered.The Health Plans denial should be upheld. The submitted evidence does not include objective documentation that use of an inversion table has been beneficial for the patient. As is standard of care with physical therapy equipment modalities, a trial should be undertaken by the patient to clearly demonstrate efficacy prior to authorization. The Health Plans recommendation that the patient undergo a trial of inversion traction in a clinical setting is medically reasonable and appropriate. Therefore, I have determined that the requested equipment 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 45-year-old female who was diagnosed with inclusion body myositis (IBM) approximately 12 years ago. She has been receiving IVIG therapy for treatment of IBM for approximately 12 years. She is seeking continued treatment with IVIG. The Health Plan has denied this request because it does not believe IVIG is an effective treatment for IBM and because there is a national shortage of IVIG and the Health Plan is reserving IVIG for patients with life-threatening illnesses. Although there may be some anecdotal evidence that IVIG may help IBM, there is no objective, tested evidence demonstrating IVIG is an effective therapy for the treatment of IBM. Furthermore, based upon the information provided there is no clear evidence IVIG has benefited this patient. Because of a lack of scientific and clinical evidence, I have determined IVIG is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 50-year-old female with OB positive stool. Based upon the information provided, the patient has never undergone an endoscopy. The patient has requested authorization for a colonoscopy. The Health Plan indicates the patient does not meet criteria for authorization of a colonoscopy. Therefore, the Health Plan has determined the requested colonoscopy is not medically necessary.The Health Plans denial should be overturned. Based upon the information provided, it appears the patient has never undergone endoscopic evaluation. It is not likely that flexible sigmoidoscopy in a setting of OB positive stool in a 50-year-old patient is likely to be adequate. In light of the unknown etiology of the patients symptoms, as well as her age, a colonoscopy is medically appropriate and indicated. Therefore, I have determined that the requested colonoscopy is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 47-year-old male with degenerative disc disease. He is seeking authorization for multi-level artificial disc replacement utilizing the Prodisc implant. The Health Plan has denied this request because it considers artificial disc replacement experimental.The use of cervical artificial disc replacement has no prospective evidence of superiority over cervical fusion. Additionally, the proposed advantage of reduced adjacent level disease has not been shown to be effective for patients such as this patient. At this time, there is insufficient data demonstrating the proposed procedure is likely to result in a superior clinical outcome to standard treatment modalities. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 47-year-old male with degenerative disc disease. He has significant degenerative disc disease at C5-6 and C6-7. His provider has recommended two-level artificial disc replacement with the Prodisc. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery at two levels. There are no known outcomes at two years or more. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the safety and efficacy of a two-level disc replacement, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 3: The patient is a 47-year-old male with two-level degenerative disc disease at C5-6 and C6-7. The patient has tried and failed conservative therapy. A two-level disc replacement has been recommended. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental with no established efficacy. There are no studies supporting a two-level disc replacement. The safety profile is unknown. There is no clinical indication for the proposed procedure. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.