Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician #1:  The patient is a 45-year-old female with a history of a neck injury. She has subsequently experienced persistent neck and back pain. The patient tried multiple pain medications and received physical therapy, but continued to experience pain.  The patient has been using an RS-4i interferential stimulation device, which she reports has been effective. At issue is whether interferential stimulation is likely to be more beneficial than any available standard therapy.The RS-4i interferential stimulator remains investigational at this time. It is not widely used and has not been generally accepted as a suitable treatment option for painful neck and back conditions. There is insufficient evidence in the peer-reviewed literature demonstrating that the requested interferential stimulator is efficacious for patients such as this patient. Therefore, I have determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than available standard therapy.  The Health Plans denial should be upheld.Physician #2:  The patient is a 45-year-old woman with a longstanding history of neck and back pain. She has requested coverage from her Health Plan for an interferential stimulator that was prescribed in December 2005. The Health Plan has denied coverage for the device indicating interferential stimulation therapy is considered investigational.There is no Class I data to establish the efficacy of interferential stimulation for the treatment of neck and back pain. The device is not within the mainstream of care for orthopedic practice. Available data does not demonstrate an advantage to the RS-4i sequential stimulator over standard pain management modalities. Therefore, I have determined that the requested device 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 #3:The patient is a 45-year-old woman with a long history of neck and back pain secondary to a neck sprain. She has attempted treatment with multiple conservative measures without sustained success. Her provider prescribed an interferential stimulator in December 2005 for pain management.  In February 2006 the patients provider noted improvement in her condition. The Health Plan has denied coverage for the interferential stimulation unit on the basis it is investigational in nature.The Health Plans denial should be upheld. The requested device remains of unproven efficacy in the treatment of musculoskeletal pain. There are no long-term, prospective studies to warrant its use in this clinical context.  Although the risks are minimal, the benefits have not yet been substantiated.  For these reasons, I have determined that the requested device 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician #1:  The patient is a 63-year-old female with metastatic breast cancer who experienced worsening back pain over a six-month period.  Her pain was not relieved by narcotic pain medications and she was hospitalized for pain management in May 2005.  While inpatient she underwent vertebral biopsy and T11 kyphoplasty.  The patient now requests reimbursement for the kyphoplasty procedure. The Health Plan considers this procedure experimental/investigational and has denied coverage.Kyphoplasty is an excellent treatment modality for vertebral pathologies and spinal fractures.  It has been shown to resolve chronic pain in patients such as this one who have experienced pain for several months without improvement. The short and long-term outcomes of kyphoplasty are excellent and it was an appropriate treatment option in this case.  Therefore, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician #2:  The patient is a 63-year-old woman with metastatic bone disease. She had acute pain due to vertebral fracture and was hospitalized in May 2005. The patients clinician performed an emergency kyphoplasty (and vertebral biopsy) to relieve her pain symptoms. The Health Plan has denied the patients request for reimbursement citing the investigational nature of the procedure in this clinical context.The patient had an acute fracture with collapse of the vertebral body and severe pain.  She was an appropriate candidate for kyphoplasty and by her own account, the procedure was very successful in alleviating her pain. Kyphoplasty is not an experimental procedure. The procedure has been performed successfully for many years and the devices involved are FDA approved.  For the reasons stated, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician #3:  The patient is a 63-year-old female with a diagnosis of breast cancer.  She developed a vertebral fracture and kyphoplasty was used to repair the injury.  The patient has submitted a request for reimbursement for the cost of the procedure.  The Health Plan considers kyphoplasty experimental/investigational and has denied coverage and reimbursement.The clinical efficacy of kyphoplasty has not been established in controlled, blinded studies. Kyphoplasty has been associated with a large number of adjacent level fractures and until its safety and efficacy have been better established, this procedure cannot be recommended. Additionally, this was an off-label use of the procedure and it was not indicated in this context. Consequently, I have determined that 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 36-year-old female who has a diagnosis of a major depression with refractive symptoms of sleepiness and lethargy.  She has been seen in continuing therapy since October 1998.  Prior to starting samples of Provigil she was prescribed Lamictal, Anafranil and Wellbutrin.  Her provider gave her samples of Provigil from May 2005 through October 2005.  The progress note on December 2005 states that the patient reported: I can tell the difference. The use of stimulant medication was suggested by the psychiatrist but the patient refused such for fear of the addiction potential.  The patient continues to have symptoms of lethargy and sleepiness without the use of Provigil.  The patient has requested authorization and coverage for Provigil.  The Health Plan denied her request based upon a determination that the medication is not medically necessary.The provider does feel that the patient has had short-term improvement in her Major Depressive Disorder (MDD) with the samples of Provigil that he supplied to her.  Her subjective report of improvement is consistent with the results described in the literature for the initial three months of treatment with Provigil. However, there is no evidence in the literature that the long-term use of Provigil for treatment of MDD is efficacious.  There is also support in the literature for the use of a stimulant medication for the symptoms described with this patient, as an alternative to Provigil.  Such use, when prescribed by a psychiatrist, does not increase the possibility of dependency on amphetamines as the patient fears. These fears can be addressed in the patient-therapist relationship. The use of stimulant medication for the augmentation of other medications in the treatment of depression is approved by the FDA and is considered efficacious. This approach has few aversive side effects and continues to remove symptoms over a period of time beyond 80 days.  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 55-year-old male with a long history of asthma and allergic rhinitis presumably secondary to multiple inhalants. This is confirmed to some extent by his significantly elevated total IgE. On the other hand, the spirometric study is not particularly remarkable and the graph suggests an incomplete maximal effort.  The patients provider has requested authorization for Xolair.  The Health Plan denied the request based upon a determination that the medication is not medically necessary.Although the FEV1 is 81% of predicted, the FEV-1/FVC is only minimally abnormal. Additionally, a review of pharmacy records suggests only intermittent use of anti-asthmatic medications.  As such, the spirometric values clearly do not fulfill medical necessity criteria for Xolair use.  Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old woman who underwent a total knee replacement in November 2004. Following surgery, her surgeon prescribed a CPM device that was utilized for three weeks.  The patient had continued pain; therefore her provider prescribed an additional six weeks use of the CPM device.  The patient now requests reimbursement for the additional rental cost of the device.  The Health Plan does not consider the extended use of the CPM device medically necessary, and has denied coverage.A CPM device is commonly prescribed by surgeons for postoperative rehabilitation following total knee replacement. There is no dispute that the CPM device was medically necessary for the initial three weeks following surgery.  The treating surgeon felt that additional time with the machine was indicated for this particular patient. His decision was based on the patients subjective report of her status at the end of the first three weeks and individualized to her condition at that time. 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: Overturned Decision of Health Plan

The patient is a 61-year-old male who apparently became dependent on narcotic pain medications following a back injury in January 2005.  There is no other history of substance abuse/dependence noted in the record. The patients symptoms of withdrawal were noted to included dyspepsia, back pain, tension, nervousness, anxiety, diaphoresis, tremors and sleep disturbance.  Reportedly, attempts at detoxification through the Health Plan failed.  The patient received non-plan treatment with Suboxone in January 2006 and is now requesting reimbursement.  The Health Plan denied his request based on a determination that Suboxone detoxification was not medically necessary.The patient has thoroughly researched the treatment options available for opiate detoxification and would appear to meet the criteria for medically supervised withdrawal. In comparison to other detoxification regimens, Suboxone is known to result in less severe symptoms of withdrawal.  In addition, the opiate detoxification can be accomplished on an outpatient basis and over a shorter period of time.  Therefore, I have determined the therapy at issue was 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 36-year-old female with diabetes mellitus type 2.  Her blood glucose levels were poorly controlled on metformin and Actos.  The patients hemoglobin A1c was 7.2% in August 2005 while taking metformin and 7.4% while taking Actos.  In December 2005, after a trial of Byetta, she and her endocrinologist assert that monitored blood glucose values improved tremendously. The patients hemoglobin A1c was 6.1% in March 2006, suggesting that she had obtained better blood glucose control.  The patient has requested authorization and coverage for continued treatment with Byetta. The Health Plan determined Byetta was not medically necessary, and denied her request.Patients who are not well controlled on oral agents generally progress to insulin therapy.  Byetta is at least as effective as insulin in improving blood glucose control.  Byetta may have an added advantage for an obese patient, as it is associated with weight loss, not the weight gain that frequently results from treatment with insulin.  Byetta is indicated as adjunctive therapy to improve glycemic control in patients who are taking metformin, a sulfonylurea, or both, but have not achieved adequate blood glucose control. This patient was not well controlled on metformin or Actos as demonstrated by hemoglobin A1c values greater than 7%.  When Byetta was added to these agents, her blood glucose values dramatically improved and her hemoglobin A1c dropped to 6.1%.  The improvement in the patients blood glucose control demonstrates the medical necessity of Byetta in this case.  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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old female who experienced significant breast pain following placement of mammary implants.  The original breast implants and the breast capsules were removed in May 2005 and overfilled saline implants were placed. The patient has requested reimbursement for cost of the procedure.  The Health Plan denied her request based upon a determination that the capsulectomies were not medically necessary.My review included the office notes of the treating plastic surgeon and photocopies of photos apparently taken on the day of the procedure. A letter from the provider to the Health Plan dated one month after the procedure was also reviewed. It is not possible to determine the location (above or deep to the pectoralis muscle) of the contracting implants from the providers notes or the photographs. Similarly, it is not possible to determine the degree of firmness of the capsules from this limited documentation.  Based on the lack of documented clinical findings, I have determined the procedure 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: Upheld Decision of Health Plan

The patient is a 44-year-old female who is status post gastric bypass surgery. She had a subsequent weight loss of approximately 120 pounds. She underwent abdominoplasty in March 2005. The patient reports experiencing intertriginous rashes in the thigh area due to excess skin. She has requested authorization and coverage for a bilateral medial thigh lift. The Health Plan has denied the patients request on the basis the procedure is not medically necessary.The records do not establish medical necessity for the proposed thigh lift.  The surgery has been proposed as a treatment for recurrent infections, but the records do not include objective evidence to verify the patients reported history.  The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin infections in the thigh folds, and the submitted photographs do not document cellulitis, ulcerations or rashes.  The plastic surgeons office note and preauthorization letter indicates that the patient has failed conservative treatment, but office notes confirming this have not submitted. The records do not include office notes that document evaluation and treatment of persistent rashes by an internist or dermatologist.  The medical records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. Although the patients social worker believes that the proposed thigh lift will improve the patients depression, most patients will have improved self-esteem following cosmetic surgery. As such, the patients depression is not a clinical indication for the procedure. Nor does the patients condition meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss. According to the ASPS Position Paper, skin resection is medically necessary if panniculitis or uncontrollable intertrigo is present. The records do not document panniculitis or the failure of medically supervised conservative therapy to control this patients intertrigo. Physician supervised treatment is the simplest, and safest method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. Based upon the information set forth above, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old male with a longstanding history of major depression and obsessive-compulsive disorder.  He is afflicted with depressed mood, episodes of sadness, agitation, anxiety, sleep disturbance, poor concentration, poor energy, decreased motivation, and social isolation. The patient has experienced feelings of hopelessness, helplessness and guilt. He is presumed to have had closed head injuries in 1972 from a motor vehicle accident (MVA) and in 1991 during a mugging; though the details of both injuries are unclear. The patient had neuropsychological testing in 1993, the test results of which were felt compatible with a post-concussion syndrome from the 1991 insult. No particular cognitive deficits were attributed to the 1972 injury.  The patients provider has requested authorization for VNS therapy. The Health Plan has denied authorization based upon a determination that VNS therapy is not medically necessary.In the course of his outpatient psychiatric treatment, beginning in 1996, the patient has been treated with Anafranil, Zoloft, and Wellbutrin with no particular gain, and Buspar, Metadate, Depakote and Lexapro with some positive results. His most recent medication regimen includes Abilify 5mg, Provigil 400mg, Lexapro 40mg, and Topamax 225mg daily in divided doses of 125mg and 100mg. He has taken this particular dosage of Lexapro for the past year. The patient also had a formal endocrinology evaluation, which found no abnormality of the pituitary or hypothalamus. It does not appear there are no other options for treatment other than VNS therapy.  There are a number of approaches to choose from, with more evidence of efficacy than VNS therapy. One option would be Lithium augmentation, particularly relevant in light of the patients history of mood swings and his favorable response to Depakote. Other options would include Lamictal, monoamine oxidase inhibitors (MAOI), or even electro-convulsive therapy (ECT). There is evidence in many of the providers notes that the patient has had positive responses to some of the treatments already afforded him. For example, the patient evidently felt extremely favorably about EMDR, thought that Ritalin was quite helpful and he appeared to have some response to Depakote and to Lexapro. All told, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old male with type II diabetes mellitus diagnosed about three years ago. He weighs 348 pounds and has significant lower extremity edema. He has hypertension and dyslipidemia. In addition, he has nephropathy. His creatinine is 1.5 associated with microalbuminuria. His Hemoglobin A1c was 9.1% in October 2005. When he saw the endocrinologist in November 2005 he was taking Actos 45mg. At that time Amaryl was added and Actos was reduced to 30mg. Metformin is not indicated because of renal dysfunction. The patient is a commercial driver and did not want to start insulin. His endocrinologist added Byetta 5mcg twice daily with a subsequent increase in dosing to 10mcg twice daily. The patients fasting and postprandial blood glucose values improved with the addition of Byetta and Amaryl. He has lost five pounds. Amaryl was increased to 6mg and Lasix and Diovan were added.At issue is whether the addition of Byetta to the patients medication regimen is medically necessary for treatment of his diabetes.Per Food and Drug Administration guidelines, Byetta is only indicated with sulfonylureas and/or metformin. Although studies of Byetta in combination with Actos have been completed and submitted to the Food and Drug Administration, to date such usage of the drug has not been approved.Review of the submitted clinical information indicates the patient is morbidly obese and has severe fluid retention. Actos has significant weight gain and fluid retention potential. The patient has responded well to Byetta. If Actos were discontinued, the use of Byetta along with Amaryl and a strict low carbohydrate diet and exercise program would be medically appropriate. However, based upon the data available at this time the concurrent use of Byetta and Actos cannot be recommended.For the reasons 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

This patient is a 13-year-old female with a history of ataxic cerebral palsy with cognitive delays, expressive and receptive language delays and dysarthria. She has been receiving speech therapy through the school system and privately from 9/01 through 12/05, based on the records provided. The Health Plan denied the parents request for reimbursement and continued authorization of speech therapy based upon a determination that the therapy was/is not medically necessary.I evaluated all of the private speech therapy progress notes from 9/01 through 12/05 in the course of my review. The evaluations use primarily a narrative format for assessment, with no real quantification of the patients progress.  The two most recent reports of 7/05 and 12/05 fail to outline goals and objectives for the patient and there is no documentation of improvement between the 7/05 evaluation and the 12/05 evaluation.  Instead, the comments in the 12/05 report refer back to the initial evaluation in 2001 for comparison and measurement of progress. This documentation does not support a conclusion that the patient is making functional progress. Therefore, I have determined the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.