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

The patient is a 33-year-old female who wishes to undergo a panniculectomy for treatment of excessive skin that developed following gastric bypass surgery in February 2002. It appears the patients weight has fluctuated since the gastric bypass procedure from a high of 306 pounds to a low of 213 pounds. The patient describes symptoms relative to her panniculus. The Health Plan has denied authorization for a panniculectomy on the basis that it is not medically necessary for treatment of the patients medical condition.The records submitted demonstrate the patient has not attained the weight loss anticipated with her gastric bypass procedure. Though the patient reports symptoms relative to her panniculus there is no physician documentation of these symptoms in the submitted records. The requested procedure poses a significant risk to the patient and should not be performed until the patient has attained the weight goal and diminished her comorbidities. 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 64-year-old female with diabetes who is currently on dialysis. The patient has experienced decreased mobility and ability to ambulate.  She was admitted to a skilled nursing facility (SNF) on 5/12/04. The submitted notes indicate the patient does well with physical therapy on days when she does not have dialysis but is too fatigued on days when she has dialysis to fully participate in physical therapy. A request has been made for continued SNF services. The Health Plan has denied the request on the basis that SNF services were not medically necessary after 6/13/04.The submitted records indicate the patient progressed from maximum assistance with bed mobility to standby assistance in a period of one month. Additionally, there is evidence the patient progressed from moderate assistance with ambulation to contact guard assistance within one month. Thus, the submitted medical records demonstrate the patients condition was improving with therapy. Furthermore, though it was noted the patient had trouble with physical therapy on days she had dialysis, there is no evidence that an attempt was made to schedule the patients physical therapy sessions in the morning followed by dialysis in the afternoon. Given the patients documented progress additional SNF services are medically appropriate and indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 42-year-old male diabetic with erectile dysfunction. The patient indicates his condition has responded to treatment with Viagra in the past. He has requested authorization and coverage for Viagra. The Health Plan has denied the patients request on the basis that Viagra is not medically necessary for treatment of the patients medical condition.Diabetes mellitus is a recognized and documented cause of organic erectile dysfunction. Treatment with PDE-5 inhibitor medications is accepted primary therapy for treatment of erectile dysfunction and is often successful. If not contraindicated by concomitant use of organic nitrates or drug intolerance to the medication, the patient should be treated with Viagra. Therefore, 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: Overturned Decision of Health Plan

The patient is a 49-year-old male who has been diagnosed with HIV-related symptoms. In addition to taking prescribed medications to control his symptoms, the patient is pursuing more natural alternatives via exercise, proper nutrition, vitamin/herb supplementation, and acupuncture. Because of his HIV condition and required medications, the patient apparently experiences side effects of insomnia, depression, anxiety, high blood pressure, and digestive problems. In addition, the patients provider notes the patient reports always being thirsty and experiencing frequent urination.The submitted records indicate the patient has received approximately 19 acupuncture visits. The acupuncturists notes dated 2/18/04 indicate the patient experienced a slight improvement in his symptoms. Notes of 3/9/04 indicate a lengthening of sleep time and anxiety was rated as 7 on a scale of 1-10.  Notes of 4/2/04 show a slight worsening of symptoms. On 4/9/04, it was noted the patient had a good nights sleep without taking medication. Treatment notes for the remainder of April 2004 show no significant increase or decrease in symptoms, but apparently the patient was able to cut back on his anti-depressant medication. Treatment notes for May 2004 indicate no worsening of insomnia, but the patients anxiety was slightly elevated due to stress. The patient has requested authorization for continued acupuncture treatments. The Health Plan has denied the request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.Upon review of the submitted acupuncture treatment notes it appears the patient has experienced a beneficial result from the treatments. The patient has received approximately 19 acupuncture treatments with favorable clinical response. His symptoms have lessened to some degree and he has been able to reduce and/or discontinue his use of anti-depressant medications. Based upon the patients response additional acupuncture treatments are medically indicated. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive four to six additional acupuncture treatments followed by re-evaluation by his acupuncturist and primary care physician.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old female with hypercholesterolemia and a family history of coronary disease. She has been experiencing symptoms of chest discomfort and pressure with heavy exertion and with rest. The patient has a left bundle branch block on ECG. She underwent an exercise stress echo, which did not demonstrate ischemia. An exercise stress nuclear study was abnormal. The nuclear test demonstrated evidence for a prior nontransmural infarct in the distribution of the left anterior descending with residual ischemia. The patient has requested an additional non-invasive electron beam computed tomography (EBCT) scan as an alternative to coronary angiography to confirm or exclude the presence or absence of significant coronary artery disease.EBCT is not a medically approved or accepted screening or confirmatory test for the diagnosis of coronary artery disease and is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing. In addition, EBCT is not an accepted substitute for coronary angiography and would not be able to confirm or exclude important coronary obstruction. The use of EBCT in the diagnosis and prognosis of coronary disease currently remains an unproven application of this technology. Therefore, I have determined that the requested EBCT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old man with long-standing lateral epicondylitis. He has attempted treatment with several modalities including physical therapy, prescription pain relievers, nonsteroidal anti-inflammatories, and steroid injections. The patient continues to experience pain and wishes to undergo extracorporeal shockwave therapy for treatment of lateral epicondylitis. The Health Plan has denied his request on the basis that extracorporeal shockwave therapy is not medically necessary for treatment of the patients medical condition.Extracorporeal shockwave therapy for treatment of lateral epicondylitis is not considered to be standard of care. A recent article in the Journal of Bone and Joint Surgery found that the procedure had little benefit and therefore, was not recommended. The current scientific literature does not demonstrate the efficacy of the requested therapy or the associated complications or risks. The requested therapy is not medically indicated for this patient since it is not likely to be beneficial. 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 a 44-year-old woman with a body mass index (BMI) of 48. She has undergone the necessary presurgical evaluations in preparation for weight loss surgery. The patient has requested authorization for the duodenal switch procedure. The Health Plan has denied the patients request indicating that the duodenal switch procedure is not medically necessary for treatment of the patients medical condition.Techniques in duodenal switch have been available since the 1980s. There is now sufficient data to show that duodenal switch has a superior long-term outcome when compared to gastric bypass for patients such as this patient. In the Roux-en-Y procedure dumping syndrome, stomal ulcers, and vitamin deficiency are commonly seen. Long-term studies of the duodenal switch procedure demonstrate equal effectiveness with less need for a highly restrictive diet than with gastric bypass. Therefore, I have determined 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 17-year-old female whose parent has requested authorization for augmentation mammaplasty. The patient was seen and evaluated by a plastic surgeon. The submitted notes indicate the patient has a lack of fullness of the left breast with approximately an 80cc difference between the left breast and right breast. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary.Review of the submitted records and photographic evidence of the patient demonstrates no medical necessity for augmentation mammaplasty. The patient has been examined by a plastic surgeon without findings of medical necessity for augmentation mammaplasty. There is no indication that the requested procedure is medically warranted in order to treat clinical symptoms or functional complaints. 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: Upheld Decision of Health Plan

The patient is a 41-year-old female who is 56 weighing 304 pounds with a body mass index (BMI) of 48. The patient underwent Lap-Band surgery in 1998. At the time of surgery the patient weighed over 500 pounds. Her weight reportedly dropped to 180 pounds following the procedure. She has been experiencing weight gain and worsening of distal esophageal dilation. The patient is status post multiple Lap-Band adjustments. She wishes to undergo revisional gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically indicated for treatment of the patients medical condition.Review of the medical literature indicates revisional weight loss surgeries have a high complication rate. A patient who has failed a restrictive operation (Lap-Band) is more likely to fail another restrictive operation longer-term unless a malabsorptive element is added. The study cited above reported high incidence of protein and nutritional deficiency after revision of gastric bypass to distal gastric bypass.  Furthermore, a patient with a BMI of 48 may have a high failure rate after a restrictive procedure. A more suitable option may be a hybrid procedure such as duodenal switch. Removal of the Lap-Band is medically indicated to prevent any further esophageal dilation. Revisional gastric bypass is not likely to be of benefit and is not medically indicated for treatment of the patients medical condition. The patient should be evaluated for consideration of a duodenal switch procedure.Based upon the information set forth above, I have determined that the requested procedure 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 43-year-old woman who has a history of vitiligo involving at least her hand and knees. The submitted information indicates treatment with Estrostep, Protopic, Westcort, and Psorcon has been unsuccessful. The patient has been using Elidel cream with improvement of the knee lesions and some improvement of the hand lesions. She has requested authorization for continued use of Elidel. The Health Plan has denied the request on the basis that the requested medication is not medically necessary for treatment of the patients medical condition.Vitiligo can be a disfiguring skin condition. Success with any treatment modality is occasional. Review of the submitted documentation appears to indicate that Elidel has resulted in improvement in some of the patients skin lesions. As such, it is medically reasonable and appropriate to continue treatment with Elidel. 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 50-year-old female who experienced traumatic brain injury as the result of a fall from a horse in May 2004. In addition, the patient was previously diagnosed with multiple sclerosis. Following the injury the patient received neurobehavioral rehabilitation services on a 14-day referral. The patient was subsequently readmitted to residential care. The patient remains severely impaired. The patients representative has requested authorization and coverage for additional neurobehavioral cognitive services. The Health Plan has denied authorization for the requested services on the basis that additional neurobehavioral cognitive services are not medically necessary for treatment of the patients medical condition.Review of the submitted materials indicates the patients rehabilitation team believes the patient is appropriate for discharge to outpatient therapy and no longer requires inpatient rehabilitation. The patient did not make significant gains as a result of previous neurobehavioral cognitive services. There is no evidence that additional neurobehavioral cognitive services are likely to result in improvement in the patients cognitive abilities. Ongoing outpatient rehabilitation services appear to be medically appropriate. 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: Upheld Decision of Health Plan

The patient is a 16-year-old female with an apparent history of depression evidenced by acting out aberrant behaviors, substance abuse, poor attendance and grades in school, and three psychiatric hospitalizations. Although the duration of treatment is unknown, the patient has been treated with Depakote and Lexapro. The patients biological mother is reported to have serious substance abuse issues and is unavailable to the patient who was raised by various family members and then adopted by an aunt and uncle. The patient has been receiving intensive outpatient therapy; however, inadequate treatment records have been submitted for review. The Health Plan has denied authorization for continued intensive outpatient therapy.Although there is some initial clinical information and a treatment plan available for review, there are no clinical records documenting the services the patient received and the patients progress. Although it is apparent the patient required some therapeutic intervention, there is no documentation supporting the need for intensive outpatient therapy. A review of the information submitted indicates the Health Plan made a number of attempts to obtain further clinical information from the patients providers without success. Based upon the information submitted, there is no documentation supporting the need for the requested services. 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 42-year-old woman with a toenail fungus infection, which is painful. The patient indicates her pain worsens when she works; she has two jobs, both of which require standing. The patients provider has prescribed Lamisil. The Health Plan has denied authorization and coverage for Lamisil on the basis that it is not medically necessary for treatment of the patients medical condition.The patient states that her onychomycosis is painful, perhaps worsened by standing for prolonged periods of time. The pain associated with the patients onychomycosis constitutes a functional impairment. Lamisil is an effective anti-fungal agent that is likely to improve the patients onychomycosis and relieve her pain. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1The patient is a 59-year-old female who has an L5 compression fracture with back pain and leg pain that has been unresponsive to conservative treatment. The patient also has end-stage liver failure. The patients provider indicates a kyphoplasty for treatment of the patients back pain is the least invasive option in light of her end-stage liver disease. The Health Plan indicates the efficacy of the requested procedure has not been demonstrated.This patient has a pathologic fracture of the L5 vertebrae with severe pain. Review of the current medical literature demonstrates kyphoplasty has been shown to be very effective for immediate and lasting pain relief. The patient is more likely to obtain relief from her back pain with kyphoplasty than with any other procedure. Therefore, I have determined that the requested procedure is 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 2The patient is a 59-year-old woman with an L5 compression fracture. She has persistent pain. Additionally, the patient has end-stage liver disease and is on the liver transplantation list. A kyphoplasty has been recommended by the patients provider as the most appropriate treatment option available. The Health Plan has denied authorization for a kyphoplasty on the basis that it is considered experimental.Kyphoplasty is a standard means of treating fractures of the vertebrae in patients with persistent pain. Kyphoplasty has been well studied and has been approved by the Food and Drug Administration. Furthermore, this patient as presented is an excellent candidate for this procedure. Due to the patients end-stage liver failure other procedures are contraindicated. Kyphoplasty, a minimally invasive technique involving a local anesthetic, is the most appropriate treatment option for patients such as this patient. Therefore, I have determined the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any other available therapy. The Health Plans denial should be overturned.Physician 3The patient is a 59-year-old woman with a pathologic L5 compression fracture. She has severe back and leg pain. The patient wishes to undergo a kyphoplasty. The Health Plan has denied authorization and coverage for the requested procedure on the basis that it is considered experimental.The clinical efficacy of kyphoplasty has not been clearly established. It is unclear whether this procedure will provide significant benefit to the patient. Furthermore, in this particular subset of fracture there is substantial risk of spinal cord compression and paralysis/paraplegia. Given that the safety and efficacy of kyphoplasty has not been established this procedure cannot be recommended. Therefore, 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: Overturned Decision of Health Plan

The patient is a 42-year-old female with a documented history of right temporomandibular joint pain and dysfunction. It appears the problem started after a motor vehicle accident in 1987 in which she sustained severe head injuries and the loss of some teeth. The maxilla is edentulous as is the posterior mandible bilaterally. The patient wears a full upper denture prosthesis and partial lower denture prosthesis. There is documented degenerative disease in the right temporomandibular joint, atrophy of the maxillary and mandibular alveolar ridges, and poor stability of her denture prostheses.  The patient has undergone bone grafting and placement of dental implants and has requested reimbursement for these services. The Health Plan has denied the patients request on the basis that the services at issue were not medically necessary.The services at issue constitute treatment for a condition affecting both the upper and lower jawbones as well as the right temporomandibular joint. Treatment with augmentation bone grafting, placement of endosseous dental implants and fabrication of new prostheses was necessary to restore function and relieve pain. The patients existing denture prostheses were inadequate to provide stable dental occlusion and temporomandibular joint pain and dysfunction were exacerbated by this unstable dental occlusion. Therefore, I have determined that the services at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.