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

The patient is a 59-year-old male requesting coverage for treatment with growth hormone (GH) therapy for adult growth hormone deficiency (AGHD). He is being treated for hypothyroidism secondary to radioiodine ablation of an overactive thyroid, dyslipidemia, and depression.  The patient has also been given the diagnosis of metabolic syndrome presumably on the basis of his obesity and dyslipidemia for which he was started on metformin. He had a normal level of IGF-1 and normal GH stimulation testing according to his endocrinologist. He is noted to have adrenal insufficiency but is on no pituitary tropic hormone replacement and no pituitary function tests are submitted to substantiate the clinical diagnosis.  His testosterone, cortisol, DHEA, TSH and alpha subunit hormone tests are all normal.  The Health Plan has denied authorization and coverage for GH therapy based upon their determination that it is not medically necessary.The medical records from the patients treating endocrinologist from December 2003 through August 2005 do not substantiate the diagnosis of AGHD.  The patient has normal GH function testing and there is no evidence of any other pituitary dysfunction to support a diagnosis of panhypopituitarism. Patients who have documented AGHD do have an increased incidence of coronary artery disease and increased mortality. However, the use of GH in patients with metabolic syndrome to prevent an acute coronary event is experimental at this time.Based upon the information set forth above, 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: Overturned Decision of Health Plan

The patient is a medically-complex six-year-old female diagnosed with failure to thrive whose oral intake is not sufficient to meet her daily nutritional requirements.  With the benefit of occupational therapy she can feed orally, but is still gastrostomy tube (G-tube) dependent for the majority of her calories.  Her last noted feeding regimen consisted of two jars of baby food, 21 ounces of Neocate Jr. formula, and 14 ounces of a specially-mixed high calorie formula.  The patients mother reports an effort to gradually replace the specially mixed formula with Neocate Jr. based on the patients tolerance of the change.  The patients parents dispute the Health Plans denial of coverage due to a lack of medical necessity.Although the patients diagnosis and course of treatment are not clearly determined, she is likely to require G-tube feedings for some time into the future. The patient is making progress in transitioning from G-tube feeding to oral intake and from specially mixed formula to a readily available pediatric formula, but for now her current feeding regimen is necessary to meet her nutritional needs. The patient should receive another year of nutritional supplementation and then the need for nutritional supplements should be reviewed again after a gastroenterologist has reviewed the patients progress.Based upon the information set forth above, I have determined the requested nutritional supplements are 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 case concerns a 10-year-old male with short stature.  He fell off of the growth curve at the age of four years and at seven years he had a workup that revealed low GH dependent IGF-1 and IGFBP-3 levels together with a small pituitary on MRI of the brain. At the age of seven, the patients bone age was read as being retarded by approximately 1.5 years and his predicted adult height was close to the target height estimated from parental heights. At age nine, the patient had a GH stimulation series and passed one of the two tests given but failed the other. His bone age was no longer retarded and according to my calculations, his predicted adult height near the initiation of GH therapy in May 2005 was in the 51 to 52.5 range. The patient had normal IGF-1 and IGFBP-3 levels three months after beginning his GH therapy. His parents have requested authorization for GH therapy which the Health Plan has denied based on their determination that it is not medically necessary.The patients initial workup suggested GH deficiency and it remains possible that he does have impairment of GH secretion. However, the more recent evaluation suggests idiopathic short stature with a low predicted adult height. GH therapy is medically appropriate on that basis as approved by the Food and Drug Administration in July 2003.  Therefore, 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 59-year-old male who has a history of abdominal pain, heartburn and reflux since September 2004. He has been treated with Nexium with good results. He also tried Achiphex, Prilosec, and Protonix, which were not as effective as Nexium. The Health Plan has denied authorization and coverage for Nexium indicating it is not medically necessary for the patients medical condition.This patient was treated with Nexium for abdominal pain with good results. The submitted evidence demonstrates that Nexium relieves the patients symptoms. Additionally, the patient has tried Aciphex, Prilosec, and Protonix but did not experience the same results as with Nexium. Based upon the proven success of Nexium for treatment of this patients abdominal pain, as well as the failure of other medications, the requested medication is medically appropriate and indicated. Accordingly, 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: Overturned Decision of Health Plan

The patient is a 52-year-old man with bilateral knee arthritis. He has received Synvisc injections in the past with good results. His most recent course of Synvisc was administered in October 2005. A request has been made for reimbursement for these injections as well as prospective authorization for a series of Synvisc injections every six months. The Health Plan has denied this request indicating that Synvisc injections are not medically necessary for treatment of the patients medical condition.The patient is relatively young for knee replacement surgery. He has had no relief with cortisone or medications. The submitted clinical evidence indicates the patient has had a good response to Synvisc in the past. There was no contraindication to the series of Synvisc injections the patient received in October 2005 and it appears the patient benefited from the injections. However, there is no evidence that Synvisc injections every six months are useful for treatment of arthritis of the knee. Therefore, prospective authorization of twice yearly Synvisc injections is not medically appropriate or indicated. Based upon the information set forth above, I have determined although the Syvnisc injections the patient received in October 2005 were medically necessary, Synvisc injections every six months are not medically necessary. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a five-year-old male with a diagnosis of DiGeorge syndrome with facial weakness on the right. He has had two heart surgeries. The patient has had a history of chronic otitis media requiring TM tubes; the tubes have been removed. He has documented hearing loss on the right. The patient has been receiving speech therapy since April 2004 secondary to speech production delays and expressive language delays. At issue is whether continued speech therapy is medically necessary for treatment of the patients condition.Review of the submitted clinical records demonstrates the therapist began seeing the patient in April 2004 with the goals of: increased expressive language, increased speech production, and parent and teacher education objectives for improved speech production. The stated goal of completion of five to seven oral motor exercises per week is a monitoring objective and does not require active therapy. The progress report also does not use objective findings to document the gains. Further, the stated goal of exhibiting improved motor planning does not use objective findings to demonstrate improvement. It simply states he continues to improve. Moreover, the progress report from January 2005 only states the objectives without providing any documentation the patient is achieving them, so it is unknown if the patient has been making progress toward goals.Based on the documentation provided, it has not been established that the patient requires or has benefited from speech therapy. 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 52-year-old female with a history of chemical hepatitis, severe persistent asthma and breast cancer. According to a letter dated December 2005, the patient was on Advair 500, Zyrtec-D, Singulair, albuterol MDI and albuterol via nebulizer.The patients pulmonologist indicates he has requested Xolair since September 2004. The patient had 20 unscheduled office visits in the past year. The pulmonologist did not want to keep the patient on high dose inhaled corticosteroids because she gets oral thrush. The IgE level was 465. Pulmonary function tests performed in September 2005 showed normal flow rates with an FEV1 of 117% of predicted. The pulmonologist states that the normal PFT is only a snapshot of the patients lung function. There were no records of flow-volume loops during the patients office visits.The Health Plan has denied use of Xolair on the basis that the patient did not meet the necessary inclusion criteria, specifically, a normal FEV1 and inconsistent use of controller medications based on pharmacy records.The purpose of this review is to determine if Xolair is medically necessary for treatment of the patients medical condition.Xolair is indicated in patients with moderate to severe asthma and positive skin test reactivity to aeroallergens. The initial study has patients with FEV1 between 40-80% of predicted, a change of FEV1 of more than 12% after bronchodilators, total IgE between 30-700 IU and a body weight of less than 150 kg. If a patient has an FEV1 greater than 80%, he or she must be on oral prednisone of a dose of 5 mg or more.According to the submitted records the patients FEV1 was 117% of predicted. The records do not indicate that the patient was placed on oral corticosteroids despite multiple episodes of exacerbations. The pulmonologist states he did not want to use oral corticosteroids because of its systemic side effects. While there is an appreciable need to minimize the use of systemic corticosteroids because of the long-term adverse effects, the records do not indicate even intermittent use by this patient. If the patient has experienced many exacerbations, the inflammatory changes can result in lung remodeling and worsening lung functions. Because of the normal pulmonary function tests, alternative diagnoses such as vocal cord dysfunction should be considered. In addition, a trial of oral prednisone would be appropriate. Significant improvement on prednisone would be a better predictor of whether or not Xolair will be effective. However, at this time there is insufficient evidence that the use of Xolair is medically indicated or necessary for this patient.As 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 39-year-old male with an ankle injury. His provider recommended a right ankle osteochondral allograft procedure, which was performed in January 2005. The Health Plan has denied reimbursement for the procedure indicating it is considered investigational for treatment of the patients medical condition.Osteochondral allografting is an accepted procedure, which is performed specifically in cases such as this. The procedure provides coverage of cartilage where it is missing in order to alleviate pain and avoid fusion. Osteochondral allografting is clearly superior to ankle fusion for patients such as this patient. 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 an active 39-year-old male who had a climbing accident and sustained multiple injuries including a fracture dislocation of the right ankle. He underwent surgical repair with internal fixation and subsequent removal of hardware. In January 2005 he underwent an osteochondral allograft for severe ankle arthritis. Since the procedure the patient reports ongoing continued improvement in ankle function as well as relief of pain. Reimbursement for the procedure has been denied by the Health Plan on the basis that the procedure is considered investigational.Osteochondral allograft has had documented success and was likely to result in a superior clinical outcome over standard therapies in this case. With the osteochondral allograft, the patient has the capacity to retain some mobility, which is lost with a fusion. Furthermore, if subsequent problems develop the procedure is amenable to revision of the grafting or, if necessary, fusion would still be a viable option. As such, I have determined 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 39-year-old male with post-traumatic ankle arthritis. An osteochondral allograft procedure was performed in January 2005. He is requesting reimbursement for the procedure, which has been denied by the Health Plan.Osteochondral allograft transplantation for post-traumatic ankle arthritis is an unproven treatment. The long-term results remain unknown. The standard of care for the diagnosis is ankle fusion. The results of ankle fusion surgery are excellent for this condition. Therefore, I have determined that the procedure at issue was 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 history of uterine fibroid tumors. She has had a recent tumor that has resulted in significant pain and bleeding. After reviewing her treatment options she has decided to undergo uterine artery embolization (UAE). Her physician has requested a pelvic MRI to assist in evaluating if the UAE procedure is a viable surgical alternative for the patients medical condition. The Health Plan has denied authorization and coverage for the requested MRI on the basis it is not medically necessary.Review of the submitted clinical evidence indicates the patient has the diagnosis of uterine myomas already confirmed by an ultrasound. The criteria for performing an MRI of the pelvis as listed in Milliman Care Guidelines are: cervical cancer, endometrial cancer, hip pain - adults, hip pain - pediatrics, osteomyelitis, ovarian cancer/adnexal mass, suspected bone tumor, pelvic organ prolapse/incontinence, bladder cancer, rectal cancer, fetal anomalies, vulvar cancer or congenital uterine anomalies.Diagnosing uterine myomas after they have been previously diagnosed on an ultrasound is not an indication for an MRI of the pelvis. There is no medical literature showing a clinical benefit in performing an MRI of the pelvis before an initial UAE. One article states, In women who have been treated with failed primary UAE, continued enhancement of leiomyomas on MR imaging can be used to identify candidates for successful repeated UAE. However, this study only looked at patients who had previously undergone a UAE and did not study the use of MRI on patients who were being considered for an initial UAE. An MRI of the pelvis prior to UAE in a patient who has had her uterine myomas confirmed with an ultrasound is not medically indicated.Based upon the information set forth above, I have determined the requested MRI 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 64-year-old man with hepatitis C and hepatocellular carcinoma since at least 2003. He was judged non-resectable and treated with chemoembolization. He has since been treated with octreotide, but has been found to have progression of his tumor and biopsy proven extra-hepatic nodal metastasis at endoscopic ultrasound. The submitted materials indicate that the patient is being considered for liver transplant.  The patient is currently ambulatory. He is requesting authorization and coverage for chemoembolization. The Health Plan has denied this request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.The patient has metastatic disease and there is no evidence he has been evaluated by a transplant center and determined to be an appropriate candidate for liver transplant. He has non-resectable hepatocellular carcinoma, and the question is whether transcatheter chemoembolization is necessary medical treatment for this condition.  The topic is the subject of controversy because the available randomized controlled trials have yielded conflicting results. The studies available to date do not favor transcatheter chemoembolization for patients with metastatic disease.  The available positive clinical trials had strict criteria including Okuda 1 and 2 patients who did not have metastatic disease.  Although length of survival was increased in these carefully selected patients, there is no evidence that transcatheter chemoembolization is medically necessary or superior to systemic treatment for patients such as this patient with metastatic disease.Based upon the information set forth above, 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 52-year-old female with a diagnosis of chronic Lyme disease. She evidently had a positive Lyme Western Blot in May 2005 and coinfection with Ehrlichiosis. Her symptoms consist of poor balance, vertigo, blurry vision, headaches, confusion, joint pain and difficulty with concentration. No abnormal exam findings are noted. An MRI of the brain revealed a few small foci in subcortical white matter, which may be consistent with neuroborreliosis. The patient has been treated for four months with four antibiotics. She is seeking an additional twelve weeks of therapy with intravenous ceftriaxone. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients medical condition.The above-mentioned study by Klempner, et al. did not demonstrate any efficacy to prolonged antibiotic therapy. In addition, studies by Kaplan and Krupp have not shown any benefit to antibiotic therapy beyond thirty days. Although individual experience, case studies, and non-placebo controlled trials are important in advancing the science of medicine, they cannot be the basis for treatment guidelines for larger populations. The body of scientific evidence for the treatment of late stage Lyme disease (Lyme arthritis or neuroborreliosis) is 30 days of intravenous antibiotic, with a possible repeat course. Trials are ongoing for longer courses of treatment, but there is no published data in peer-reviewed journals of double blind, placebo controlled trials showing their efficacy. Thus, there is inadequate evidence to show extended antibiotic therapy will result in a benefit to the patient beyond standard therapy. Based upon the information set forth above, 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: Overturned Decision of Health Plan

The patient is a 45-year-old female with a body mass index (BMI) of 43 who is seeking authorization for weight loss surgery. She has multiple comorbid conditions including diabetes mellitus, hyperlipidemia, hypertension, and coronary artery disease. The information provided indicates the patient has not undergone a psychological examination. The Health Plan has denied authorization for the requested surgery on the basis it is not medically necessary for treatment of the patients medical condition.With a BMI of 43 and significant comorbidities, the patient meets nationally accepted guidelines for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery. Such an evaluation is considered standard of care prior to authorizing weight loss surgery.Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the procedure should not be authorized.