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

The patient is a 42-year-old female with previously diagnosed depression, morbid obesity, and binge eating disorder, though not bulimia per se. The patient was admitted to partial hospitalization on 2/16/04 where she was treated with a number of psychotherapies as well as Lexapro. Pertinent social stressors have included her mothers alcohol dependence, an emotionally abusive husbands past infidelity, and her teenage sons involvement with drugs and alcohol and poor performance in school. Her tendency has been to overeat when distressed. During her stay in the partial hospitalization program, the patients weight decreased from 334 pounds to 319 pounds by 5/12/04. The chart notes point to the patients growing insight about her aforementioned stressors and her emotional reaction by way of overeating. The therapists notes of 5/5/04 indicate, her family is emotionally reacting to her positive changes. In discussing this the patient made many realizations and showed great insight. The patient has requested authorization and coverage for continued partial hospitalization services. The Health Plan has denied the request indicating that the submitted documentation does not demonstrate partial hospitalization services were medically necessary as of 5/12/04.Analysis and Findings:While the patient entered partial hospitalization to better contain her overeating and anxiety, she had a rather protracted course of such treatment for a multitude of problems that are often treated with no more intensive therapy than outpatient care. In any event, the submitted records indicate the patient improved during partial hospitalization, experiencing a weight loss of approximately 15 pounds, and a growing awareness of the triggers for overeating. There is nothing in the submitted records to indicate the patient warranted partial hospitalization beyond 5/12/04. There is no evidence that as of 5/12/04 the patient was experiencing any particularly acute problems. Outpatient treatment services as recommended by the Health Plan are medically reasonable and appropriate for the ongoing care of this patient. Based upon the information set forth above, I have determined that the requested services are 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 60-year-old woman with chronic obstructive pulmonary disease and cardiomyopathy.  In February 2001, a pacemaker was implanted for symptomatic second-degree atrioventricular block. The patient underwent a screening mammogram in June 2003. The patient reports the procedure caused her pacemaker to dislodge. In February 2004, the patient reported her pacemaker had moved. A chest x-ray confirmed the pacemaker was lower in the chest than previous studies. The pacemaker was revised and a new pacemaker implanted. The patient is concerned a mammogram will dislodge her pacemaker. Therefore, she has requested authorization and coverage for a breast ultrasound as an alternative to a mammogram. The Health Plan has denied authorization and coverage for the requested ultrasound on the basis that it is not medically necessary for evaluation of the patients medical condition.The Health Plans denial should be upheld. Pacemaker dislodgement is not a recognized complication of mammography. A pacemaker is normally attached to the pectoral muscle in the deltopectoral groove. This location is cephalad and dorsal to the breast. Compression of the breast should not affect the pacemaker. Therefore, I have determined that the requested ultrasound 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 26-year-old female with chronic pain due to fibromyalgia. She has requested additional physical therapy after receiving 83 visits. The Health Plan has denied the patients request on the basis that continued physical therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld. There is no objective documentation demonstrating the patient requires continued supervision by a physical therapist. The patient has received 83 physical therapy visits. This is an adequate amount of time to learn a home exercise program of myofascial release, stretching, progressive strengthening, body mechanics, and postural control. The goal of physical therapy for patients such as this patient is to teach patients how to independently manage their symptoms. The information provided demonstrates the patient can be safely and effectively treated through a home exercise program. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the 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 10-year-old female with attention deficit hyperactive disorder (ADHD) and developmental delay. She has been treated with Adderall and Strattera. Based on the submitted information, it does not appear the patient has been tried on amphetamines or methylphenidates. The patients mother has requested authorization and coverage for Strattera. The Health Plan has denied the request on the basis that Strattera is not medically necessary for treatment of the patients ADHD.Review of the submitted clinical information demonstrates conventional therapy has not been attempted. There is no evidence the patient has undergone a trial of amphetamines or methylphenidates. Absent a trial of these medications, there is no medical indication for use of Strattera. Furthermore, Strattera in combination with Adderall is not recommended. Therefore, I have determined that the requested medication is not medically necessary for the 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 56-year-old female with neck pain and temporomandibular joint (TMJ) dysfunction and jaw clicking, as well as low back pain. The patient received 12 physical therapy visits with an emphasis on low back pain and hip pain. The patient is able to open her mouth 40mm but continues to have pain. The Health Plan has denied the patients request for continued physical therapy on the basis that the requested therapy is not medically necessary.The 12 physical therapy visits received by the patient were for treatment of multiple problems with a focus on the patients low back pain and hip pain. The submitted information demonstrates the patient continues to have TMJ pain despite being able to open her mouth 40mm. Though it appears the patients back and hip pain has improved, she requires additional physical therapy that emphasizes the TMJ and neck area. Future therapy should emphasize an active approach and a home program.Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The patient should receive an additional 12 physical therapy visits followed by reevaluation to determine if additional physical therapy is indicated.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 39-year-old female followed annually by her primary care physician. She was noted to have significant weight gain when placed on steroids two years ago. The patient complained of back, neck, and shoulder discomfort. Weight reduction was recommended. Despite steady weight loss over the last two years the patients symptoms persist. She was referred to a chiropractor and a plastic surgeon for reduction mammaplasty evaluation. The plastic surgeon recommended the patient undergo a bilateral breast reduction. The Health Plan has determined that bilateral breast reduction surgery is not medically necessary for treatment of the patients back, neck, and shoulder pain.The submitted medical records and photographic evidence demonstrate significant mammary hypertrophy. Several medical observers have documented that the patient has appropriate symptoms for the physical findings. The appropriate and medically necessary procedure for this patient is breast reduction. According to the American Society of Plastic Surgeons (ASPS) guidelines, the weight of the removed breast tissue does not determine whether the procedure is medically necessary. In this case, the examining provider noted symptoms of back, neck, and shoulder pain related to large pendulous breasts, which have not been relieved by weight loss. The requested procedure is within ASPS guidelines and is medically indicated. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 20-year-old male who was struck in the head with a baseball bat in April 2004. The patient experienced loss of consciousness and continues to have symptoms. An MRI of the brain has been recommended by the patients provider. The Health Plan has denied authorization and coverage for the MRI on the basis that it is not medically necessary for evaluation of the patients head injury.MRI scanning is standard of care for head trauma with persistent symptoms, especially in cases of prolonged loss of consciousness. The submitted evidence demonstrates the patient continues to have post-traumatic pain following a trauma to the head, which caused loss of consciousness. An MRI has been recommended by the patients neurologist who is in the best position to determine appropriate care and management of the patient. Though reference has been made to the US Headache Consortium Neuroimaging Guidelines, the Guidelines do not address the clinical problem presented in this case.  MRI scanning is medically appropriate and indicated for further evaluation of this patient. Therefore, I have determined that the requested MRI is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 33-year-old female with a BMI of 37. Though she has some obesity related comorbidities, she does not have any severe comorbidities such as diabetes or intractable hypertension. She wishes to undergo gastric bypass surgery. The Health Plan has determined that the requested procedure is not medically necessary for treatment of the patients medical condition.The Health Plans denial is correct. This patient does not meet nationally accepted medically necessary criteria for weight loss surgery. With a BMI of 37 and no severe comorbidities such as diabetes or hypertension, weight loss surgery is not medically indicated or necessary for this patient. The patient should make further attempts at conservative weight loss and behavior modification prior to considering surgery. 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 seven-year-old male with a diagnosis of high-functioning autism with documented severe language delays as shown on the clinical evaluation of language fundamentals revised (CELF-R). He also has mild oral-motor impairment, severe receptive language and expressive language skills. The patient is in a special day class at school and receives speech therapy twice per week. The evaluating therapist has recommended additional speech therapy two times per week. The Health Plan has denied authorization and coverage for the requested therapy on the basis that it is not medically necessary for treatment of the patients condition.Review of current medical literature reveals no evidence that intensive speech therapy at four times per week is superior to the amount of therapy the patient is already receiving. Additionally, the speech therapist who recommended more intensive therapy did not identify specific goals establishing the need for the additional therapy. The submitted evaluations do not delineate between the goals of therapy performed by the school and the goals established through additional therapy. Therefore, I have determined that the requested therapy is not medically necessary for the 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 36-year-old female with a history of migraines and cluster headaches since 1994, six months after delivery of her second child. The patient has been diagnosed with trigeminal neuralgia. She has been tried on numerous medications, acupressure, acupuncture, massage, and biofeedback, none of which have been effective. The only medication regimen that appears to have been effective is opiates. The patient is currently on Avinza as a baseline medication. She has requested authorization for Actiq for her breakthrough pain, which also causes nausea and vomiting, making oral medication regimens difficult. The Health Plan has determined that Actiq is not medically necessary for treatment of the patients pain.The patient has severe pain, which has failed to respond to conservative treatment. Based upon review of the patients records, her medication regimens are reviewed monthly to ensure appropriateness of her dosages. She also fills out monthly questionnaires indicating the positive benefits of her treatment regimen. As long as the patient continues to be closely followed on her current medication regimen so that abuse of Actiq or other narcotics does not occur, she should be able to continue her current regimen, which has helped her to avoid emergency room visits and allowed her to function at home. Given the severity of the patients intractable pain, continued use of Actiq is medically indicated.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 62-year-old male with a body mass index of 50. He has significant obesity related comorbidities. The patient is estimated to be a high operative risk (5%). The patient wishes to undergo gastric bypass with duodenal switch. The Health Plan has determined that the requested procedure is not medically indicated for treatment of the patients medical condition.With a body mass index (BMI) of 50 and significant comorbid conditions, the patient appears to be an appropriate candidate for weight loss surgery. Given the patients BMI and comorbidities duodenal switch would be the preferred weight loss procedure. However, given the significance of his comorbidities he is a high operative risk. As such, updated cardiac and nephrology evaluations are necessary to determine if surgery is a viable option for this patient. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. If the results of the cardiac and nephrology evaluations indicate the patient is a viable candidate for surgery, the requested procedure should be authorized. If the results of the cardiac and nephrology evaluations indicate the patient is not a viable candidate for surgery, the requested procedure should not be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 26-year-old female with a history of chronic facial pain secondary to trigeminal neuralgia. The patient also has a diagnosis of fibromyalgia and has recently been diagnosed with Lambert-Eaton syndrome. She has been tried on numerous pain medications in the past including many narcotics. The patient experienced reactions such as rashes, pruritus, and even anaphylaxis to various narcotics tried. The patient is also unable to tolerate fentanyl patches secondary to sedation. She has been able to tolerate Actiq and therefore, has requested authorization and coverage for the medication. The Health Plan has denied the patients request on the basis that Actiq is not medically indicated for treatment of the patients medical condition.The submitted records document the patients history of intractable chronic pain and her inability to tolerate numerous narcotics utilized in trials to control her pain. The patient has obtained pain relief from Actiq without the intolerable side effects she experienced with other medications. In light of the patients severe intractable pain, Actiq is medically indicated and should be authorized. However, since Actiq is a potent narcotic the patient will need to be closely followed by a pain specialist with an appropriate narcotic contract. The patients emergency room visits should be monitored to show decreased emergency room utilization secondary to Actiq prescription contract, as well as increased daily function with Actiq usage. 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: Overturned Decision of Health Plan

The patient is a 55-year-old female with symptomatic breast problems. Multiple lesions of the left breast recently biopsied have left a deficit of breast tissue. The patient also has ptosis of the contralateral breast. The pathology review of the removed tissue did not find the suspicious atypical cells noted on the aspiration biopsy and therefore, the breast is not cleared and potentially will require future biopsy. Because of the asymmetry, the patient sought consultation with a board certified plastic surgeon who examined her both before and after the left breast biopsy. The plastic surgeon recommended the patient undergo reconstructive procedures to restore normal breast symmetry. Photocopies of pictures of the patient in March 2003 and May 2004 demonstrate marked changes in the size and contour of the left breast. The Health Plan has denied the recommended surgery as cosmetic in nature and not medically necessary.Review of the submitted evidence reveals the requested surgery is reconstructive rather than cosmetic in nature. The patient has a defect resulting from fibrocystic disease (a tumor) and its excision. Breast reconstruction surgery has been requested to restore the patient to a normal appearance to the extent possible. The procedures proposed are not cosmetic in nature, but are considered reconstructive as defined by California law and the guidelines of the American Society of Plastic Surgeons. Therefore, I have determined that the requested surgery 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 58-year-old male who experienced a right radial head fracture in December 2003 as the result of a fall. The patient is status post open reduction with internal fixation. He received physical therapy from January 2004 until May 2004. In April 2004, it was noted the patients elbow flexion range of motion was 136 degrees and extension was 16 degrees. The patient is concerned his extension has regressed; he has requested authorization for an additional two months of physical therapy. The Health Plan has denied the request on the basis that additional physical therapy is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The submitted records indicate flexion is over 130 degrees and extension is 16 degrees. The patient is six months post surgery. Given the patients age, and the length of time since surgery, his condition is not likely to improve with additional physical therapy. The patient has had an excellent outcome; continued supervised physical therapy will not have any functional impact. 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: Upheld Decision of Health Plan

The patient is a 51-year-old female who has requested authorization for a neuromuscular stimulator and supplies. The patient is experiencing shoulder and arm pain after an injury in September 2003. She has also been diagnosed with myofascial pain syndrome. The Health Plan has determined that the requested equipment is not medically necessary for treatment of the patients medical condition.There are no randomized, controlled, peer-reviewed outcome trials demonstrating the efficacy of neuromuscular stimulation for treatment of myofascial pain syndrome. Thus, it is unlikely that a neuromuscular stimulator will be of any benefit in this case. The Health Plans recommendation that the patient undergo a workup with a physiatrist and/or a neurologist is medically reasonable and appropriate. There is no medical indication for a neuromuscular stimulator in this clinical setting. Therefore, I have determined that the requested equipment is not medically necessary for the 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 56-year-old female with a history of migraines successfully aborted with one to two Maxalt tablets. The submitted information documents a trial of only one preventive medication. The patient states she is able to control her migraines with two Maxalt tablets. She has requested authorization and coverage for 12 Maxalt tablets per month. The Health Plan has denied her request indicating that the requested quantity of Maxalt tablets is not medically indicated for treatment of the patients migraine headaches.The patients headache frequency warrants preventive agents. Such agents will likely reduce the patients headache frequency and severity as well as increase her response to Maxalt, thereby allowing her to take one tablet per headache instead of two. Patients such as this patient often benefit from preventive medications such as Topamax, Depakote, Neurontin, etc. The patient should be followed by a neurologist to identify a preventive medication that is effective. Thus, the Health Plans recommendation that the patient follow-up with a neurologist for consideration of prophylactic management is medically reasonable and appropriate. Based upon the information set forth above, I have determined that the requested prescription is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld. However, the patient should receive 12 Maxalt tablets per month for a period of two to three months while preventive treatment is pursued.