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

The patient is a 40-year-old male with chronic pain due to peripheral neuropathy. He is requesting Anodyne therapy (infrared) for treatment of his chronic pain. The Health Plan has denied the patients request indicating Anodyne therapy is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Anodyne and other infrared therapy modalities have not been proven efficacious in peer-reviewed literature. Such therapies are not currently among the accepted standard of medical care for treatment of peripheral neuropathy pain. As such, there is insufficient evidence that Anodyne therapy is likely to be of greater benefit to the patient than standard treatment modalities. 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 61-year-old female with chronic hepatitis C active viral replication, genotype 1. She did not respond to treatment with interferon and ribavirin. The patient was then started on Pegasys and Copegus; however, due to side effects she was switched to PEG Intron, which she also was unable to tolerate. She was ultimately started on Infergen and Actimmune. The patient is also receiving treatment with Procrit. The Health Plan has denied coverage for Actimmune and Procrit on the basis these medications are not medically necessary.Infergen (interferon alfacon-1) is FDA approved for patients with hepatitis C who are non-responders. Actimmune (interferon gamma-1b) does not have FDA indication for hepatitis C therapy. There is insufficient evidence Actimmune is beneficial for treatment of the patients condition. As such, the use of Actimmune in this clinical setting is not medically necessary. Regarding the patients request for Procrit, sustained viral response is key in this patient. The drop in hemoglobin is of concern, as any level at or below 10 should be taken seriously. Addition of Procrit to her regimen is medically reasonable and appropriate. Many studies have looked at the benefits of the addition of growth factors such as Procrit and Neupogen in HCV-infected patients. Use of Procrit is medically reasonable and appropriate and is a needed therapeutic approach in this patient who, though responsive to medicinal therapy, has had problems with side effects. Procrit should be authorized to enable the patient to finish her course of therapy.Based upon the information set forth above, I have determined that although Actimmune is not medically necessary for treatment of the patients medical condition, Procrit is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 44-year-old female with premature natural menopause beginning at an unknown date and treated with oral estradiol for an unknown duration. In addition, the patient has had two insertions of estrogen and testosterone pellets and is seeking reimbursement for this therapy. The information submitted does not demonstrate the patients response to either the oral estradiol therapy or the pellet therapy. The patients blood tests indicate an estradiol level in the premenopausal range with testosterone in the low male range initially and twice the normal female range subsequently. The Health Plan has denied reimbursement for the pellet therapy.Evidence regarding the safety and efficacy of hormone pellets is lacking. There were other safe and effective therapies available for the patient including estrogen patches with or without progesterone. Dose control of blood levels of hormones with pellets is difficult and has associated risks. This is especially a concern in this patient whose testosterone levels were too high and therefore, having a significant concern relative to cardiovascular disease. Furthermore, the evidence of testosterone therapy in a patient such as this is at best equivocal. Based upon the information set forth above, I have determined the therapy at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: This case involves a 60-year-old female who indicates she has refractory migraine headaches. She has received Botox injections in the past, which she reports have been effective in relieving her headaches. The patient has requested reimbursement for the Botox injections at issue. The Health Plan has denied coverage for Botox on the basis it is considered investigational for treatment of migraine headaches. There are a variety of safe and approved medications, either for prophylactic use or for occasional acute bouts of headaches. The submitted records fail to provide sufficient information and details concerning the patients headaches or medications that have been tried in the past. Thus, there is inadequate evidence the patients headaches were refractory to standard therapies. As such, I have determined that the therapy 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.Physician 2: The patient is a 60-year-old woman with a reported history of refractory migraine headaches. The submitted records do not specify the patients past history of medications used to help alleviate her symptoms. The patient received Botox injections in May and June 2004. Her physician indicates she has had a positive response to Botox. The patient is requesting reimbursement for the injections. The Health Plan has denied this request indicating there is insufficient evidence Botox therapy is efficacious for migraine headaches.Though there is growing evidence supporting the use of Botox for treatment of migraines refractory to multiple prophylactic medications, the submitted records do not provide sufficient detail regarding the patients previous use of prophylactic therapies. As such, the severity and refractory nature of the patients migraines has not been established. Therefore, I have determined that the therapy 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.Physician 3: The patient is a 60-year-old female who indicates she has refractory migraine headaches. She indicates that she has received Botox injections, which provided effective headache relief. The Health Plan has denied reimbursement for the Botox injections at issue on the basis Botox is considered investigational for treatment of the patients condition. The submitted materials do not include detailed information regarding the patients history, prior therapies, or current therapy. Nor is there sufficient documentation of the patients response to Botox in the clinical notes provided. As such, it has not been established that Botox was likely to be more beneficial for treatment of the patients medical condition than any available standard therapies. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 56-year-old woman who has a progressive neurological disease. In an evaluation by the patients physician in October 2003, he reported the patient had been bitten by a tick in California in 1986. In 1988 she had episodic loss of bladder control. In 2000, she had episodes of loss of balance followed by weakness, spasticity, fatigue and rigidity. She has had progressive weakness, muscle spasms, and loss of coordination in the last two years. When assessed by her physician, the patient was dependent on a walker.In a follow-up visit in January 2005, the patients physician noted the patient had increasing problems with speech, fatigue, and muscle spasms. He reported a tremor at rest and slurred speech. He noted plans for Mepron and Biaxin therapy, and stated that the Rocephin should be continued.Laboratory tests include a single Babesia WA-1 serology that was positive at a low level [1:640]. A Lyme IgM Western Blot performed in October 2004 was not positive by CDC criteria. IgG and IgM tests for Babesia microti performed at the same time were negative. A Babesia FISH study was also negative. There is a note that a Bowens test for Lyme was positive.In June 2004, the patients provider ordered Rocephin via a PICC line. The patient was to continue on Rocephin until December 2004.A request has been made for reimbursement for the Rocephin injections the patient received. The Health Plan indicates the medication at issue was not medically necessary for treatment of the patients medical condition.Review of the submitted clinical information reveals no evidence of Babesia or Borrelia infection. In addition, the Bowen test for Lyme disease has not been validated and is not an accepted component of the serological diagnosis of this disease. Furthermore, the Western Blot for Lyme disease that has been provided was an IgM, which is usually positive rather soon after infection. This test was negative by CDC criteria. Moreover, evidence of an IgG test, which is more reflective of distant infection, has not been provided. The Babesia WA-1 test was a single determination in a patient who has clinical symptoms, which do not fit a diagnosis of Babesiosis.The patients clinical findings are not consistent with Lyme disease. The patient has a progressive neurological disease that is clinically not consistent with nervous system Lyme disease. Even if there was clear documentation of Lyme disease, the maximum recommended duration of treatment with Rocephin is 30-60 days. Therefore, I have determined that the medication 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: Overturned Decision of Health Plan

The patient is requesting a consultation with an ocuplastic surgeon to assess the degree of visual dysfunction from her drooping eyelids and/or eyebrows. She states she needs to raise her eyebrows in order to see through the drooping eyelids. It appears a taped visual field exam was performed, as was a separate visual field exam on a different date. The submitted photographs are fair to poor quality. It is difficult to tell if the patient is contracting the frontalis muscle to elevate the eyebrows from the quality of the photographs. The Health Plan has denied coverage for the requested consultation on the basis it is not medically necessary for evaluation of the patients condition.Based upon the information provided, surgical authorization is not medically necessary at this time; however, it is medically reasonable for the patient to receive a consultation with an ocuplastic surgeon to take appropriately lighted/focused/oriented photographs, and to examine the position of the eyelids and eyebrows with the patients upper facial musculature in repose. It would also be helpful to obtain serial visual fields with the patient in a relaxed mode and as well as with her eyelids/brows manually elevated/taped to determine the degree of visual field improvement. Performing the two fields on the same date would eliminate confounding factors in the test results. As such, I have determined that the requested consultation 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 39-year-old female with chronic plantar fasciitis. She has requested authorization for extracorporeal shock wave therapy (ESWT). A review of the documentation provided indicates various treatments including night splints, orthotics, steroid injections, and physical therapy have failed. Therefore, the patients provider has requested authorization for ESWT.While review of the literature demonstrates there is some evidence ESWT can provide a moderate degree of pain relief in selected patients with chronic plantar fasciitis who have failed conservative therapy, optimal treatment parameters have not been established, patient selection criteria have not been adequately defined, and there is a lack of information regarding the durability of ESWT or any adverse effects it may cause. In addition, there have been some conflicting results among the randomized, controlled studies thereby raising doubts regarding the efficacy of ESWT. A recent randomized, placebo-controlled, double-blind, clinical trial yielded results that contradicted the positive findings of previous studies. At this time, there is nothing to indicate that ESWT is 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 53-year-old female with a history of hip pain. She has been diagnosed with osteoarthritis. The patients physician recommended metal-on-metal hip surfacing, which the Health Plan has denied due to a lack of scientific evidence in peer-reviewed medical literature to support its efficacy.Metal-on-metal hip resurfacing is still in experimental/investigational studies. Short-term data is sparse, with no long-term prospective study establishing its effectiveness. In addition, the procedures risks are uncertain. Furthermore, there are other treatments available for this patient. At this time, metal-on-metal hip resurfacing cannot be recommended as there is very little data to warrant its general use. 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 25-year-old male with back symptoms that have not responded to medication or physical therapy. The patient has attempted closed and open MRI scans without success because of severe claustrophobia. For two of the attempts the patient took oral anti-anxiety medication. The Health Plan approved the open and closed MRI scans. The patients provider has requested a stand-up MRI, which the Health Plan has denied. The alternative service offered by the Health Plan is a closed MRI with conscious sedation. The patient states he has a past history of problems with intravenous sedation.There is no dispute that an MRI of the patients spine is medically necessary. There is some risk involved with conscious sedation. Furthermore, because of the patients high level of claustrophobia and his apparent prior history of problems with IV sedation there is likelihood the risks of conscious sedation are even greater in this patient. For these reasons, a stand-up MRI is medically indicated and appropriate for this patient. Therefore, I have determined the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 41-year-old female who has migraine associated vertigo and a left peripheral vestibulopathy. She has a long-term history of these symptoms. In February 2005, her provider recommended balance retraining with vestibular rehabilitation therapy. The Health Plan has denied coverage for the therapy the patient received.Vestibular therapy is useful for patients who have suffered acute episodes of vestibular problems due to viral disease, stroke, benign positional vertigo or vestibular dysfunction of unknown etiology. However, vestibular therapy is considered ineffective for chronic or recurrent vestibular problems. This patient has chronic vestibular problems. Therefore, the therapy at issue was not medically indicated for this patient. Prophylactic medications such as Topamax or Depakote may be beneficial for this patient. Based upon the information set forth above, I have determined the therapy at issue was 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 58-year-old female who has treatment refractory depression with suicidal ideation that has failed to respond to several medications such as Zoloft, Celexa, Wellbutrin, Effexor and Effexor augmented with Ritalin. However, her physician states she has had a response to Effexor and Provigil with her mood becoming euthymic with a cease in suicidal ideation and an increase in her interest in work. She is requesting further treatment with Provigil. The Health Plan has denied this request and has recommended empiric trials of other medications. This patient is stable on her current medications including Provigil. There is a growing body of evidence indicating Provigil is effective in the treatment of depression. There is no medical indication to have the patient start new empiric trials, which may or may not be effective. There is potential if the patient is taken off her current medications and new trials are initiated the patient could deteriorate leading to hospitalization. The patient is benefiting from her current medication regimen and there is sufficient evidence in the medical literature to support Provigil as useful for treatment of her condition. 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 38-year-old female who is requesting growth hormone therapy. She has a history of variable weight between 150 and 210 pounds over approximately the last five years. She also has a potential diagnosis of hypothyroidism made by an alternative medicinal provider based on a 60-pound weight gain, fatigue, and low temperature. It is not clear if any documenting biochemical tests were performed at the time of the diagnosis. The patient was placed on Armour thyroid in high dose and based on her suppressed TSH has been biochemically hyperthyroid for most of the time since. It should be noted that over 10 years ago the American College of Physicians recommended the removal of Armour thyroid from the prescription medication market due to variable potency and effectiveness.The patient went to see an endocrinologist for her thyroid problems. Though the patients IGF-1 was normal, an arginine GHRH stimulation test was performed. The stimulation test results returned with a barely normal peak GH response. Based upon these results and the patients non-specific symptoms a diagnosis of AGHD was made and treatment with growth hormone injections prescribed. No other tests indicated growth hormone or other pituitary insufficiency. A MRI was normal.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 16-year-old male with a history of attention deficit disorder (ADD). His ADD has been treated with Provigil since September 2004. While taking Provigil the patients academic performance improved. Prior to Provigil the patient attempted other therapies without benefit. The Health Plan has denied coverage for Provigil.The patient is benefiting from his current medication regimen. Although the evidence is still evolving, there is evidence supporting the use of Provigil in the treatment of ADD. Similar to many other medications, the off-label use of Provigil for the treatment of ADD is considered reasonable in the Pediatric community. Furthermore, because of the success the patient has had with Provigil there is no indication for him to be tried on other medication trials. Based upon the information set forth above, I have determined 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

This patient is a five-year-old female with difficulties with speech. The patient has been exposed to in utero drugs and has had recurrent middle ear infection requiring myringotomy tubes on three occasions, most recently at the beginning of 2005. The patient has received speech therapy through a regional center and the school system since 2002. A speech evaluation from the school system performed in May 2004 reported average expressive language skills and receptive language skills. However, the patient presented with a moderate phonological disorder. The patients provider performed a speech evaluation in March 2005, which supported the earlier conclusion of normal expressive and receptive language delays, but delays in the production of sounds.At issue is whether speech therapy is medically necessary for the patients condition.In reviewing the literature regarding intrauterine drug exposure and speech delays there are no reports of speech delay with heroine. Cocaine use causes both expressive and receptive language as well as global developmental delay. It is well documented by two therapists that this patients expressive and receptive language have normalized and only articulation errors remain so there does not appear to be a strong correlation between drug exposure and speech.Furthermore, review of the relevant literature regarding hearing loss and effusion reveals the outcomes are mixed regarding the use of tympanic membrane tubes. There is little data regarding speech therapy and intermittent hearing loss as documented in this case. A study by Paradise, et al. reports only approximately 35% of children with intermittent hearing loss below the age of three have speech delay. Expressive language is the most common problem with chronic hearing loss. Articulation errors as described by the patients therapist are educationally based deficiencies rather than medical issues. As such, standard of care is to manage the patients condition through other means than individual speech therapy. The primary need in this case is for the patient to practice articulation in real-life situations, in the home, school and the community. 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: Upheld Decision of Health Plan

The patient is a 50-year-old female who had an onset of tinnitus in 2004 with increased symptoms in December 2004 and January 2005. The tinnitus disturbs her sleep. Tinnitus matching was performed and matching occurred at 6000 hertz. The patients providers have recommended a GHI Tranquil RR sound generator for treatment of the patients tinnitus. The Health Plan has denied this request. Tinnitus retraining therapy is a new form of treatment for tinnitus involving sound generators. Although it is showing some promise in the treatment of tinnitus, there is still insufficient evidence demonstrating its long-term effectiveness. Because of this lack of evidence the Health Plan is correct that the medical necessity of sound generators in the treatment of tinnitus has not been demonstrated. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.