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

The patient is a 44-year-old male who is requesting Provigil for excessive daytime sleepiness. He has severe obstructive sleep apnea confirmed by polysomnography. His titration study indicated effective pressures of 7cm to 9cm H2O.  The patients respiratory disturbance index (RDI) was 45.2 and he had hypoxemia with desaturations to 86%.  His sleep latency was 18 minutes, within the normal range. There is reported non-compliance with the CPAP mask preventing definitive conclusions regarding the efficacy of the therapy.   The patients request for Provigil was denied by the Health Plan based upon a determination that the medication is not medically necessary.The patient clearly has severe obstructive sleep apnea as indicated by an RDI of 45.2 with associated hypoxemia. The titration study confirmed that CPAP is effective at pressures of 7cm to 9cm H2O.  At this point, the patients sleep apnea is essentially untreated due to his intolerance of the CPAP mask.  The use of Provigil in this clinical setting is not consistent with its intended usage.  The patient still has nocturnal hypoxemia and there is no control data to determine if Provigil is effective under these circumstances.   Although Provigil apparently allows the patient to function, its use is potentially harmful by facilitating a delay in the treatment of the underlying pathology. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 33-year-old female who is status post laparoscopic Roux-en-Y gastric bypass in 2001 with significant weight loss (207 pounds).  She has since had weight regain and several bowel obstructions requiring laparoscopic lysis of adhesions and reduction of internal hernias.  Her providers request for authorization of a revisional duodenal switch procedure was denied by the Health Plan based upon a determination that the procedure is not medically necessary.The biliopancreatic diversion with duodenal switch is not an investigational procedure.  However, the surgical conversion from a Roux-en-Y gastric bypass to biliopancreatic diversion with duodenal switch is a technically demanding procedure as it requires complete take down of the Roux-en-Y gastric bypass, jejunojejunostomy, gastrogastrostomy, sleeve gastrectomy and small bowel reconstruction.  In the case of this patient, there has not been sufficient workup to determine why the Roux-en-Y gastric bypass failed.  The record did not include an upper gastrointestinal series with small bowel follow through (UGI/SBFT), reports of endoscopic examinations or details of the original surgery to determine what was done previously.  It is not medically appropriate to proceed absent a comprehensive workup of the failed Roux-en-Y gastric bypass.  The problems of anemia and weight regain can be addressed non-surgically.Based upon the information set forth above, I have determined 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 reported history of Aspergers syndrome who has received an initial evaluation for sensory integration therapy in August 2005 and visits from September 2005 through October 2005. He is working primarily on a sensory deficit. The submitted records do not include documentation from a developmental pediatrician or pediatric psychiatrist confirming a diagnosis of Aspergers syndrome. The Health Plan has denied coverage for past and future sensory integration occupational therapy on the basis that it is not medically necessary.Although sensory integration therapy is the standard of care for autism spectrum disorder, review of the submitted clinical information reveals no documentation of the diagnosis of Aspergers syndrome from a physician. Sensory integration abnormalities, in and of themselves, are not a diagnosis but rather symptoms. The therapy at issue is not medically warranted in the absence of a confirmed medical diagnosis. Accordingly, I have determined that the therapy at issue 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 nine-year-old male with short stature and IGF-1 deficiency.  He participated in a clinical trial and began growth hormone therapy in June of 2004.  Indications for the therapy included short stature, a subnormal rate of growth of 2cm per year, low IGF-1 levels at 52ng/ml and 63ng/ml, low IGFBP-3 levels at 0.83ng/ml and 0.87ng/ml, and a bone age read as 72 months at a chronological age of 99 months. He had normal thyroid function and his growth hormone responses to arginine and GHRH were supra-normal rising to 81.70ng/ml and 91ng/ml. After one year of growth hormone therapy, the patients growth rate has increased to 10cm per year and his IGF-1 level increased to 188ng/ml. The patients initial response to standard doses of GH was minimal and his dosage was increased from 0.8mg to 1.875mg per day (0.73mg/kg/week), to achieve his enhanced growth.  The patients GH (if not IGF-1) therapy should be continued based on the clinical findings outlined above.  He appears likely to have GH insensitivity, which has been overcome by large doses of GH therapy.   If so, he may be a candidate for the IGF-1 therapy recently approved by the FDA, rather than the high dose GH therapy that he is receiving at present. A blood level of IGFBP-1/2 would be diagnostically helpful if found to be elevated in his initial serum samples. Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 64-year-old female who presented with left sided chest pain and coughing with rib tenderness for which her primary care provider (PCP) ordered a chest CTA.  No records previous to the chest CTA in December 2005 were included in the review.  There is however a note from January 2006 indicating the patient was hypertensive (146/76), had a negative review of respiratory symptoms, and had mild, relapsing left chest wall tenderness to palpation (which had originally started in May 2005). The patient has requested reimbursement for the cost of the CTA.  The Health Plan denied her request based upon a determination that CTA was not medically necessary to evaluate for possible pulmonary embolism.There is no record of tachycardia, hypoxia, or predisposing risk factors for deep vein thrombosis (DVT) or pulmonary embolus (PE) found in the record. The patients history and physical examination after the chest CT revealed mild chest wall pain with palpation but no symptoms of respiratory distress or tachycardia. This constellation of findings would make pulmonary embolus very unlikely and would more often indicate musculoskeletal chest wall pain. Therefore, I have determined the CTA at issue was 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 61-year-old male with an apparent diagnosis of post concussion syndrome secondary to a head injury in late 2004.  There is neuropsychological testing consistent with the stated diagnosis and a brain MRI with no abnormal findings.  The patient has requested authorization for cognitive rehabilitation therapy. The Health Plan denied his request based upon a determination that therapy is not medically necessary for the treatment of his post concussive syndrome.According to the literature, a `cognitive therapy program` which consists of physical, occupational, speech and or psychotherapy, is indicated when there has been head trauma with evidence of brain injury, deficits in specific areas of functioning, and less than six months has passed since the brain was compromised. Although there is an inference that a `program` is necessary, the record provided does not support such a global need and well over six months have passed. The injury in this case, `post-concussion syndrome,` is mainly evidenced in this individual by depression, anxiety, and memory problems, approximately 18 months after the fact. There is no apparent need for the multidisciplinary approach typical of a cognitive rehabilitation program.  If the patient wished to pursue psychotherapy for treatment of his depression and anxiety, he might benefit from some cognitive training techniques incorporated into the course of that treatment. Based on the evidence cited 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 19-year-old male with idiopathic short stature and constitutionally delayed puberty. He was born the smaller of two twins weighing 2 pounds with his sibling weighing 5 pounds 4 ounces. The mid-parental height approximates 68 inches. On October 2005 the patients bone age was 15.5 years, while his height was near 53. His adult height prediction on these bases should approximate 54. He has had an endocrine workup, which revealed normal GH responses to stimuli, normal adult male hormone levels and a normal IGF-1 level of 184 in October 2004. Based upon the information provided, it appears the patient has been on growth hormone therapy since January 2006. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence demonstrates the patient meets medical necessity criteria for growth hormone therapy. In accordance with the AACE Medical Guidelines for growth hormone therapy, the therapy is medically necessary for patients such as this patient who was a small for gestational age infant who has not caught up, and is falling further from normal percentiles, and/or has idiopathic short stature and is not projected to achieve an adult height in the normal range and is under the care of a pediatric endocrinologist. The problem is however that the patients remaining growing time is very short and it is not known to what extent such therapy will be beneficial. Therefore, growth intervals should be obtained on a regular basis (every three months) to document that the patient is continuing to grow. In addition, a knee x-ray would be helpful to show the state of the epiphyses in the knee. Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 51-year-old woman with pain in the right temporomandibular joint (TMJ) and right-sided muscles of mastication. Also noted among her symptoms was reciprocal clicking with range of motion in the right TMJ. Her diagnoses were: right-sided articular cartilage disorder, right-sided TMJ capsulitis and right-sided facial/cervical myositis.  The patient received services in September 2005 for which she is now requesting reimbursement.  The Health Plan denied her request based upon a determination that the services she received were not medically necessary.  Following the September 2005 consultation, the patients provider submitted a plan of treatment directed toward the general goals of avoiding surgery and reducing pain, inflammation and adverse joint loading. There were no specifics with respect to radiographic findings, treatment notes, metrics of progress or the need and design of an interdental fixation device. This type of device is usually employed for management of jaw fractures, dental trauma or postoperative splinting following orthognathic surgery.  The clinical rationale for the use of the interdental fixation device in this instance has not been provided.  More commonly, a dental occlusal splint would be applied in this type of circumstance.  Electrical stimulation and manual therapies were also provided in September 2005. The clinical documentation does not explain the medical/dental basis for these therapies; and they are considered experimental and not supported in the literature.  Therefore, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician #1:  The patient is a 53-year-old woman with refractory ovarian cancer in the lungs and abdomen. The patients provider has recommended treatment with Avastin. The Health Plan has denied coverage for Avastin on the basis that there is insufficient peer-reviewed medical literature establishing the efficacy of Avastin in this clinical setting.Review of the scientific literature reveals only a single case report regarding the use of Avastin in advanced refractory ovarian cancer. This does not meet accepted criteria for approval of a new therapy. The use of Avastin in ovarian cancer remains of proven benefit. There is insufficient safety data and a high observed incidence of visceral perforation with the therapy. Therefore, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician #2:  The patient is a 53-year-old woman with recurrent epithelial ovarian cancer. Treatment has included carboplatin, Taxol and topotecan followed by tamoxifen, carboplatin, Taxol, cisplatin, gemcitabine, and Doxil. The patient has experienced a recurrence in her abdomen and multiple lesions in her lungs. Her oncologist has recommended the use of Avastin. The Health Plan considers Avastin experimental for treatment of ovarian cancer.To date, there is insufficient published evidence on the use of Avastin for ovarian cancer. Additionally, it has not been approved by the Food and Drug Administration for this indication. There is no data demonstrating it is more effective than any other third or fourth line agent for ovarian cancer including altretamine, which the patient has not yet received. Accordingly, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician #3:  The patient is a 53-year-old woman with refractory ovarian cancer. She is status post multiple chemotherapy regimens. She has requested authorization for treatment with Avastin. The Health Plan has denied the patients request indicating that the requested therapy is considered investigational.Avastin remains experimental/investigational in the management of ovarian cancer. Although there are some phase II trials suggesting a benefit, a formal report is soon to be published indicating an increase in risk of bowel perforations with Avastin. Furthermore, other standard options are available in this case including CPT-11, oral etoposide, and navelbine. For these reasons, I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old male with headaches and daytime somnolence. His provider noted an increase in the patients headaches and fatigue approximately six weeks after stopping Provigil. Elavil has been prescribed to treat the patients headaches and there is a note from the provider suggesting the patient may be taking Celexa as well. The patients provider indicates that Provigil has been prescribed to to keep (the patient) awake and more focused during the day.  The patients request for authorization of Provigil was denied by the Health Plan based upon a determination that the medication is not medically necessary.The FDA approved indications for Provigil include narcolepsy syndrome, sleepiness due to obstructive sleep apnea, and sleepiness due to shift work sleep disorder. Additional off-label uses include the treatment of attention deficit disorder, fatigue associated with chronic diseases, psycho-stimulant abuse, and depressive disorders. None of these indications apply to this patient as he is reportedly being prescribed Provigil for excess daytime sedation without an identified etiology. The patient also notes that he has mild narcolepsy, although there is no mention of this in the providers notes and no medical test results have been provided to substantiate this claim.Review of the relevant research revealed no studies demonstrating that Provigil has been used successfully for the treatment of headaches or for the fatigue associated with Elavil. Furthermore, the records provided do not document trials with alternative agents to address the patients sedation or to control his headaches. Numerous other medications such as calcium channel blockers, beta-blockers, less sedating antidepressants, and anti-seizure medications are available to treat headaches. Many of these medications have a lower incidence of sedation. There are also other treatment modalities including sleep hygiene interventions, increased exercise, and/or dietary modifications that have not been explored. The patients continued fatigue, sleep complaints, and headaches may also be indicative of a continued mood disturbance. Finally, the potential side effects of Provigil are significant and include cardiovascular and psychiatric symptoms. Hence the risks associated with this medication are not outweighed by the patients subjective report of symptom improvement.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 13-year-old male who has cystic fibrosis, diabetes and short stature.  His bone age is delayed and IGFBP-3 and IGF-1 levels were marginal.  The patients predicted adult height is less than 63 in comparison to a mid-parental height of 72.5.  The patients provider has requested authorization for growth hormone therapy. The Health Plan denied authorization for the therapy based upon a determination that it is not medically necessary.The treating pediatric endocrinologist has provided a well-compiled letter in support of growth hormone therapy and suggests that his patient has GH neuro-secretory dysfunction on the basis of an IGF-1 level that was low normal. However it is well known that IGF-1 levels trend low in conditions such as cystic fibrosis where malnutrition is a factor. GH deficiency is not a recognized feature of cystic fibrosis, therefore some documentation of the proposed GH deficiency should be provided before the therapy is given. This is particularly important in this case because GH therapy increases insulin resistance and could worsen the patients diabetes. The provider suggests that growth rates alone can be used for the diagnosis of growth hormone deficiency, but the publications cited dealt with otherwise healthy children not those with cystic fibrosis.  GH therapy is of unproven benefit in children with cystic fibrosis and could possibly worsen the situation when diabetes is a factor.  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 43-year-old female with a body mass index (BMI) less than 50. The patients comorbid conditions include mild asthma and obstructive sleep apnea. The patient has requested authorization and coverage for a Lap-Band procedure. The Health Plan has denied the patients request citing a lack of medical necessity.Current scientific literature does not demonstrate that Lap-Band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not medically warranted in this case. 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

This patient is a 55-year-old female who has Hepatitis C and was treated with pegylated interferon from July 2005 to January 2006.  In January 2006 she still had a viral load of 28,000 IU/ml, which rose to over 700,000 IU/ml in March 2006. Her provider recommended a change from PEG Intron to Infergen and requested authorization for the proposed therapy.  The Health Plan denied the request based on a determination that therapy with Infergen was not medically necessary for the treatment of the patients Hepatitis C.Infergen has been approved by the FDA and is specifically indicated for the treatment of patients who have not responded to pegylated interferon therapy. This patient has been treated for a sufficient period of time with a pegylated formulation without a response and it is reasonable to conclude that she will not respond to the pegylated therapy. At this point in her treatment, the use of Infergen is a reasonable next step.  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: Upheld Decision of Health Plan

The patient is a 41-year-old male who has been treated with chiropractic care for neck and shoulder area pain and a diagnosis of ankylosing spondylitis. The patient has tried medications, physical therapy and chiropractic treatments but states the chiropractic care is the most helpful. His complaints continue however, with no apparent conclusion to his recent plan of care. The patient has requested reimbursement and authorization and coverage for additional chiropractic services. The Health Plan does not consider the services medically necessary and denied his request.It appears from the records provided that the previous chiropractic services were medically appropriate and beneficial to the patient.  However, at this stage of the patients care it would be prudent to pursue consultation with a medical orthopedist or physiatrist for medical evaluation and further treatment recommendations. I would not recommend authorization of additional treatment unless this approach failed to resolve the patients symptoms.  In that event, periodic care with a chiropractor in concurrence with a home program should be authorized to help calm exacerbations.Based upon the information set forth above, I have determined past chiropractic services were medically necessary and the patient should be reimbursed.  Additional chiropractic services are not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be partially overturned.