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

The patient is an 18-year-old woman with a history of myofascial pain and masticatory dysfunction with chronic progressive degenerative changes in both temporomandibular joints. The patient has a dysfunctional dental malocclusion with asymptomatic class II deep bite deformity. The patient experiences pain relief and improved function of muscles of mastication when the dental malocclusion is neutralized with a dental occlusional splint. A request has been made for orthognathic surgery. The Health Plan has denied the request indicating that orthognathic surgery is not medically indicated.The patients pain and disability are directly related to her dysfunctional dental malocclusion. The submitted records document confirmed degenerative joint disease in both temporomandibular joints. In addition, the patient experiences relief of her symptoms when the malocclusion is neutralized. The patient has a severe dental malocclusion, which cannot be adequately corrected with orthodontics alone. Given these factors, orthognathic surgery is medically appropriate and indicated.Based upon the information set forth above, I have determined that the requested procedure 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 61-year-old woman with extensive, severe psoriasis with itching. The patient has been on Soriatane and received PUVA phototherapy from July 2003 to December 2003. The patient states that prior to PUVA therapy, she scratched her lesions because of severe itching with resultant open sores. The patient reports that during PUVA therapy, the itching and extent of her psoriasis improved markedly. The Health Plan has denied authorization and coverage for additional PUVA therapy on the basis that the requested therapy did not improve the patients psoriasis. The patient indicates that her condition improved considerably since she began receiving PUVA therapy and she has submitted copies of photographs in support of this contention. However, the submitted dermatology notes do not document whether the patients psoriasis has improved. While the dermatology notes address the areas of involvement, the extent of involvement is not documented. Therefore, I have determined that the requested therapy is not medically indicated at this time. The Health Plans denial should be upheld at this time. However, if the patients dermatologist provides documentation that PUVA therapy has resulted in improvement in the severity of the patients psoriasis, additional PUVA therapy should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old woman with a medical history including chronic asthma and allergies. The patient indicates that in the past she received Serevent metered dose inhaler (MDI), which contains 120 puffs per canister. Her typical dose is two puffs BID (twice a day), which is equal to 120 puffs per months. The manufacturer has converted the MDI into a dry powder inhaler (Serevent diskus inhaler). The diskus formulation dosage is one inhalation BID or 60 per month. The patient wishes to receive 120 doses per month.The submitted progress notes indicate the patient has been on a variety of inhalers including Serevent, Foradil, Flovent and Pulmicort. The patient has requested authorization for an additional Serevent diskus inhaler per month. The Health Plan has denied the patients request on the basis that an additional Serevent diskus inhaler is not medically necessary.Upon review of the submitted records, it appears the patient was previously well-controlled while on Serevent inhaler two puffs BID. When the manufacturer converted the drug to a dry powder inhaler the patient felt that she needed to continue to be on two inhalations BID.The Serevent diskus inhaler does not provide puffs; rather, it is a dry powder inhaler so there is no puff or use of a propellant. The previous version of Serevent was a metered dose inhaler (MDI), which delivered 21 mcg/spray and the recommended dose was two puffs BID or 42 mcg BID. The Serevent diskus inhaler delivers 50 mcg/inhalation, which is at least equivalent to two puffs of the MDI version. Therefore, an additional Serevent diskus inhaler is not medically indicated, as one Serevent diskus inhaler is equivalent to the previous version of Serevent. Furthermore, doubling the dose beyond the Food and Drug Administration recommendation would put the patient at risk for adverse side effects (see SMART research trial).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. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a four-year-old male with a developmental delay that has affected his speech and auditory comprehension. The patient has been receiving speech therapy twice per week and appears to have improved. The patients mother has requested authorization for additional speech therapy. The Health Plan has denied this request on the basis that continued speech therapy is not medically necessary.Children with developmental delays need to receive treatment as early as possible in order to avoid interference with their learning ability and maturational process. Given this, additional speech therapy is medically appropriate and indicated for treatment of the patient. The patient has shown some improvement and is likely to benefit from continued speech therapy. Therefore, I have determined that continued speech therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should continue to receive speech therapy twice per week for six months with reevaluation at that time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old woman with avascular necrosis of the femoral head. It was recommended the patient proceed with total hip replacement. The patient then consulted another provider who indicated that the patient is a candidate for biostructural augmentation. The patient has requested authorization for biostructural augmentation. The Health Plan has denied authorization for the requested procedure indicating that it is not medically necessary.Review of the clinical evidence does not demonstrate that biostructural augmentation is likely to benefit this patient or result in a better clinical outcome than a total hip replacement. The patient is a good candidate for total hip replacement, which is very likely to have a high success rate with minimal negative effects. Thus, biostructural augmentation is not medically indicated for the patient; a more appropriate alternative is available and should be pursued. 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 20-year-old man who sustained a traumatic brain injury in a motor vehicle accident. The patient received inpatient rehabilitation services following the accident. In July 2003, the patient was transitioned to a program, which provided physical therapy, occupational therapy, speech and language pathology, and neuropsychology in the home setting. The patient continued to receive these services until 12/3/03. The Health Plan indicates that such services were not medically necessary after 8/21/03.  As of 8/21/03, the patient was functioning with limited supervision in the home and was able to perform strength exercises and to play basketball with supervision. Although the patient continued to have some cognitive deficits, he was progressing well. There is no evidence to demonstrate that comprehensive rehabilitation services were required after 8/21/03; the patient had achieved a level of functioning that no longer required comprehensive rehabilitation services. Therefore, I have determined that the services at issue were 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 man with a well-documented history of obstructive sleep apnea. His previous treatment with tonsillectomy and uvulopalatopharyngoplasty has not solved the problems. The patient is intolerant of CPAP. There is no record of treatment with dental occlusal splints. There is a history of significant obesity. A request has been made for orthognathic surgery.Review of the submitted documents indicates there is no history of maxillomandibular deformity requiring correction with orthognathic surgery. The proposed orthognathic surgery (Lefort I maxillary osteotomy and bilateral mandibular ramus sagittal split osteotomies with bimaxillary advancement) is not medically indicated because more conservative surgical treatment involving repositioning the tongue and floor of mouth musculature including the suprahyoid musculature has not yet been carried out. If successful, it would obviate the need for orthognathic surgery. Also, there appears to be no demonstrable mandibular deformity or malposition that is contributing to the problem and therefore, there is no obvious need to proceed with orthognathic surgery. Furthermore, the patient is obese, which may be a major contributing factor and the obesity problem should be resolved before further surgical intervention. Based upon the information set forth above, I have determined that the requested procedure 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 six-year-old male with a history of speech delay and poor social interaction skills. The patient has a history of chronic diarrhea and failure to thrive as well as chronic otitis media requiring PE tubes. A request has been made for continued speech therapy. The Health Plan has denied the request indicating that continued speech therapy is not medically necessary.This patient has well documented speech and language delays affecting overall communication and social interactions. The diagnosis of control auditory processing disorder is somewhat controversial and the theory has not been scientifically tested. Despite this, there have been general studies and meta-analysis of childhood speech disorders that do demonstrate efficacy in the treatment of speech and language. The patients developmental pediatrician has documented improvement in the patients social skills, speech fluency and communication since the patient began speech therapy. Given the documented improvement and the likelihood that the patient will continue to benefit, from continued speech therapy is medically indicated.Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. Speech therapy should continue as long as gains can be documented using standardized validation testing. Objective goals that demonstrate functional gain should be documented. The patient should be reevaluated at bi-monthly intervals by his developmental pediatrician to review standardized testing and document improvement.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 64-year-old female with type II diabetes mellitus who was treated with insulin (regular and Lantus) and Avandamet from 2/500 twice a day. After changing to Avandamet from Glucotrol XL, the patient had several hypoglycemic events and therefore, there was a decrease in both her insulins with apparent improved glycemic control. Based upon the information provided, she has not been treated with individual Avandia and Glucophage. Her last A1c obtained prior to her medication change was 7.8%; her current level of glycemic control under her current treatment regimen is unknown (other than reported home glucose monitoring results).The Health Plans recommendation for titration of individual medications is reasonable and appropriate prior to starting fixed combination therapy. In addition, the Health Plan has stated that once glycemic control is stabilized then fixed combination therapy will be approved. Based upon this information, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 31-year-old man who has requested authorization and coverage for orthotics. Review of the documentation provided indicates that the patient is being treated for chronic heel pain secondary to calcaneal spur and plantar fasciitis. The patient has been treated with taping, local steroid injections, anti-inflammatories, and stretching with no relief of symptoms. The patients provider has recommended orthotics to control excessive pronation and reduce pull of the plantar fascia on the heel bone. The Health Plan has denied authorization for orthotics indicating the requested equipment is not medically necessary.The Health Plans denial should be overturned. Review of the submitted records indicates the patient has tried various forms of conservative treatment with no relief of symptoms.The medical literature supports orthotic therapy in cases where other conservative measures have failed. Custom corrective foot orthotics function by maintaining the rear foot in a biomechanically neutral position to prevent abnormal motion in the rear foot during gait. Orthotics also support the metatarsal joint and disperse abnormal pressure off the plantar fascia. By reducing this stress the chronic inflammation should subside in the majority of cases.Based upon the information set forth above, I have determined that the requested equipment is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 50-year-old man with mandibular hypoplasia. The treating oral surgeon indicates there is no functional contact of the anterior dentition and therefore, a satisfactory result for correction cannot be obtained by orthodontic treatment. The submitted materials include the following measurements: overjet-6mm and overbite 5-6mm. A request has been made for bilateral ramus osteotomies. The Health Plan indicates that the requested procedure is not medically indicated. While the information submitted by the patients surgeon indicates a significant dental occlusal discrepancy, this alone does not constitute a health or medical problem. Many people are tolerant of this type of dental malocclusion. No disability or discomfort has been documented by the patients providers. Given the absence of documented symptomatology resulting from the malocclusion, the requested procedure is not medically indicated. 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 56-year-old woman with a diagnosis of polyneuropathy. She is seeking authorization for a POV to utilize inside her home. It appears that she already has a POV for utilization outside her home. The evidence submitted does not demonstrate that the patient cannot functionally ambulate inside her home or that she cannot utilize a manual wheelchair inside the home.The patient does not meet nationally accepted criteria for authorization of the requested equipment. As set forth above, there is no evidence that the patient cannot functionally ambulate inside her home or that she cannot operate a manual chair within her home. In addition, there is no evidence demonstrating that the patients home cannot accommodate a manual wheelchair. For these reasons, I have determined that the requested equipment 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 47-year-old man with a history of exotropia/phoria. The patient underwent cataract surgery. In addition, he underwent treatment with Botox injections. There is a high incidence of exotropia in muscular dystrophy, which tends to worsen with time. The patient has requested authorization for Lasik surgery. The Health Plan has denied the patients request on the basis that Lasik surgery is not medically indicated.It is likely that after the patients left eye cataract surgery in 1994, his right eye vision slowly faded. An eye with poor vision is not utilized and tends to drift. It appears that the phoria progressed to a trophia. Following cataract surgery in his right eye in 1996, the patients vision was clear but the exotropia is so large he cannot maintain fusion. If the patients exotropia is to be relieved, surgery will be needed. Lasik surgery to correct the small amount of anisometropia is unlikely to improve the situation. It is only .75 or 1.00 diopter. The patients provider has indicated it is not large enough to account for the patients symptoms. Furthermore, Lasik surgery is not without risk. One of the common problems is dry eye, which the patient is already experiencing. Thus, the requested procedure may actually aggravate his condition and is not likely to result in significant improvement of his vision.Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is an 18-year-old obese female with low exercise participation. The patients physician has prescribed Zetia for this patient with cholesterol of 252 and LDL of 145. It does not appear that the patient has primary relatives with premature coronary artery disease. The Health Plan has denied authorization for Zetia indicating that it is not medically indicated for treatment of the patients condition.The Health Plans denial is medically appropriate. There are no recommendations for cholesterol lowering agents for anyone under the age of 35, especially females, with a lipid profile in the range the patient has (LDL less than 190). In addition, the submitted information does not demonstrate that the patient has a family history of a first degree relative with premature coronary artery disease. Furthermore, no other risk factors are noted. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 64-year-old woman with early progression following carboplatin and Rituxan for adenocarcinoma of the lung. The patient has not undergone treatment with Taxotere. The patient has begun salvage treatment with Iressa. The Health Plan has denied authorization for Iressa indicating that it would be considered a second-line therapy and not medically necessary.Iressa is a standard second-line therapy for non-small-cell lung carcinoma. There is no medical evidence to indicate that Iressa is not medically justified and should be withheld from the patient. Iressa has a better risk-benefit profile and should result in better patient compliance and quality of life. Furthermore, if the patient undergoes a trial of Taxotere followed by failure, she will be in a much less favorable condition to benefit from Iressa. As such, 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 57-year-old woman with osteopenia of the spine without vertebral or other fractures. The patient has declined hormone replacement therapy. She has requested authorization for Miacalcin nasal spray. The patients request has been denied by the Health Plan on the basis that the requested medication is not medically necessary in the absence of a diagnosis of osteoporosis.Upon review of the submitted information there is no evidence that Miacalcin nasal spray is medically necessary. There is no evidence that the patient has a history of fracture; nor is there any indication of osteoporosis. Miacalcin is not indicated for prevention of osteoporosis. 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: Upheld Decision of Health Plan

The patient is a 53-year-old woman who has bilateral breast implants. A mammogram was performed in September 2002, which showed bilateral implants. There were also benign appearing calcifications in the left breast. The patient wishes to obtain a breast ultrasound instead of a mammogram. The Health Plan has denied the patients request indicating that a breast ultrasound is not medically indicated.It is true that there is a small risk of rupturing the implants with mammography, especially with older implants. However, ultrasound of the breast has never been considered a primary screening method. Ultrasound has been used in addition to mammography to evaluate a specific finding or to further evaluate breasts with dense tissue. Currently, breast ultrasound as a screening exam is under evaluation. Ultrasound cannot evaluate microcalcifications, which may be an indication of malignancy. Current scientific literature indicates that if screening sonography is to be used, it should be considered a supplement to screening mammography; a woman should not forgo mammography. Ultrasound is not a substitute for mammography and therefore, is not medically necessary at this time. Ultrasound may be indicated in the future, depending on the physical exam and mammogram findings. Based upon the information set forth above, 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: Overturned Decision of Health Plan

The patient is a 56-year-old male with hypertension, dyslipidema, and coronary artery disease (CAD). The submitted information indicates the patient has been successfully treated with Zocor (a statin) and Zetia for his dyslipidemia and coronary artery disease. Several years earlier the patient had been treated with Lipitor, which was discontinued because of joint and muscle pains. The Health Plan has denied coverage for Zocor indicating that no evidence has been provided that the patient has been unsuccessfully treated with two formulary statins. Current guidelines for the treatment of coronary artery disease include treatment of serum LDL to levels less than 100. In multiple clinical trials, statin therapy has been demonstrated to reduce the incidence of cardiac events in individuals with established coronary artery disease. Continued use of Zocor is medically appropriate in this case because the patient has achieved therapeutic goals while on Zocor. Furthermore, the patient has avoided previous statin associated side effects. Thus, use of Zocor is medically indicated given the patients clinical history.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.