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

The patient is a 48-year-old female and has a well-known complication of myocardial infarction - a left ventricular aneurysm. She meets criteria for surgical intervention. The patient and her provider have requested coverage for a referral to out-of-network surgeon on the basis that he is uniquely qualified to evaluate the patient.It appears the patient has a left ventricular aneurysm with CHF and would probably benefit from surgical resection. This is a relatively common cardiac problem that can be appropriately treated by most cardiac surgeons. All cardiac surgeons are trained in this area of cardiac surgery. A consultation with an in-network cardiac surgeon is medically reasonable and appropriate for further evaluation of the patients condition. If the surgeon believes the patient is an appropriate candidate for a heart transplant, an appropriate referral can be made at that time. As such, I have determined the requested consultation is not medically necessary for evaluation and 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 49-year-old female with migraine headaches. The records from her neurologist dated February 2006 indicate a change in frequency from two headaches per month to four headaches per month.  He prescribed Imitrex nasal spray and injectable Imitrex. There are no additional notes regarding a previous failure of oral triptans or her response to this treatment plan. It is unclear if the patient has had any ongoing follow-up with the specialist.  The patient has requested authorization for 10 Imitrex injections per month.  The Health Plan determined the requested quantity of medication is not medically necessary, and denied her request.The records provided for review document that the patient has migraine headaches and that these headaches respond to Imitrex injections. However, the records indicate the migraines occur four times per month, and the evidence does not support the need for 10 Imitrex injections per month. Therefore, a request for 10 Imitrex injections to treat four migraines per month is not medically necessary.  If the frequency of the patients migraines should increase substantially, preventative therapy and a trial of oral or nasal triptans would be recommended.Based upon the information set forth above, I have determined the requested quantity of 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 41-year-old male with a past medical history of anemia who was admitted through the emergency department of a hospital in October 2005. He presented status post syncopal episode with vomiting, diaphoresis and loss of consciousness. Previously, there was no evidence of seizure activity. The patient had apparent seizure activity in the ER. The patient was admitted and evaluated by gastroenterology/hematology. Endoscopy revealed deformity in the pyloric area and no active bleeding at site. A colonoscopy was negative for active bleeding. The patient also underwent a bone marrow biopsy. He received blood transfusion/IV. The patient was discharged from the hospital in October 2005. At issue in this case is whether continued hospitalization was medically necessary as of October 2005.There was no documentation provided necessitating inpatient hospitalization as of October 2005. The GI evaluation (endoscopy/colonoscopy) was completed by October 2005. No active bleeding site was identified and transfusion had been completed and the patient was hemodynamically stable. No neurology evaluation was conducted regarding the seizures. The patient underwent bone marrow aspirate for issues related to his chronic anemia. Based on the evaluations provided for review, the patient was medically stable, and appropriate for discharge in October 2005. There was a history of alcoholism but there was no requested treatment or clinical evidence of withdrawal. A full workup of the patients presenting symptoms was completed by October 2005.  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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee has requested authorization and coverage for gastric bypass surgery. The patient has a body mass index (BMI) of 46. His comorbidities include hyperlipidemia, degenerative disc disease, bladder incontinence, diabetes mellitus, sleep apnea, and depression. He has requested authorization for gastric bypass surgery. The Health Plan states the patient needs to obtain psychological clearance and undergo nutritional counseling before weight loss surgery can be authorizedWith a BMI of 46 and comorbid conditions, the patient is likely to benefit from gastric bypass surgery. He does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese. However, the patient has not yet obtained psychological clearance for weight loss surgery. Therefore, gastric bypass surgery is not medically indicated at this time. The patient should receive another psychological evaluation in six months to determine if he is an appropriate candidate for weight loss surgery. If he is considered an appropriate candidate at that time, then the requested surgery should be authorized.Based upon the information set forth above, I have determined the requested surgery is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. The patient should undergo another psychological evaluation in six months.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 55-year-old man with knee pain secondary to arthritis. He has been treated with Synvisc injections over the past two years and has found them to be beneficial. The patients provider has requested authorization for a repeat series of Synvisc injections. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.The patient is relatively young and has severe arthritis in his right knee.  Although he will eventually require knee replacement, the requested treatment with Synvisc may effectively delay the eventuality. The last series of injections was performed more than one year ago and resulted in significant pain relief and improved functionality. A repeat series of Synvisc injections is appropriate at this time to alleviate his pain and to postpone surgical intervention. 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 48-year-old female with back pain and major depression with associated fatigue. She is under the care of a pain management specialist. She has been treated with multiple medications including Prozac, Cymbalta and Provigil. The patient reports that Provigil has been very effective in relieving her pain, depression and fatigue and therefore she has requested authorization and coverage for the drug. The Health Plan has denied this request on the basis that Provigil is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Provigil is not generally utilized as a first-line agent in the management of major depression and its associated somatic complaints. Such use does not fall within the FDA-approved indications for the drug. Although the patient indicates she has been tried on multiple anti-depressants in the past, no objective evidence of the patients previous regimens or her response to these medications has been provided. Furthermore, there are no peer-reviewed studies advocating the use of Provigil for the treatment of fibromyalgia. While a few small studies showed a short-term positive effect, no long-term outcome data is available. 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: Overturned Decision of Health Plan

The patient is a 52-year-old man with a five-year history of chronic inflammatory demyelinating polyneuropathy (CIDP), treated successfully with intravenous immunoglobulin (IVIG) therapy. When IVIG treatment is delayed he becomes unable to ambulate independently. He was reported to have polymyositis and a history of melanoma. He is under the care of a neuromuscular specialist. The submitted records indicate the patients status worsened after IVIG was discontinued so he has resumed the therapy.At issue is whether IVIG therapy is medically necessary for treatment of the patients medical condition.The patient has been diagnosed with CIDP by a neuromuscular specialist. He has been successfully treated with IVIG for almost five years, which has allowed him to continue working. The medical literature supports the use of IVIG as first-line therapy for CIDP. This view is also widely held by members of the neurological community. Since IVIG is viewed as the standard of care in this clinical setting and no alterative therapy has been proposed, the patients previous and continued use of IVIG therapy is medically appropriate and indicated. Therefore, I have determined the therapy at issue was/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 37-year-old female with symptomatic internal derangement of both temporomandibular joints as confirmed by a December 2005 MRI. The patients symptoms include pain, locking, crepitation and diminished range of motion. Her attending surgeon indicates that the use of conservative measures such as NSAIDs, dental occlusional splints and soft diet have not been effective in reducing pain or improving function. Surgical intervention has been recommended. At issue is whether the proposed surgical procedures are medically necessary.The patient has symptomatic bilateral internal derangement of both temporomandibular joints with no resolution of her medical problem by non-surgical methods. Arthrocentesis of the joints with lavage and hydrodistention has been shown to be an effective treatment for this problem. As such, the requested procedures are medically indicated medical/surgical treatment in this case. The proposed treatment plan meets the standard of care within the medical community. Therefore, I have determined the requested procedures are 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 46-year-old male with a history of substance abuse and depression. In June 2005 the patient was admitted to a partial hospitalization program. A patient assessment completed on admission indicated that his mother and father were supportive; that he had a marked weight loss; that he was binging on cocaine on a daily basis (up to $200-300/day); that he was isolating himself; that he was motivated for treatment; that he was sad, irritable and angry, and that he was just getting settled into a Sober Living house with several other men. The submitted chart notes reflect the following. A psychiatric evaluation performed in June 2005 noted a prior history of major depressive disorder characterized by depressed mood, anhedonia, insomnia, suicidal ideation and hopelessness even when sober. Current symptoms included some hopelessness, isolation and worthlessness (at times), but no suicidal ideation. A mental status evaluation was positive for a depressed mood, but revealed normal psychomotor function, orientation and memory. No dangerousness or suicidal or homicidal ideation was noted. A history of job changes was noted. A diagnosis of depression - not otherwise specified was given along with cocaine dependence and a possible cocaine-induced mood disorder. At issue is whether the partial hospitalization services were medically necessary.A detailed review of the submitted treatment records does not demonstrate the services at issue were medically necessary. There is an absence of any evidence of any suicidal or homicidal ideation or activity prior to or at the time of admission or at any time during the treatment. In addition, the patient had supportive parents and also his own motivation for services. The patient had a supportive living environment that specifically was designed as a Sober Living home. The patients illness did not manifest a level of severity of illness that met nationally recognized guidelines for partial hospitalization. It is recognized that this patient has a co-occurring disorder, which is a very frequent finding among individuals presenting for treatment of depression. While he initially presented with concerns over his cocaine abuse, the inter-relationship with his depression is significant and the approach to both issues concurrently is consistent with current best practices. However, such treatment could have been provided at a less intensive level of care. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old male who presented to his urologist in April 2003 with a one-year history of difficulty obtaining a full penile erection and of maintaining an erection, along with decreased libido. He was treated with Viagra and in August 2004 reported that it caused heartburn and was only effective half the time it was used. In October 2004 the patient underwent a urology consultation. The patient obtained a less than 50% erection with intracavernosal injection and this was reported to be about the same type of reaction that he achieves with Cialis. Sonography of the penile artery demonstrated a small right arterial inflow with crossover to the left and no distal flow past the crossed over site. The patient was diagnosed with erectile dysfunction most likely due to poor arterial inflow. His provider recommended treatment with Cialis and that he be evaluated for potential hypercholesterolemia. In March 2005 the patient was reported to be doing well with Cialis and wished to continue treatment with the medication. The Health Plan has denied authorization for Cialis on the basis that it is not medically necessary for treatment of the patients condition.The patient has erectile dysfunction, the causation of which has been determined sonographically to be penile arterial disease. The patients condition has responded satisfactorily to treatment with oral Cialis, having failed treatment with Viagra and Levitra. The patient meets medical necessity criteria for authorization of Cialis. Continued use of the drug is medically reasonable and appropriate and should be authorized. Therefore, I have determined 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 56 year old male that underwent surgical closure of a skin cancer defect in January 2006. He requested a scar revision almost immediately following surgery.  Photographs dated May 2006 show a well-healed flap with obliteration of the upper part of the nasojugal fold. At issue is whether surgical scar revision is medically necessary for treatment of the patients condition.Scar revision is not medically necessary for this patient.  His flap has healed well and the records do not document any problems with infection, pain or persistent edema. The submitted photographs show a healed flap without significant scarring or edema. The nasojugal fold is indistinct in the area of the flap, but the patient is only five-months postoperative, and this contour may improve in time.  Most plastic surgeons recommend a waiting period of one-year prior to performing scar revision to allow all inflammation to resolve. The aesthetic result of this patients reconstruction is already quite good and should improve over the next several months.  There is no evidence the reconstruction is causing any functional problems. Accordingly, 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: Overturned Decision of Health Plan

The patient is a 55-year-old male with hepatitis C, genotype 1.  He received four months of treatment with pegylated formula interferon and ribavirin, and subsequently relapsed after the treatment was completed. The patients provider has requested authorization for further treatment with Infergen. The Health Plan denied authorization based upon a determination that the therapy is not medically necessary.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 received the pegylated formulation treatment for four months, and has now relapsed as demonstrated by a viral load of 1,370,000 IU/ml. At this point, it is reasonable to proceed with Infergen therapy.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 21-year-old male who underwent an ACL reconstruction. Postoperatively he utilized a CPM device as prescribed by his orthopedic surgeon.  He is requesting reimbursement for the rental cost of the device. The Health Plan denied coverage based upon their determination that the CPM device was not medically necessary following the patients surgery. A CPM device is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. Patient compliance appears to be high and many surgeons find that patients regain their range of motion faster and have better pain control with the device.  The orthopedic community has recognized the benefit of early range of motion following this type of surgery and the use of the device postoperatively is medically appropriate. Therefore, I have determined the device at issue was 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 58-year-old female with pancreatic cancer. The records include two abdominal CT scans (in May 2005 and in August 2005), which indicate a stable pattern of pancreatic tumor extending around the bile duct and surrounding adjacent arteries.  There is no CT evidence of peritoneal metastases and the Health Plan noted that the patients tumor marker, CA-9-19, shows there has been a response to chemotherapy. The remainder of the record consists of two procedural notes regarding placement and removal of a portacath and seven brief notes regarding chemotherapy administration. There is also a letter from the patients provider that indicates the enrollee has biopsy proven unresectable pancreatic cancer with peritoneal carcinomatosis. The provider only wants to continue the current treatment if it is shown to be effective.  He has requested authorization for a PET scan to determine if the current chemotherapy has been effective. The Health Plan denied the request based upon a determination that the diagnostic procedure is not medically necessary.F18-FDG PET has been used for a number of years to study pancreatic cancer for diagnosis, staging, restaging and response to therapy. Overall the specificity is good and sensitivity is in the 85% to 90% range based on a summary of over 950 patient studies published in the Journal of Nuclear Medicine.  For this patient, PET will provide an opportunity to determine if the glucose metabolism of the tumor (SUV) is low or absent consistent with a therapeutic response, or if an alternate therapy should be considered.  It is the current practice in Oncology and Nuclear Medicine to use F18-FDG PET in this circumstance as it is considered state of the art medical practice. Therefore, I have determined the requested diagnostic procedure 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 episodic migraine headaches, which on occasion have been associated with unilateral weakness. She has been using DHE 45 1mg subcutaneously for treatment of her migraines. There is no aura associated with the headaches and the medication has generally been successful.  The patients request for authorization of DHE 45 was denied based upon the Health Plans determination that it is not medically necessary for treatment of her migraine headaches.A review of the medical record submitted indicates the consulting neurologist has made a diagnosis of hemiplegic migraine. DHE-45 is contraindicated in patients with hemiplegic migraine. There are other available therapies that are likely to be effective for treatment of this patients migraines. 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.