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

The patient is a 22-year-old female with long-standing bulimia nervosa.  Her restrictive eating patterns began at age 12, and at the time of referral to residential treatment she was given to restricting her intake to about 600 calories. The patient reported purging after eating breakfast, restricting throughout the day, and then eating dinner and purging afterwards. She noted a fear of weight gain and strong dislike of herself. She also noted acceleration in her eating disorder accompanied by significant guilt and depression secondary to an abortion she had about a year and a half earlier.  The patients depression had previously been treated with Lexapro, Effexor-XR, and Zoloft but she reported little benefit from the medications. When referred to residential treatment in August 2004, the patient was not actively involved in psychiatric treatment and was not receiving any medications. During residential treatment, the patient was assessed as significantly depressed and she received no antidepressants. At admission, she rated her depression as 3/10 in contrast to much stronger depressive feelings in the year 2003, when she rated her depression as 9/10. She also noted that she liked herself better than she used to and felt better, in part, due to a new set of friends at work. Residential treatment included a variety of therapies and she was initially noted to have made good progress but later she grew wary of any further weight gain. All of the formal psychiatric evaluations describe the patient as attentive, affectively unremarkable, speech conversational and kinetics unremarkable. Her insight into her eating disorder was judged as modest to fairly good. The patient did not engage in purging while in the residential program.  The Health Plan denied authorization for the residential treatment admission and continued stay based upon their determination that it was not medically necessary.While the patient unquestionably suffered from bulimia nervosa, there is no evidence she was involved in any particular outpatient psychiatric treatment program prior to the referral for residential treatment. She was working about 30 hours per week and was not notably underweight. She was noted to be highly motivated to participate in treatment and she was relatively unencumbered by depressive symptoms. It is unclear why a concerted course of outpatient treatment was not recommended. Treatment options may have included an intensive outpatient program (IOP) or a partial hospitalization program. If programs such as these had failed, a referral to residential treatment would have been a reasonable next step. In this situation however, the referral to residential treatment was premature. 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 41-year-old male with a body mass index (BMI) of 44. He also has significant comorbid conditions. He has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The Health Plan has denied coverage for gastric bypass surgery based upon their determination that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 44 and comorbid conditions such as hyperlipidemia and obstructive sleep apnea, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient 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 morbidly 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 morbidly obese.  Based upon the information set forth above, I have determined that the requested surgery 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 63-year-old female treated with non-steroidal anti-inflammatory drugs (NSAIDs), but her knee condition has continued to worsen. The patient does not wish to pursue conservative treatment of her osteoarthritis and wishes to proceed with total knee replacement.  The Health Plan has denied coverage for this procedure on the basis it is not medically necessary for treatment of the patients condition.Standard of care for treatment of osteoarthritis of the knee calls for a trial of physical therapy and NSAIDs prior to total knee replacement.  There is not sufficient justification for total knee replacement at this time. The patient may respond well to non-operative measures. Based upon the information provided, there are conservative treatments available for this patient that should be considered prior to surgery. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 15-year-old female who has a history of depression, polysubstance abuse, cutting behavior, suicidal ideation, bulimic behavior, legal problems and parent-child relational problems. Apparently her drug use escalated and she was admitted to residential treatment in September 2004 with diagnoses of major depression, ADHD, parent child relational problems, and marijuana dependence. She had a GAF score of 40 and a diagnosis of bipolar disorder was also suggested. The patient continued to receive residential treatment services until March 2005 when she transitioned to a partial hospitalization program.  The Health Plan has denied reimbursement for the admission to residential treatment and the services provided from September 2004 through March 2005 based upon their determination that neither the admission nor the continued stay were medically necessary.Upon review of the submitted clinical evidence, residential treatment was medically indicated because it is unlikely that a less intense level of care would have been adequate or appropriate given the state of the patients drug use and parent-child relational problems. Although the patients admission to residential treatment was justified, she was sufficiently stable by January 2005 to warrant treatment at a lower level of care. The submitted medical and nursing notes do not justify residential treatment services beyond 2004. Significant progress in addressing the patients issues had been made by years end. Although treatment at the residential level was continued until March 2005, the patient no longer met medically necessary criteria for this level of care. Therefore, I have determined the services provided from September 2004 though December 2004 were medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a five-year-old male diagnosed with autism in November 2004. He has been receiving speech therapy once per week since March 2005. Therapy has focused on repeating 7-word sentences, wh sentences, he/she/they sentences, past tense verbs, his/hers/theirs, and other pronouns. The therapist reports modest gains in therapy. At issue is whether continued speech therapy is medically necessary.The speech therapists documentation of progress toward goals is sufficient evidence that the patient is progressing. It is well documented in speech therapy texts and developmental pediatrics texts that improvement in speech therapy for a diagnosis of autism is measured in years rather than months. Thus, I find the progress shown in this patient and the expected improvements to be reasonable and predictable. 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. The patient should continue to receive speech therapy once weekly with re-evaluation in six months to verify ongoing improvement.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 34-year-old female with a very long-standing history of anorexia, beginning at age 14-15 years of age.  There are recurrent episodes of severe caloric restriction along the way. Her eating patterns hampered her completion of medical school and ultimately led to inpatient treatment in 1998.  After withdrawal from medical school the patient later attempted business school but, in spite of continued outpatient treatment, she suffered another relapse.  When admitted to residential treatment in January 2005, the patient only weighed 91.5 pounds (65% of her ideal body weight) and was diagnosed with generalized anxiety disorder (GAD), anorexia nervosa, mood disorder, and avoidant personality disorder. She reported restricting her daily calories to anywhere from 800 to 1,000 calories or simply having stopped eating while in MBA school. She also noted taking long walks for about an hour each day and suffering disrupted sleep. The admission physical exam revealed her to be frankly cachectic and bradycardic, and she had dystrophic nails, orthostatic hypotension and a sacral pressure ulcer. Her blood work revealed anemia (hemoglobin and hematocrit of 10.7 and 30.1 respectively), hyponatremic (sodium 129), and with elevated liver function tests. She was amenorrheic with her last period occurring two years prior. By February 2005, two months into treatment, her H/H had improved to 11.4/43.3 and sodium to 131. She was treated with a combination of psychotherapies, Risperdal, and Celexa, and felt to have gained sufficient weight by March 2005 to allow for discharge.The Health Plan has denied authorization for residential psychiatric treatment services provided from January 2005 through March 2005 based upon their determination that the services were not medically necessary.Based on the submitted documentation including the notes cited above, it is apparent that the patients illness was severe and did warrant residential treatment. For example, her admission physical exam reflected signs of frank starvation. Various psychiatric notes reflect the patients dysphoria and anxiety over properly gaining weight, and this appears quite consistent throughout all of the notes. Although the patient did eventually gain enough weight to allow for discharge, going from an admission weight of 91.5 pounds to a discharge weight of 104.2 pounds, she only achieved 78% of her ideal body weight. She was noted to express urges to restrict her calories and a continuing reluctance to gain more weight. That the patient did not gain an enormous amount of weight does not mean that the treatment afforded was not medically indicated; rather, it speaks to the severity of her illness. All told, I find that continued residential treatment from January 2005 through March 2005 was 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 73-year-old male with a history of neck pain. A cervical spine x-ray revealed small posterior spurs at C4-5 and C5-6 but was otherwise normal. The patient has requested authorization and coverage for a CT scan of the cervical spine. The Health Plan has denied this request on the basis that the patient does not meet medical necessity criteria for authorization of a CT scan.  Upon review of the submitted clinical information there is no clear medical indication for a CT scan of the neck. The patient requested a CT scan to identify the source of his neck pain. A CT scan is very unlikely to yield any information that will be useful in the management of the patients condition. Standard of care in this setting calls for a trial of physical therapy before embarking on a diagnostic imaging protocol. Therefore, I have determined the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 65-year-old female with leg heaviness and fatigue symptoms, who had sclerotherapy in 1990. The submitted clinical information indicates the patient had not used compression stockings to try to alleviate her symptoms. In 2004 the patient consulted a provider who recommended diagnostic evaluation and duplex-guided sclerotherapy. The Health Plan has denied reimbursement for these services on the basis they were not medically necessary for treatment of the patients condition.Though the patient reported non-specific symptoms of lower extremity fatigue and heaviness, there is no documentation the patient was experiencing chronic pain. In the absence of objective evidence of pain that is refractory to a three-month trial of conservative measures (e.g., stocking use, elevation, etc.), the services at issue were not medically warranted. Furthermore, duplex-guided sclerotherapy for primary treatment of greater saphenous vein reflux is not considered standard therapy for patients such as this patient. 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 33-year-old female with degenerative disc disease. She has had a positive discogram at L4-5 and L5-S1. She is status post laminectomy and discectomy at L4-5. Her provider is recommending two-level artificial disc replacement at levels L4-5 and L5-S1. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. There is no evidence supporting the safety and efficacy of a two-level disc replacement. Accordingly, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 33-year-old female with back pain. An MRI revealed disc protrusion at L4-5 and L5-S1 as well as degenerative changes at L3-4. Her physician has recommended multi-level artificial disc replacement at L4-5 and L5-S1. The Health Plan indicates the efficacy of artificial disc replacement has not been established.Artificial disc replacement has only recently been FDA approved. The procedure is of unproven efficacy. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time. Therefore, I have determined the requested procedure 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 33-year-old female who has degenerative disc disease at L4-5 and L5-S1. Conservative treatment modalities have not been effective. Her physician has recommended two-level artificial disc replacement surgery. The Health Plan has denied authorization for the requested procedure citing the lack of proven efficacy.Artificial disc replacement is experimental without established long-term safety and efficacy, particularly when a multi-level procedure is involved. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 64-year-old male with end-stage renal disease and myelofibrosis with a difficult to control anemia. His anemia was most likely related both to end stage renal disease and myelofibrosis. The patient has been maintained on dosages of Procrit in the range of 60,000 units three times a week. In addition, the patient received 150 mcg of Aranesp per week. A request has been made for reimbursement for dosages of Procrit in excess of 60,000 units per week and dosages of Aranesp in excess of .45 mcg/kg per week that were received while the patient was traveling abroad. The Health Plan has denied this request indicating that the dosages the patient received exceeded the recommended amounts and therefore, were not medically necessary.The patients nephrologist indicates the patient has responded only to large doses of erythropoietin (Procrit). As such, it was quite reasonable to continue to treat him with increased dosages of Procrit while he was out of the country. However, there is no justification in the submitted materials for the increased dosage of Aranesp the patient received while in Germany. There is no evidence that increased dosages of Aranesp are any more effective than the recommended dosage. Furthermore, it is not clear that combining Aranesp and Procrit is beneficial. As such, the increased Aranesp dosages were not medically necessary for this patient.Based upon the information set forth above, I have determined that although the increased dosages of Procrit were medically necessary for treatment of your medical condition, the increased dosages of Aranesp were not medically necessary for treatment of your medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 50-year-old female with a two-year history of back pain. She has degenerative disc disease at L2-3, L3-4, L4-5 and L5-S1 and is status post percutaneous disc decompression at L3-4 and L4-5. The patients provider has recommended a single level artificial disc replacement at L5-S1. The Health Plan has denied this request on the basis that artificial disc replacement remains experimental.Artificial disc replacement remains an unproven procedure at this time. Long-term results are unknown and the procedures risks, long-term viability, and complications are unclear. Though a small study has been completed and short-term results are favorable, further studies and results are needed. As such, the procedure cannot be recommended at this time. Therefore, I have determined the requested procedure 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 50-year-old female with multi-level degenerative disc disease. Her provider is recommending artificial disc replacement at L5-S1. The Health Plan considers this procedure experimental and therefore, has denied authorization and coverage.The Health Plan is correct that the proposed procedure is considered experimental. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Therefore, I have determined the requested procedure 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 50-year-old woman who has degenerative disc disease at L2-3, L3-4, L4-5 and L5-S1. She has attempted conservative measures without sustained relief of her back pain. In May 2005, she underwent percutaneous disc decompression at L3-4 and L4-5. She has now requested authorization for artificial disc replacement at L5-S1. The Health Plan has denied authorization for the requested procedure citing the lack of proven efficacy.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 38-year-old male who sustained a fall in July 2005 with resultant bilateral calcaneal/lumbar fracture. He was hospitalized then transferred to skilled nursing care in August 2005. Once there, he received extensive physical and occupational therapy. The patient was ultimately discharged in December 2005. The Health Plan denied coverage for skilled nursing facility services as of October 2005 on the basis that continued services were not medically necessary.Review of the submitted medical documentation indicates the patient no longer required a level of skilled care services as of October 2005. He was stable for outpatient physical therapy at that time. He no longer required wound care after September 2005. The physical therapy notes state the patient completed his initial goals as of September 2005 and was re-evaluated on October 2005 with new goals established including improved transfer, increased balance and increased gait capacity. A physical therapy notation from October 2005 indicates the patient had made significant progress in all balance and functional mobility activities. He was described as independent of gait throughout and continued to fatigue quickly with steps. The patient was medically stable and able to perform all transfers, toileting and showers independently. As such, continued skilled nursing facility services were not medically necessary or indicated as of October 2005. Based upon the information set forth above, 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.