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

The patient is a 54-year-old female with a history of fibromyalgia and pain in her neck, right hip, feet, knees, hands and wrists.  She had land-based physical therapy in the past which did not help with symptom reduction. She also had cervical epidural steroid injections and subacromial injections with temporary relief of symptoms. Aquatic therapy was recommended by her provider in January 2005. The patient received aquatic physical therapy with therapeutic pool exercises in February 2005. A subsequent prescription for a pool exercises program dated July 2005 was also included in the record.  The patient has requested reimbursement for the aquatic therapy provided in February 2005 and prospective authorization for additional aquatic therapy.  The Health Plan has denied these requests based upon a determination that the therapy was/is not medically necessary.Although the patient has a chronic condition, she had not had much relief with traditional land-based physical therapy alone.  A trial of aquatic therapy was reasonable and consistent with Medicare guidelines and standards within the medical community. The aquatic therapy provided in February 2005 was medically necessary and should have also included a component of patient education.  Authorization for ongoing aquatic therapy is not medically necessary, as the patient should have been provided with the instruction necessary to continue her aquatic exercise program independently.Based upon the information set forth above, I have determined that although additional aquatic therapy is not medically necessary for treatment of the patients medical condition, the therapy provided in February 2005 was medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 46-year-old female who has undergone transanal excision of a rectal tumor.  She has completed postoperative chemotherapy and radiation therapy.  The patient is now one year out from her surgery and is due for a follow-up colonoscopy.  She has requested that the colonoscopy be performed by her out-of-network colo-rectal surgeon. The Health Plan denied her request based on a determination that it is not medically necessary that the out-of-network surgeon perform the procedure.There is no evidence in the record of any specific issue that would require the same surgeon that performed the patients surgery to also perform the surveillance colonoscopy. Any experienced colonoscopist can perform a routine surveillance colonoscopy. If a problem is encountered, reevaluation by the out-of-network surgeon should be authorized.   As discussed above, I have determined the requested provider 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 66-year-old male with prostatic symptoms. He reports to have had tried Cardura, Hytrin and to have had a laser prostatectomy yet remains symptomatic. He indicates he was given Avodart with improvement and wishes to obtain authorization and coverage for the medication. The Health Plan has denied the patients request on the basis that he must undergo a trial of alpha-blocker before being given an antiandrogen.The treatments for benign prostatic hypertrophy include: alpha-blockers such as Hytrin, Cardura and Uroxatral, antiandrogens such as Avodart and Proscar, and procedures such as transurethral resection of the prostate, laser prostatectomy, transurethral needle ablation (TUNA) or transurethral microwave therapy (TUMT).Avodart is a recognized and acceptable treatment for benign prostatic hypertrophy (BPH). It blocks the conversion of testosterone to dihydrotestosterone and results in shrinkage of the prostate. It takes a minimum of four to six months to see an effect.Alpha-blockers work immediately by relaxing the smooth muscle in the prostate.  Alpha-blockers are not medically equivalent to antiandrogens and are not a pharmacy substitution. Some patients improve with one type of medication and some with the other. In some cases patients are given both.The patient indicates he has already tried alpha-blockers without benefit. He has also had a laser prostatectomy so the tissue that Avodart works on, or that alpha-blockers affect, is typically gone. In theory, after a laser prostatectomy a transurethral resection is more likely to be effective in cases of BPH (90%) than either alpha-blockers or antiandrogens (50% to 60%). Nevertheless, it is appropriate that the patient be given an adequate trial of medication prior to further surgical intervention. Given the failure of alpha-blockers, the patients request for Avodart is medically reasonable and appropriate. 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 64-year-old male with a six-month history of weight loss, abdominal cramps and nausea. Colonoscopy, EGD, CT scan of the abdomen and pelvis and ultrasound have all been performed and the results were unremarkable. The patients stool cultures are negative and other laboratory work was also unremarkable. The patient has been treated with various medications including Zelnorm, creon, Beano and senna.  It appears from the providers notes that a small bowel follow through (SBFT) study is planned.  The patient is now requesting authorization for a capsule endoscopy.  His request was denied by the Health Plan based upon a determination that the diagnostic procedure is not medically necessary. The medical record provided does not support the use of capsule endoscopy.  Numerous diagnostic studies have already been performed, and it is not clear what diagnosis is being entertained by the patients provider or why a capsule endoscopy is specifically required. The patients request may require reconsideration pending the results of the SBFT.  Based upon the information set forth above, I have determined the requested procedure 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 71-year-old male who was diagnosed with localized prostate cancer. He consulted with a radiation oncologist within the Health Plan who recommended hormone therapy followed by external beam radiation treatment (EBRT). The patient then consulted a non-plan radiation oncologist who recommended proton beam radiation therapy.  The patient proceeded with proton beam radiation therapy and is now requesting reimbursement.  The Health Plan denied the request based upon a determination that the therapy was not medically necessary for the treatment of the patients prostate cancer.In general, proton beam therapy is more conformal than external beam radiation treatment. However, no randomized trials have been performed directly comparing proton beam to the Health Plans proposed EBRT.  As there is no clinical evidence that proton beam is more beneficial than the Health Plans proposed EBRT, 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 55-year-old male with bilateral knee pain from osteoarthritis. He was treated with a series of Synvisc injections in 2003 and a second in April 2005 with good results.  He is now requesting authorization for a third series of Synvisc injections to treat his knee pain. The Health Plan denied the request based upon a determination that the requested therapy is not medically necessary.The use of Synvisc for osteoarthritis is an established course of treatment. In some cases relief is provided for an extended period of time. In this case two years elapsed between the first and second series and six months between the second series and the request for the third series. A repeat series is reasonable for patients who get relief from the previous treatment.  In this case, the second series of Synvisc injections was helpful, and therefore a third and final series is appropriate to attempt to alleviate the patients pain. Accordingly, 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

This patient is a 44-year-old female with low back pain and muscle spasms. She is being treated with medications and facet blocks by a neurologist. The Health Plan indicates that the patient does not require neurology specialty care and can be appropriately treated by a pain management specialist. At issue is whether ongoing neurology specialty care is medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. This patients chronic low back pain would be more appropriately managed by a pain specialist with fellowship training in pain management and spinal blocks than by a neurologist. This is no clinical indication for neurologic care based on the information provided. The services offered by the Health Plan are medically reasonable and appropriate for this patient. Therefore, I have determined the requested specialty care 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

This patient is a 12-year-old male with a history of otitis media from ages three months to two-years requiring PE tube placement in March 1999. There is no documentation of effusion or hearing loss provided. The patient was seen for speech therapy from September 2004 through September 2005 for difficulty with /r/ in all positions. He had a previous evaluation in December 2002 that recommended speech therapy for similar problems. The enrollees mother is requesting reimbursement and continued authorization for speech therapy.  The Health Plan has denied this request based upon a determination that the therapy is not medically necessary.The September 2004 evaluation documents a loss of speech production of /r/ in all positions.  However, it does not show how significant the delays are. The September 2005 report documents that the patient can produce initial /r/ at the word and sentence level with 80% accuracy, which would be considered within a normal range. Medial and final /r/ are at a 60% level with cueing.  Based on the patients care and the duration of his inability to produce the /r/ sound, I would conclude that the problem is one of a developmental nature and not a medical one.  Additionally, I was unable to ascertain a correlation between the loss of /r/ in the patients speech production and the otitis media. The record did not include evidence of effusion or of a hearing loss. Therefore, I have determined the therapy at issue was/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 53-year-old female with back pain and a diagnosis of scoliosis and segmental somatic spinal dysfunction with her cervical and lumbar spine. She requests additional chiropractic care of six treatments over three months. The treating record reveals x-ray findings of scoliosis at her thoracic and lumbar spine. A review of the submitted records does not reveal a developed and practiced home program of concurrent self-care. The Health Plan has denied further chiropractic care recommending referral to a physical therapist. The patient finds the chiropractic care to be helpful and has requested reconsideration of her authorization request. At issue is whether the requested chiropractic services are medically necessary for treatment of the patients medical condition.The patients diagnosis is one that is treatable by both physical therapy and chiropractic. The patient has benefited from chiropractic and wishes to continue receiving treatments. The requested chiropractic care of six treatments over three months is medically reasonable and necessary for the patients diagnosis and her current status. It is also appropriate for the patient to receive concurrent physical therapy given her diagnosis. The treatment goals should be similar but the physical therapy sessions should focus on home program development. Based upon the information set forth above, I have determined the requested services are 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 59-year-old female with large pendulous breasts that are symptomatic for back and shoulder pain. She underwent subpectoral augmentation mammaplasty over twenty years prior. The patient was evaluated by the Health Plans plastic surgeon who subsequently sought authorization for a bilateral reduction mammaplasty and extraction of the intact mammary implants. In January 2006, the patient indicated she is only seeking authorization and coverage for a mammaplasty. The Health Plan has denied the requested surgery based upon a determination that it is not medically necessary.Review of the submitted documentation including the patients letters, the plastic surgery consultation note, and photocopies of photographs of the patient demonstrate the requested mammaplasty is medically necessary. The photographic evidence demonstrates the apparent weightiness of the breasts and shoulder grooving caused by the digging in of the bra straps attempting to support the excess tissue. These findings, along with the patients complaints of back and shoulder pain, necessitate a reduction mammaplasty. Therefore, I have determined the requested surgery 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 15-year-old female with longstanding difficulties with self-mutilation, suicidal statements, distractibility, short attention span, restless and intrusive behavior, impulsivity, and excessive anger and aggression that was admitted to a residential treatment center in January 2005. She participated in a variety of therapies and was medically managed with Strattera, Seroquel, and Prozac with no apparent adjustment in medication dosages. The facility records indicate the patient was initially quite hostile and aggressive. For example, in February 2005 she and another resident left the facility AWOL and thereafter she was combative with staff, attempting to hit them with a metal bar. At other times, she was described as agitated and disrespectful to staff. Her behavior and demeanor seemed to improve during March and early April 2005, but the improvement was not sustained.  In April 2005 it was noted that she was very agitated and disrespectful to staff during class. She is still not completing her schoolwork. She has made threats to show staff how bad she can really be, making more threatening statements to peers, continues to sneak things into her room. Therapist reports that she is very hateful and even made threatening statements to therapist. In April 2005, she was described as agitated and volatile, giving the impression that she is on the verge of physical aggression. Unmotivated and fairly unworkable at this time.  The patients parents dispute the Health Plans denial of coverage due to a lack of medical necessity, and have requested reimbursement for the treatment interim from March 2005 through May 2005.The patient has a longstanding history of aggressive and impulsive behavior. The staff notes through April 2005 point to a continuance of those behaviors. The patient stating that she is doing well, is not particularly compelling and doubtfully ought to be taken at face value. Clearly, her sense of how she is faring is not consonant with the staffs perspective. Considering the context of her persistent aggressiveness as documented in the submitted treatment notes, continued residential treatment was indicated through May 2005. All told, I have determined the services at issue were 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 41-year-old female with a history of past addictions to benzodiazepines and opiates. She apparently was subsequently prescribed narcotics for pain associated with a diagnosis of multiple sclerosis and became addicted to Vicodin. Her physician prescribed Suboxone to gradually withdraw the patient from Vicodin. It appears the patient left his care prior to completion of the planned treatment. A urine drug screen in October 2005 was clear. The Health Plan indicates Suboxone was not medically necessary for treatment of the patients medical condition and therefore has denied reimbursement for the drug.The submitted records indicate Suboxone was prescribed to gradually wean the patient off of opiates. Apparently the patient continued to get prescriptions for benzodiazepines but no opiates during the Suboxone taper. Based on the records provided, it appears the patient was compliant with the prescribed treatment as Suboxone was last filled in October 2005. A hydroxyzine prescription was filled in November 2005. No opiate prescription was filled during treatment with Suboxone. As such, the medication at issue was medically appropriate and indicated for treatment of the patients opiate dependence. Accordingly, 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 20-year-old female who states that she has been ill since age 12 with symptoms that include low grade fevers, headaches, lightheadedness, dizziness, night sweats, sore throat, swollen glands, stiff neck, right-sided weakness (knees, hip) heart palpitations, nausea, poor sleep, poor concentration and memory loss, back pain and jaw pain.  From the records provided by her treating physician it appears she received IV Rocephin from July 2005 through October 2005.  In late August 2005 the record indicates that her percutaneously inserted central catheter (PICC) was removed due to an intravenous line infection.   Records from mid September 2005 note her drug therapy regimen and remark that she had diarrhea while on Augmentin. Notes from late September indicate that she had headaches, that her fever had declined and that she had a pituitary microadenoma.  When the patient was seen in October 2005, a positive Lyme serology and treatment with Rocephin were documented. Laboratory tests provided for review included abnormal liver function tests [AST, ALT] and an elevated serum potassium (5.9 mEq/L) on 9/27/05.  In November 2004 the Lyme IgG Western Blot is negative and the IgM is positive. The patient requested continued authorization and coverage for IV Rocephin, which was denied by the Health Plan based upon a determination that the IV antibiotics were not medically necessary.The patient has already received at least three months of treatment with IV Rocephin. This greatly exceeds the recommended therapy for any form of Lyme disease. Additionally, the evidence provided does not support a diagnosis of Lyme disease. The Centers For Disease Control approach (screening test followed by Western Blot studies) remains the accepted route to a serological confirmation of Lyme disease.  In this case, there was a positive IgM Western Blot in the face of a negative IgG Western Blot. Given the lack of any clinical evidence of acute Lyme disease in prior months, this is most likely a false positive result, as the IgM is often falsely positive.In this case, the diagnosis of Lyme disease has not been substantiated.  Even if there was good evidence of Lyme disease, there is no support for treatment with IV antibiotics for a period of over 30 days. Therefore, 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 an 82-year-old female who sustained a right hip fracture in February 2004 and a left hip fracture in April 2004. The patient was admitted to a skilled nursing facility (SNF) in May 2004. She began physical and occupational therapy in that same month. She progressed steadily with therapy. Physical and occupational therapy were discontinued in June 2004. The patient was discharged from the SNF later that same month. At issue is whether continued skilled nursing facility services were medically necessary as of June 2004.  Based on the records provided, the patient had not reached a plateau as of June 2004. She could not safely be discharged to home as of that date. The clinical evidence demonstrates that as of June 2004 the patient was progressing with therapy and there was an expectation she would continue to progress with additional therapy. The patient did not reach a plateau or near plateau until mid-June 2004. As such, the SNF services the patient received were medically appropriate and indicated through mid-June 2004.Based upon the information set forth above, I have determined the services at issue were medically necessary for treatment of the patients medical condition through mid-June 2004. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 61-year-old male who has had multiple anorectal surgical procedures. He now suffers from levator ani muscle spasm, and his surgeon has recommended biofeedback and electrical stimulation of the pelvic muscles to treat the condition.  The Health Plan has denied authorization for the therapies based upon a determination that they are not medically necessary.Biofeedback for levator spasm has been shown to be effective in multiple studies in the colorectal literature. The surgical text reference submitted by the patient is one of many sources that support its efficacy. While biofeedback is considered ineffective for many other conditions, it has been shown to be very effective for pelvic floor and anorectal pathology. As the alternative medical therapies are limited to long-term narcotics, sedatives or muscle relaxants (which are not nearly as effective) biofeedback and electrical muscle stimulation are perfectly appropriate therapies in this clinical situation.Based upon the information set forth above, I have determined the requested therapies are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.