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

The patient is a 64-year-old female who requested authorization for Provigil.  She has had transient ischemic attacks (TIAs) occurring over the past two years, fatigue and excessive daytime sleepiness.  Her provider has diagnosed circadian rhythm disorder, as the patient is unable to remain awake during the day.  A one-month trial of Provigil appeared to be effective in relieving her excessive daytime sleepiness and fatigue.  The Provigil was used in conjunction with the sleep aid medication, Ambien. The patients daughter stated the medication improved the patients quality of life. Based on the one-month trial, the patients provider has prescribed Provigil 200mg day.  The Health Plan has denied authorization for Provigil as not medically necessary for the treatment of the patients daytime sleepiness.The patient has a history of TIAs and has been diagnosed with circadian rhythm disorder apparently because she has developed unexplained fatigue and excessive daytime sleepiness. It is not clear if or why her TIAs should be the cause of her symptoms. Although the one-month trial of Provigil was effective in relieving the patients symptoms, the Provigil was used in conjunction with Ambien.   The patient should be more thoroughly evaluated in an effort to identify the cause of her hypersomnia.  There has been no polysomnography to defend or refute the current diagnosis, and obstructive sleep apnea should be ruled out. Additionally, it is not clear why Ambien would be prescribed along with Provigil. Perhaps the patients fatigue and excessive daytime sleepiness are treatment related, and due to her medications. If, after further workup, there is objective evidence indicating a need for treatment with Provigil, the patients request should be reconsidered.  Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 69-year-old male patient is requesting treatment with a PDE-5 inhibiting medication, specifically Cialis, for erectile dysfunction.  This medication has been effective for him when prescribed earlier.  His provider has diagnosed him with impotence of organic origin.  He also has a diagnosis of hyperlipidemia and treatment with lovastatin has been prescribed.  The Health Plan has denied coverage for Cialis on the basis that there is no recognized medical causation for the patients erectile dysfunction, and therefore, no medical necessity for Cialis.Review of the submitted evidence indicates this patient does have an organic basis for his erectile dysfunction, specifically vascular disease with documented hyperlipidemia. Treatment with PDE-5 inhibitor medications such as Cialis is accepted primary therapy for erectile dysfunction and is often successful. In fact, the patient has experienced benefit from Cialis in the past. 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: Overturned Decision of Health Plan

The patient is a 39-year-old female who has had low back pain for over a year with intermittent episodes of left leg radicular pain.  An MRI of the lumbar spine performed in October 2004 showed grade I spondylolisthesis at L5-S1 and a bulging disc at L4-5. The patient was recently seen by an orthopedic surgeon for acute exacerbation of her left leg pain and numbness and was started on medication as of September 2005. An MRI was ordered at that time, but authorization was denied by the Health Plan. The patient had no improvement and saw her provider again in October 2005, at which time they discussed surgical intervention. The patient indicated she was unable to do much physiotherapy due to her pain and discomfort. Authorization for an MRI was requested again and denied. At issue in this case is whether an MRI of the lumbar spine is medically necessary.In general most back pain is treated with medication and physical therapy with no need for imaging. The submitted records are not clear about how much physical therapy the patient has participated in. However, this patient is beyond the status of uncomplicated back pain. She has a documented alignment abnormality of her lumbar spine and experiences intermittent episodes of radicular pain. With this new acute exacerbation of her leg pain, she has been evaluated by a specialist, had a trial of medication, and is now a possible candidate for surgery.  The requested MRI is required to identify any changes from the prior MRI and to assess the patients current condition.  It is also a critical component in the surgeons evaluation.  Based upon the information set forth above, 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 13-year-old female who is reported to have Lyme disease and babesiosis. Treatment notes from February 2005 indicate the patients joint pain and fatigue were improved and a note from June 2005 states that babesiosis was resolved. Laboratory results from June 2005 were negative for IgM and IgG antibodies for Babesia microti. Findings from August 2005 revealed a negative IgM and equivocal IgG [1:20] titer. In September 2005, it was noted there had been a relapse of the babesiosis. The patients provider has prescribed 250mg of Zithromax twice a day. The Health Plan has denied authorization and coverage for Zithromax on the basis it is not medically necessary for treatment of the patients condition.Review of the submitted clinical information reveals no evidence of symptoms consistent with babesiosis or of the high antibody titers usually seen with an acute infection. The patient only has a single modestly elevated IgG titer for Babesia microti. There is no evidence of a positive blood smear or PCR. This single value is not diagnostic of babesiosis. Virtually all those who study and write about Babesia note that testing should be performed in the setting of clinical evidence of babesia infection, and that single abnormal values need to be repeated. In this case, the one isolated value is at the borderline of significance and is not diagnostic or even strongly suggestive of babesiosis. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 47-year-old male with chronic back pain and is status post multiple lumbar surgeries. In addition, the patient underwent gastric bypass surgery in 2004. He is requesting authorization for 630 80mg OxyContin tablets per month for pain control. The Health Plan has authorized 540 80mg tablets of OxyContin per month. At issue is whether the requested prescription is medically necessary for treatment of the patients chronic pain.The Health Plans denial should be upheld. The amount of OxyContin the patient is requesting is well beyond the standard of care in pain management medicine, even in extreme cases. The requested prescription is excessive and not medically appropriate. The patient should pursue alternative forms of pain management in addition to narcotic management in order to allow for a decrease in his current level of OxyContin. Accordingly, I have determined the requested prescription is not medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 45-year-old female who has degenerative disc disease and low back pain.  An MRI revealed an annular tear at L5-S1. She is requesting authorization and coverage for artificial disc replacement surgery at this level. The Health Plan has denied the patients request because it 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. Because there is insufficient evidence supporting the safety and efficacy of artificial disc replacement, 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 45-year-old female with chronic progressive low back pain secondary to internal disc disruption syndrome at L5-S1. Her physician has recommended artificial disc replacement surgery. The Health Plan indicates the efficacy of artificial disc replacement has not been established.The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300-patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial, the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. 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 45-year-old woman who has degenerative disc disease at L5-S1. She has failed conservative treatment options. The patients provider has recommended a single level artificial disc replacement procedure. The Health Plan has denied authorization for the requested procedure citing a 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. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a four-year-old male with a diagnosis of arthrogryposis, SCAD and history of cerebrovascular accident who is being fed during the night and needs to be maintained in an upright position (it is unclear from the submitted documentation if he is tube fed or fed by mouth).  The parents document that he is somewhat mobile in bed and is thus a fall risk. They also plan to use the bed in order to change his diapers since he is getting larger and is incontinent.  At issue is whether the requested SleepSaferplus is medically necessary.The patient has several needs that should be addressed.  First, routine care necessitates a bed that can be raised and lowered.  The specialty bed requested by the patients parents has a feature that allows for automatic raising and lowering of the bed. This feature is for the purpose of caregiver convenience because this function could be performed with a manual crank.  A second consideration is the possibility that the patient is being tube fed over night.  If so, it is appropriate to have a hospital bed with the ability to raise and lower the head of the bed to prevent aspiration while providing nighttime feedings.  If this is not the case, and the patient is fed orally, then it is not appropriate to feed the child in any form of a reclined position and a hospital bed would not be appropriate.Finally, the safety of the patient is an issue given his documented mobility.  Padded side rails are needed with any style of bed utilized by the patient.  Although the patient does not medically require all of the features of the requested specialty bed, a semi-electric hospital bed with padded side rails would be medically appropriate and indicated if tube feedings occur overnight. It is not recommended that the patient be propped with pillows during feedings if feedings are administered overnight due to the risk of aspiration if the patient rolls off of the pillows.  Based upon the information set forth above, I have determined 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: Overturned Decision of Health Plan

The patient is a 19-year old male with disabling chronic daily headaches who was seen at an out of state facility for additional medical opinions.  He was previously seen by many neurologists, headache specialists, and pain management physicians. The patient underwent diagnostic testing of the brain (MRI/MRV/MRA) in September 2004. The consulting neurologist reviewed these films and ordered an additional MRV with contrast, which was performed on 1/26/05.  The Health Plan denied coverage stating the MRV was not medically necessary.Review of the submitted clinical evidence indicates the patient underwent a MRV in September 2004, which included a MRV without contrast. Upon reviewing the results, the patients consulting neurologist determined a MRV with contrast was warranted to rule out superior sagittal venous sinus thrombosis and for comparison with the September 2004 MVA to better evaluate an anomaly in that study. Given the identified clinical objectives of the repeat study, I have determined the MRV at issue was medically necessary for evaluation 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 55-year-old female with low back pain, chronic in nature. She is status post laminectomy. The patient is requesting authorization for ongoing physical therapy with the Back Strong device. The Health Plan has determined that the requested therapy is not medically necessary.The Back Strong device is not essential for continued rehabilitation of the patients back pain. There is no peer-reviewed literature demonstrating the superiority of this device when compared to traditional skilled physical therapy and back care strengthening stabilization exercises. Future physical rehabilitation programs should include a daily home exercise program so that the patient can maintain her back strength. 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: Upheld Decision of Health Plan

The patient is a 42-year-old male with significant brow ptosis and dermatochalasia of the upper eyelids. He has been evaluated by an ophthalmologist and noted to have visual field defects secondary to this aging change. The ophthalmologist has determined the patients condition would be best corrected by performing a brow lift. The Health Plan has authorized this procedure. A plastic surgeon has also evaluated the patient and has recommended a bilateral blepharoplasty in addition to the brow lift. The plastic surgeon makes no statement regarding the visual field defect. The Health Plan has denied coverage for the requested blepharoplasty on the basis it is cosmetic in nature and is not medically necessary for treatment of the patients condition.This patient has a documented visual field brow ptosis and upper lid excess and drooping. There is no evidence demonstrating what affect the brow lift will have on the patients upper lids. As such, the potential functional result of the brow lift is not known. It is possible that the brow lift alone will resolve the patients functional issues. If after the brow lift is performed a documented visual defect remains, the patients request for a blepharoplasty should be reconsidered. Based upon the information provided at this time, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is 33-year-old female who is status post duodenal switch bariatric surgery.  Abdominoplasty and panniculectomy were performed approximately one year ago.  The record indicates she has a reported body mass index (BMI) of 39. The patient is now seeking further body contouring procedures, specifically, a belt lipectomy for redundant buttock folds and excess thigh tissue. The patient has been evaluated by two plastic surgeons, and has sought other consultations for support of her request for her excess skin removal. The Health Plan has denied authorization and coverage for the requested surgery stating it is considered cosmetic and therefore not medically necessary. The submitted records include statements from the patient, photographs, and consultation reports. These materials do not establish medical necessity for a belt lipectomy or a buttock/thigh lift. There is insufficient objective evidence of a functional impairment resulting from the patients excess skin and tissue. These procedures are cosmetic in nature and are not medically warranted. Therefore, I have determined the requested surgery 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 31-year old female who has failed traditional medical care in eliminating or managing her head pain.  The patient reports she has obtained positive results from chiropractic care. The submitted records do not include detailed outcome assessments made by her provider.  The patient has requested that chiropractic care be authorized on an unlimited basis.  The Health Plan has denied authorization for continued chiropractic care on the basis it is not medically necessary.   A diagnosis of cervicogenic headache is one that is often treated successfully with chiropractic care.  Head pain can be a quality of life issue for the patient and it can be difficult for a clinician to achieve and maintain the desired results. Often, co-management is a better approach.  In this case, the patient states she finds chiropractic helpful in providing relief and in improving her quality of life.  By her assessment, the headaches have lessened and become controlled unlike before and she requires less medication.  This patients condition however, is chronic and after the second chiropractic reassessment, she was on a supportive treating schedule. There is no documentation of objective outcome measures being consistently monitored to determine the patients progress. In the absence of such documentation, medical necessity for continued chiropractic care has not been established.The Health Plans alternative recommendation for orthopedic consultation, pain management evaluation and assessment of work and lifestyle for contributing factors is reasonable and those services should be made available to the patient.  Should that approach fail, the patients request for additional chiropractic care should be reconsidered.Based upon the information set forth above, I have determined the requested chiropractic 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 51-year-old woman with a history of diabetes mellitus type II, hypertension, spinal arthritis and obesity. The patient reports she cannot stand for extended periods of time, experiences bone pain, and is unable to ambulate.  She has requested authorization and coverage for a standard wheelchair, which has been denied by the Health Plan.The patient does not meet nationally accepted medical necessity criteria for authorization of a wheelchair. There is no evidence the patient is bed or chair confined. The submitted documentation does not indicate that the patient has impaired strength or mobility. No description of the patients gait has been provided. As such, it has not been established that the patients ability to ambulate is impaired. Therefore, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 47-year-old female with chronic back and knee pain. In addition, the patient has intestinal malabsorption. She also has a history of a mood disorder. The patient reports experiencing excellent results with Actiq and she has requested authorization for continued use of the drug. The Health Plan has denied coverage for the medication on the basis it is not medically necessary for treatment of the patients chronic pain.The Health Plans denial is correct. No information has been submitted demonstrating Actiq is necessary. Although Actiq may be indicated in certain situations (i.e., breakthrough cancer pain), there is no evidence suggesting this patient requires Actiq or that all other indicated pain relief medications and therapies are ineffective or contraindicated for the patient. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 59-year old female who is a candidate for full mouth dental extractions because of severe periodontal disease. She was treated with radiation therapy for oral squamous cell carcinoma 17 years ago.  The patient had previous dental extractions seven years ago and her healing was apparently uncomplicated.  She has requested prophylactic HBO therapy prior to and following dental extractions. The Health Plan has determined the requested therapy is not medically necessary.There is some controversy regarding the prophylactic use of HBO prior to dental extractions. Currently, there is no evidence-based standard for the prophylactic use of HBO prior to oral surgery to prevent osteoradionecrosis. As the literature indicates, there is strong support for the position that prophylactic HBO before dental extractions is not the standard of care.  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.