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

The patient is a 58-year-old woman with documented dermatochalasia and blepharochalasis. The patient has experienced decreased vision and peripheral vision. The patients provider has recommended bilateral blepharoplasty and browpexy. The Health Plan has authorized a browpexy but indicates that concurrent blepharoplasty is not medically necessary. The Health Plans denial should be overturned. The submitted evidence reveals the presence of visual symptoms, documented visual field impairment, and dermatochalasis. As such, a browpexy is a medically indicated and necessary procedure. While it is likely that a browpexy will resolve a majority of the patients problem, it is also likely that the patients surgeon may need to remove some of the patients lid skin during the procedure in order to correct the patients condition. Therefore, the patients request for a bilateral blepharoplasty is medically reasonable and appropriate and should be authorized.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 10-year-old female with a family history of mitral valve prolapse involving her father and brother. The details of the clinical condition of the patients father and brother are not known. The patient is asymptomatic at this time. A request has been made for a cardiac consultation and echocardiogram. The Health Plan indicates that the requested services are not medically necessary in the absence of symptoms or physical findings.Most cases of mitral valve prolapse are not inherited except in rare circumstances when they are associated with a generalized connective tissue disorder such as Marfans syndrome or Ehlers-Danlos syndrome. In cases involving a generalized connective tissue disorder, mitral valve prolapse is potentially inheritable in an autosomal dominant fashion (50% of offspring). If the patients father and brother do not have features suggestive of a generalized connective tissue disorder then a decision to refer the patient for a cardiac consultation and echocardiogram should be based on the patients symptoms or physical exam findings (e.g., a murmur). However, if a generalized connective tissue disorder is suspected, then providing relatives of afflicted patients with a cardiac consultation and an echocardiogram is reasonable since some findings of generalized connective tissue disorders can be elusive on physical exam (e.g., aortic enlargement).Since no evidence has been provided that the mitral valve prolapse experienced by the patients father and brother is associated with a generalized connective tissue disorder, and the patient is not currently symptomatic, the requested services are not medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time. However, if there is evidence that the patients father or brother has a generalized connective tissue disorder then the requested services should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 56-year-old man with previously diagnosed attention deficit disorder (ADD). The submitted records indicate the patient has been previously treated with Ritalin, Cylert, Celexa, and Adderall. In July 2003, it was noted by the patients provider that the patients mood, sleep, and obsessive worrying improved at a higher dose of Celexa (80 mg/day). The submitted records also indicate that as of September 2003 the patient was receiving Strattera 80 mg, Provigil 200 mg, Tegretol 200 mg, and Risperdal 0.5 mg. At that time it was noted that Provigil was helping with productivity. It was also noted the patient was afflicted with anxiety but perceived things better secondary to Strattera. The patient has requested authorization and coverage for Provigil. The Health Plan has denied the request indicating that Provigil is not medically indicated for the patients diagnosis.The submitted records do not include a definitive accounting of the patients ADD. For example, it is unclear why the patient would require Tegretol or Risperdal if he was experiencing ADD. In addition, the records appear to indicate the patient had a positive response at least in terms of mood symptoms to a higher dose of Celexa. Moreover, there was also documentation of improvement with Strattera as the patients perception of things seemed to improve after a trial of the medication. Finally, there are insufficient studies supporting the use of Provigil for bona fide ADD. Given these factors, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 46-year-old woman with a history of uretal stones involving both kidneys. The submitted records indicate the patient has undergone four extracorporeal shockwave lithotripsy (ESWL) procedures. In the past the patient has had multiple large stones measuring up to 9 mm particularly on the left. There is no documentation of any procedures from the first radiography on 2/14/03 until 1/23/04 when the patient underwent ESWL. A follow-up x-ray ordered on 1/29/04, showed no ureteral stones. On 2/27/04, the patient was scheduled for another ESWL procedure; however, the procedure was not performed because the stones could not be visualized. The patient has requested authorization for percutaneous nephrolithotomy. The Health Plan has denied the request.The submitted clinical information does not describe the patients symptoms. In addition, there are no reports of stone composition. Although it appears the patient has had some calcium containing stones, it is not known if less radiopaque stones are present. There is also no documentation of the other procedures the patient has undergone including ureteroscopy. The stone size documented on the ESWL report is 2 x 5 mm in the left pelvis and 2 x 4 mm in proximal ureter. However, at the time of the patients last scheduled ESWL treatment the stones could not be visualized. Given the lack of sustained success of the patients previous ESWL procedures a nephrolithotomy is appropriate as the next treatment option if the stones are still present. However, in the absence of evidence of the stones, the requested procedure is not medically necessary. Therefore, the Health Plans denial should be upheld at this time. If the presence of a stone in the left ureter is confirmed, percutaneous nephrolithotomy should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old woman who has requested authorization and coverage for Rocephin for treatment of neuroborreliosis. The patient has a history of being treated for Lyme disease in 1994. There are no subsequent notes to suggest pathognomonic clinical findings. The patient was treated with three weeks of a tetracycline antibiotic. At about the same time, the patient began to develop neurological signs and findings very suggestive of multiple sclerosis and was given this diagnosis by a neurologist. Review of the materials provided indicates the results of the patients clinical examination, MRI and cerebrospinal fluid (CSF) examination were consistent with this diagnosis. Although there is no evidence the patient has ever had positive serologies for Lyme disease, there is a note about a positive CSF for a borrelia antigen (OspC). The patient was also said to have had a positive IFA for babesia.The patient apparently initially received Rocephin from 1995 to 1996. The patient then received Rocephin from August 2001 to July 2002. Treatment with Rocephin was then reinitiated from October 2003 to at least January 2004. In addition, the patient has received extensive oral antibiotic therapy (e.g., Ceftin, Zithromax and Flagyl).There is no evidence that additional therapy with Rocephin is likely to benefit the patient. The cited study by Krupp et al., demonstrates that in a blinded, placebo-controlled trial antibiotic treatment for this condition was ineffective. Two randomized controlled trials of this disease demonstrated no benefit with 90 days of antibiotic therapy in patients with persisting symptoms. Furthermore, the recent articles note that no scientific evidence supports the practice of giving antibiotic therapy for months or years given the lack of efficacy and the possibility of adverse effects.There do not appear to be any trials that would support the continued use of antibiotics in this patient. While it is true that the borrelia antigen may persist in the CSF for extended periods, evidence suggests that rather brief periods of therapy (e.g., one month) with Rocephin are able to eliminate evidence of infection. Therefore, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 56-year-old male who is being treated with phlebotomies for hereditary hemochromatosis. The patient has developed erectile dysfunction. The Health Plan has denied authorization and coverage for treatment with Viagra because the patient is not over age 60 and because there is no evidence of hormone deficiency, neurogenic causation or vasculogenic causation. The Health Plans denial should be overturned. Treatment with a PDE5 inhibitor is medically necessary for this patient. Viagra is accepted primary therapy for the treatment of erectile dysfunction. The submitted records indicate the patient has erectile dysfunction and that use of Viagra has been effective. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 15-year-old female with a history of a pituitary lesion. The patient has been examined by a number of providers both in-network and out-of-network. A request has been made for authorization for another consultation with an out-of-network neurosurgeon. The Health Plan has denied the request on the basis that appropriate care is available in-network.No information has been presented in this case that demonstrates that it is medically necessary for the patient to obtain treatment from an out-of-network neurosurgeon. There is no evidence that the patients case involves a level of care or expertise that is not available in-network. The Health Plan is offering the patient appropriate providers for treatment of her medical condition. The patients care can reasonably be provided by an in-network neurosurgeon. Therefore, I have determined that the requested consultation 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 40-year-old woman with a BMI of 39.9 and multiple comorbid conditions including sleep apnea and depression. The patient has undergone a psychiatric evaluation and obtained clearance, but the Health Plan has denied authorization for gastric bypass surgery indicating that the patient does not meet its criteria for weight loss surgery. With a BMI of 39.9 and documented comorbidities gastric bypass surgery is medically indicated and necessary for this patient as it is not likely that she will be able to lose weight and maintain the weight loss through non-surgical means. 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.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 57-year-old man who has requested authorization for continued group psychotherapy. The submitted records indicate the patient received outpatient group psychotherapy from October 2002 through December 2003. The Health Plan denied authorization and coverage for continued group psychotherapy in September 2003.There is not sufficient evidence that continued group psychotherapy is medically necessary. Furthermore, the submitted evidence does not demonstrate that group psychotherapy was medically necessary after September 2003. Unlimited group psychotherapy is not medically indicated in most clinical situations. There should be a defined end point or treatment plan with specific goals. The patient should be evaluated by a psychiatrist and a treatment plan should be formulated. The patient may have symptoms that would respond to pharmacotherapy. Therefore, I have determined that 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 29-year-old female with a body mass index (BMI) of 43, with comorbid conditions including diabetes, hypertension, and urinary stress incontinence. The submitted information does not include evidence that the patient has undergone a psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. The patient has requested authorization and coverage for gastric banding. The Health Plan has denied the patients request on the basis that the requested procedure is not medically necessary.With a BMI of 43 and multiple comorbid conditions the patient meets nationally accepted criteria for weight loss surgery. However, gastric band surgery is not considered standard of care. Furthermore, gastric banding is known to have higher complications and greater risk than other weight loss procedures. This patient can be appropriately and effectively treated through Roux-en-Y gastric bypass. However, although medically the patient meets criteria for consideration of Roux-en-Y gastric bypass, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that although gastric banding is not medically necessary for treatment of the patients medical condition, Roux-en-Y gastric bypass is medically necessary depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be partially overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, Roux-en-Y gastric bypass should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, Roux-en-Y gastric bypass should not be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old female who, after having a biopsy of a lesion on her right cheek in October 2003, was diagnosed as having pseudocarcinomatous hyperplasia versus well-differentiated squamous cell carcinoma. The excised specimen, which measured 0.5cm at its greatest dimension, was noted to have a positive deep margin. Further excision is needed in order to obtain clear margins. The patient states she is an actress and is quite concerned about facial scarring. In addition, the patient indicates the skin lesion overlies an implant that was placed in 1998. Because of these issues, the patient is requesting a referral to a plastic surgeon for further excision of the lesion on her right cheek. The Health Plan has referred the patient to an in-network otolaryngologist with specialty training in cosmetic and facial reconstructive surgery. The submitted evidence does not demonstrate that a referral to a plastic surgeon is medically indicated. The patient will have a scar at the excision site whether the procedure is performed by a plastic surgeon or otolaryngologist/facial plastic surgeon. Cutting the skin leaves a scar. Review of the submitted records indicates this is a small lesion that appears to be located at or near the nasolabial fold so that the scar may be camouflaged, but it will still be present. How well a scar heals generally depends more on a patients skin quality, age, and health status (e.g., smoker versus non-smoker) than on how the excision and repair is done. Furthermore, an otolaryngologist/facial plastic surgeon is qualified to excise a lesion such as the patients lesion. With some variation depending upon institution, training in general plastic surgery involves the completion of a general surgery residency (approximately five years of non-plastic training) followed by two years of general plastics. This latter segment covers training in plastic surgery of the body and face. This is different from the training of an otolaryngologist/facial plastic surgeon. Training of an otolaryngologist/facial plastic surgeon currently involves one to two years of general surgery training, followed by four years of study regarding diseases and surgery of the head and neck (including the face), and is sometimes followed by another year of fellowship emphasizing plastic and reconstructive surgery of the face and neck only. As such, an otolaryngologist/facial plastic surgeon generally has had at least as much experience and often more training in the care (both medical and surgical) of lesions involving the face than a general plastic surgeon. Having undergone this training, an otolaryngologist/facial plastic surgeon is fully qualified to perform excision of facial lesions such as this patients cheek lesion. Based upon the information set forth above, I have determined that the requested referral is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a five-year-old male with a history of developmental motor (fine) delay and a visual/sensory processing issue. The patient was evaluated by a neurologist who was not able to provide a specific diagnosis, but indicated the patient might have attention deficit hyperactivity disorder (ADHD) or a pervasive developmental disorder. The patient began receiving weekly occupational therapy in February 2003. A request has been made for continuing therapy. The Health Plan has denied the request.The submitted records document the patients occupational therapy sessions from June 2003 to February 2004. The goals documented are primarily behavioral in nature. Additionally, the patient has demonstrated only minimal improvement. Furthermore, the functional goals outlined have not been achieved. According to current literature the only treatment that benefits behavioral issues such as those exhibited by this patient is applied behavioral analysis. Continued occupational therapy is not likely to result in an improvement in the patients behavioral issues. Therefore, I have determined that 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 20-year-old female with symptomatic breast hypertrophy documented by her plastic surgeon. The patients plastic surgeon has recommended breast reduction surgery. The Health Plan indicates breast reduction surgery is not medically necessary based upon the amount of breast tissue to be removed.The appropriate and medically necessary procedure for this patient is breast reduction. According to the American Society of Plastic Surgeons guidelines, the weight of the removed breast tissue does not determine whether the procedure is medically necessary. In this case, the plastic surgeon examining the patient noted symptoms of back, neck, and shoulder pain related to large pendulous breasts for which the patient wears two bras simultaneously for comfort in activities. In addition, the submitted photograph supports the findings of the plastic surgeon. Given these findings, breast reduction surgery is medically indicated.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. As such, 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 a body mass index (BMI) of 46. The patient has comorbid conditions including sleep apnea. It does not appear the patient has undergone a psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. The Health Plan has denied the patients request for gastric bypass surgery on the basis that it is not medically indicated.With a BMI of 46 and comorbid conditions such as 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 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, although medically the patient meets criteria for consideration of weight loss surgery, there is no evidence that the patient has undergone a psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery the procedure should not be authorized.