Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 36-year-old male who has a long-term history of back and neck pain. A discogram showed disc protrusion at L5-S1. The patient was treated with nerve blocks and trigger point injections without sustained pain relief. The patients physician has recommended the patient undergo a nucleoplasty. The Health Plan has denied authorization for the requested procedure indicating the efficacy of nucleoplasty for treatment of the patients condition has not been established in peer-reviewed literature.Nucleoplasty is a treatment for radicular pain and leg pain due to a contained disc protrusion. It is not a treatment designed for low back pain. It has not been tested in this setting in any controlled clinical trials. As such, there is insufficient evidence the requested procedure is likely to result in a superior outcome over standard therapies. Accordingly, I have determined that 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 36-year-old male with degenerative disc disease. He has requested authorization and coverage for nucleoplasty for treatment of low back pain secondary to disc protrusion at L5-S1. The Health Plan has denied coverage for the requested procedure on the basis it has not been proven efficacious for treatment of low back pain.Nucleoplasty is not the standard of care for treatment of this patients low back pain. There is no Class I data with significant follow-up to support the use of nucleoplasty in this clinical setting. The proposed procedure is not of established efficacy and is not recommended for treatment of the patients medical condition. Therefore, I have determined that the procedure at issue 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 36-year-old male with a long history of discogenic back pain. He has been treated with nerve blocks and trigger point injections without sustained benefit. The patient has consulted a provider who indicates the patient is a candidate for nucleoplasty. The Health Plan has denied coverage for the proposed procedure citing lack of proven efficacy.There are no randomized, controlled trials demonstrating the long-term success of nucleoplasty in the treatment of discogenic back pain. Nucleoplasty is without proven benefit in the treatment of this patients condition. There are no prospective, controlled trials establishing the safety and efficacy of nucleoplasty for this category of patient. Therefore, I have determined that 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 59-year-old female who has a history of urinary tract nerve damage. She has been taking Detrol LA for treatment of her medical condition. The patient indicates her physician has advised against use of Ditropan because of potential side effects. The patient is requesting reimbursement for Detrol LA. The Health Plan has denied this request indicating Detrol LA was not medically necessary for treatment of the patients medical condition.The rationale for prescribing Detrol LA versus Ditropan has not been provided. Ditropan has been widely used for treatment of urinary tract nerve damage and is generally well tolerated. The submitted clinical information does not demonstrate a contraindication to Ditropan. Furthermore, there is insufficient evidence that Detrol LA is superior to Ditropan for patients such as this patient. Therefore, I have determined that the medication at issue was 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 57-year-old female who has a history of degenerative disc disease. Her provider indicates she takes four to six Vicodin a day for her pain relief. Her physician has recommended artificial disc replacement surgery at L4-5 and L5-S1. The Health Plan has denied this request indicating the requested procedure is investigational.The proposed procedure is unproven 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.Physician 2: The patient is a 57-year-old woman who has a long history of degenerative disc disease. She has been taking Vicodin without sufficient relief. Her physician has recommended multi-level artificial disc replacement.The Health Plans denial should be upheld. 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. However, artificial disc replacement has not been proven to be more effective than fusion. Long-term, randomized studies are needed to determine if artificial disc replacement is superior to standard modalities. 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 57-year-old female with degenerative disc disease at L4-L5 and L5-S1. Her provider has recommended a multi-level disc replacement. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement as the best available treatment for this patient. Artificial discs are 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 no 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 35-year-old woman with advanced multiple sclerosis (MS) with incapacitating tetraplegia with spasticity resulting in significant disability. Her current management regimen is already extremely extensive having included the use of oral agents (Baclofen, Zanaflex, benzodiazopines, gabapentin), intrathecal (Baclofen), and non-pharmacological modalities (physical and occupational therapy, stretching, etc.). Documentation notes pectoral tightness, adduction at the pectorals, and a flexor pattern in the arms. The patients physician has proposed selective Botox injections in the pectorals, pronator, and biceps bilaterally to help improve the patients functional status. Of note, there are concerns the patient may be having side effects from the high doses of oral Baclofen. The Health Plan indicates Botox is not approved for treatment of the patients condition and therefore, is not medically necessary.Botox has been studied in MS related spasticity in three peer reviewed, randomized, double blinded trials and in two additional open label trials. Although the numbers are small, these studies showed improvement in spasticity. One review concluded there is evidence that both BT (Botox) and intrathecal Baclofen are effective in reducing spasticity, and both are associated with functional benefittheir use is most appropriately restricted to people with severe disabling spasticity. The patient meets this description as she has significant functional impairment despite extensive use of alternative therapies. As such, a trial of Botox is medically reasonable and may allow reduction in the Baclofen, thereby alleviating some of its side effects as described. Based upon the information set forth above, I have determined that the requested therapy 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 50-year-old female who has a history of painful intercourse and urinary tract symptoms. She has been treated for pelvic floor myofascial trigger points and has had manual therapy of the pelvic floor. She is seeking authorization for continued therapy. The Health Plan has denied this request.The patient appears to have problems with intercourse and lower pelvic discomfort that affects the vulva, vagina, and bladder. Based upon the information provided, it appears there is a possibility the patient may have diagnoses of vaginismus, interstitial cystitis, dyspareunia, and vulvodynia. Therefore, further multispecialty (urology, gynecology) evaluation and workup is necessary to attempt to confirm the above diagnoses. Furthermore, based upon the patients condition, the pelvic floor therapy she has been receiving is not an effective long-term therapy. In addition, the records submitted demonstrate her condition has stabilized and has not improved with continued therapy.Based upon the information set forth above, I have determined the requested services are 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 45-year-old female with multiple medical problems who is requesting authorization for growth hormone therapy. The patient has a history of CVA in 1994; however, no evidence of pituitary injury has been submitted. In addition, no evidence demonstrates why the patient is on Armour thyroid. Furthermore, the patient has had two normal IGF-1 tests. The patient is on estrogen and progesterone because she is post-menopausal. The patients physician has recommended continued treatment with growth hormone therapy.There is no evidence this patient has adult growth hormone deficiency (AGHD) or hypopituitarism. Such a diagnosis is usually made based upon the clinical context that is suggestive of some disorder of the hypothalamic/pituitary axis. The patients IGF-1 appears normal and there is no other clinical evidence to support growth hormone therapy for this patient. Therefore, I have determined the requested medication is not medically necessary for this patient. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 50-year-old male who had a sub-optimal flexible sigmoidoscopy in 2000. This was followed by a barium enema demonstrating diverticulosis. He has now requested a colonoscopy for screening purposes. He otherwise has no symptoms or family history of colon cancer. The Health Plan has denied authorization for the requested colonoscopy.The patients flexible sigmoidoscopy and barium enema occurred five years ago. The specificity and sensitivity of these exams is not equal to that of a full colonoscopy. A screening colonoscopy in an otherwise asymptomatic 50-year-old male is considered within standard of care and the appropriate diagnostic tool. Therefore, I have determined the requested colonoscopy is medically necessary for evaluation 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 45-year-old female diagnosed as having fibromyalgia for approximately one and a half years. She first began treatment for this condition in July 2004 and received treatment until May 2005. The patient indicates she had symptoms six months prior to beginning acupuncture treatment. A request has been made for continued acupuncture and trigger point injections, which has been denied by the Health Plan.It appears the patient first received treatment for fibromyalgia in July 2004, which involved trigger point injections, massage and acupuncture. Based upon the records provided, it appears the patient has had approximately 39 treatments; 15 of these treatments involved acupuncture in addition to massage and trigger point injections. It appears the patient has been seen approximately once weekly from July 2004 through May 2005 for treatment of fibromyalgia with some lessening of symptoms. There is no indication the patient received acupuncture in April and May of 2005; it appears she only received massage and trigger point injections during that time. Based upon the information provided, the patient has not had acupuncture since March 2005, and there has been no worsening of symptoms. As such, continued acupuncture is not medically necessary at this time. Furthermore, the frequency of the patients trigger point injections appears excessive. The patient has been receiving injections on approximately a weekly basis. Although the injections have helped to lessen the severity of the patients symptoms, the frequency of the injections appears excessive. Therefore, while additional trigger point injections are medically indicated, it would be reasonable and appropriate to reduce the frequency of the trigger point injections to every other week for a two-month period. The patient should be re-evaluated at the end of the two-month period to determine if additional trigger point injections are indicated.Accordingly, I have determined that although the requested acupuncture is not medically necessary for treatment of the patients medical condition, additional trigger point injections are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old female with asthma who has requested authorization for a portable nebulizer. The patient apparently did not tolerate metered dose inhalers having had an adverse reaction possibly because of the propellant. The patient is seeking a portable nebulizer because she is concerned about asthma exacerbations and not being able to utilize her standard, plug-in nebulizer. The Health Plan has denied the patients request.The information submitted does not demonstrate a portable nebulizer is necessary. Prior to consideration of a portable nebulizer there needs to be further information documenting the patients inability to utilize a metered dose inhaler. The patient needs to be re-evaluated by her treating provider to assist in determining the best treatment options for the patient. Because of the lack of documentation demonstrating the need for a portable nebulizer, I have determined the requested equipment 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 16-year-old male who has a history of substance and alcohol abuse, depression, and cutting behavior and suicide ideation. His physician has stated the patient has tried several medications as well as partial hospitalizations without sustained benefit. He was admitted to inpatient services in July 2004 due to suicidal threatening.  He had apparently been abusing over the counter medications as well as marijuana, alcohol and cocaine. in July 2004, the patient was admitted to a residential treatment program where he remained until December 2004. The Health Plan has denied reimbursement for the services at issue on the basis such services were not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. There is insufficient documentation to support the medical necessity of the patients admission. Based upon the information provided, the patients mental status and behavior at time of admission is not known. Furthermore, there is inadequate documentation of the goals of treatment or of the patients progress toward such goals. There is insufficient evidence that the patients admission to this facility was medically necessary or that he required the level of care provided during the period in question. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 41-year-old woman who is requesting coverage for treatment of toenail fungus with Lamisil tablets. The Health Plan has denied this request on the basis the requested medication is not medically necessary for treatment of the patients condition.Review of the submitted medical records does not include a history or provide any physical findings. Furthermore, there is no evidence of onychomycosis or discussion of functional impairment. Nor have laboratory results (i.e. microscopic exam or fungus culture) been provided. Therefore, there is insufficient evidence to support the request for Lamisil. Accordingly, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 51-year-old male who is requesting authorization and coverage for the medication Levitra for treatment of erectile dysfunction. His history is positive for HIV, anxiety and insomnia and he is being treated medically for these conditions. The Health Plan has denied the patients request for Levitra on the basis it is not medically necessary.Treatment of erectile dysfunction is goal directed. Treatment that is successful and acceptable to the patient and his partner is appropriate therapy. The 5-phosphodiesterase inhibitors such as Viagra and Levitra are accepted primary therapy for erectile dysfunction. These medications are effective for approximately 70% of patients who have no contraindications or side effects. Based upon the information provided, it does not appear the patient has been tried on Levitra. A trial of Levitra is medically appropriate and indicated for this patient.Based upon the information set forth above, I have determined that a one-month trial of Levitra is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. If the trial is effective, Levitra should continue to be authorized. However, if the trial of Levitra is not effective, Levitra should no longer be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A sixty-two year-old male who underwent radical prostatectomy for prostate cancer is requesting reimbursement for a Prostascint scan.Reviewers Findings:  Two of the reviewing physicians found that because Prostascint may give false positive or negative readings as to local and distant recurrence of the cancer, it is appropriate to base treatment on other findings.  The third physician found that the Prostascint scan did have a valuable role, providing useful information that was not otherwise available.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

While in India the patient fell and sustained a C6-C7 fracture with quadriplegia. He was treated at a hospital in India and subsequently developed a decubitus ulcer in the sacrum. The patients family arranged transfer back to the United States via air ambulance. A request has been made for reimbursement from the Health Plan for the transportation costs. At issue is whether the air ambulance services at issue were medically necessary for treatment of the patients condition.The patient had a history of electrolite imbalance and developed a large sacrum ulcer, but the submitted clinical evidence indicates he was stable at the time of transport from India to the United States. There is no evidence that transportation was necessary to obtain essential treatment. Based upon the information provided, the care the patient was provided in India was medically reasonable and appropriate. There is no evidence appropriate care of the patients decubitus ulcer was unavailable in India. Therefore, I have determined that the services at issue were not medically necessary for the 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 25-year-old female with a prior history of medications for the diagnosis of bronchial asthma. The patients current provider notes the patient had a trial and failure of Claritin, but no history of trial and failure on Allegra. It appears Zyrtec was originally prescribed by a previous provider after trials of Claritin and Allegra failed. The patient indicates she has used Zyrtec and Advair to help treat her asthma and allergies. In addition, the patient reports that since she has been off Zyrtec and trying other over the counter allergy medications she has had an increase in asthma symptoms and has had to regularly use her rescue inhaler which was down to a minimum when she was taking Zyrtec combined with Singulair and Advair.  At issue is whether Zyrtec is medically necessary for treatment of the patients medical condition.Both the patient and her physician indicate the patients allergic asthma was under control with the use of Zyrtec, a stronger antihistamine than Allegra. The patient indicates a worsening of symptoms with discontinuation of Zyrtec. However, the submitted documentation does not demonstrate the patient has undergone a trial of Allegra. As such, I have determined the requested medication is not medically necessary at this time. The Health Plans denial should be upheld at this time. If the patient provides objective evidence of trial and failure of Allegra, then Zyrtec should be authorized.