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

The patient is a 49-year old male with right hip and lower back pain. He has tried Motrin for pain control with only mild relief and gastrointestinal (GI) upset. The patient reports a recent trial of Celebrex was very effective. He has requested authorization for the medication, which has been denied by the Health Plan on the basis that it is not medically necessary.Celebrex, a COX-2 selective NSAID, has not been proven to be more efficacious than other NSAIDs for pain relief. There are a number of NSAIDs available, and the submitted medical records do not support the need for treatment with Celebrex. Since Motrin caused GI upset, a trial of a generic NSAID, such as Naprosyn, along with a proton pump inhibitor would be a reasonable next step. 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 36-year-old female with a long-standing history of documented internal derangement of both temporomandibular joints. Multiple attempts have been made with well-accepted, non-surgical methods to ameliorate her pain and joint dysfunction to no avail. Surgical intervention with condylotomy has been recommended by her treating oral and maxillofacial surgeon. The Health Plan has authorized arthroscopic surgical intervention but has denied coverage for a condylotomy. While both condylotomy and arthroscopy offer a reasonable chance of success, there is significantly less risk of perioperative morbidity associated with arthroscopy. As such, the next reasonable step in this clinical setting is an arthroscopy. If the arthroscopy fails to solve the problem, then it may be appropriate to consider a condylotomy. However, at this time the scientific evidence supports a TMJ arthroscopy for patients such as this patient. Therefore, 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 a 48-year-old female who underwent open reduction, internal fixation of the left ankle. Following surgery the patient received five months of physical therapy, which primarily involved massage and craniosacral therapy. The Health Plan denied coverage for the patients physical therapy as of September 2005, and the patient has appealed the Health Plans decision.The Health Plans denial is correct. The type of physical therapy involved in this case, specifically, craniosacral therapy and massage, is not the standard of care for an ankle fracture status post ORIF. Furthermore, the duration of the therapy was excessive and was not clinically indicated for the patients diagnosis. There is no evidence to support the contention that additional physical therapy was warranted as of September 2005. Therefore, I have determined the therapy at issue was 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 51-year-old woman with a long-standing history of foot pain. Physical exam revealed tenderness over the MP joint of the great toe and discomfort on the extreme of dorsiflexion and plantar flexion. X-rays showed some narrowing of the MP joint. In June 2006 the patient received a steroid injection to the MP joint, which provided some relief. She is seeking authorization and coverage for a CT scan for further evaluation of her foot/toe pain. The Health Plan has denied this request citing a lack of medical necessity.The patient appears to have arthritis in the great toe. Arthritis is evident on the plain films and an injection helped to alleviate some of her pain. There is no history of trauma. A CT scan will not provide more information than has already been obtained through x-rays. As such, there is insufficient evidence that a CT scan is clinically indicated at this time. Accordingly, I have determined the requested CT scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 25-year-old male with diagnoses of excessive daytime hypersomnolence and abnormal sleep latency. His clinical history suggests normal sleep habits, without sedatives or hypnotics. The patient has been provided with samples of Provigil and indicates it has been beneficial.  Polysomnography demonstrates decreased sleep latency periods, but no evidence of obstructive sleep apnea or narcolepsy. The patients request for authorization of Provigil was denied by the Health Plan citing a lack of medical necessity.Polysomnography has confirmed pathological hypersomnolence in this patient through the demonstration of abnormally short sleep latency periods. Anecdotally, the medication has been found to be effective for him. The patient had to withdraw from several classes secondary to an inability to complete assignments due to pathological sleepiness. The use of Provigil for the treatment of idiopathic hypersomnolence was endorsed by a specialist in sleep pathology. Provigil has been part of the armamentarium for treatment of idiopathic hypersomnolence in Europe since 1988. The medication is not associated with the same serious side effects as amphetamine or methylphenidote and there are no known serious drug interactions, withdrawal symptoms or symptoms of rebound sleepiness associated with its use. Peer-reviewed literature supports the use of Provigil for idiopathic hypersomnolence and one study found that 50% of subjects taking Provigil reported near normal alertness on the Epworth sleepiness scale.Based upon the information set forth above, 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 50-year-old female who has a history of morbid obesity with a body mass index (BMI) of 48.5. She has several comorbid conditions including gastroesophageal reflux disease, low back pain, and shortness of breath. Although the patient reports she has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery, the findings from the evaluation have not been provided. The Health Plan has authorized Roux-en-Y gastric bypass for the patient. However, she believes gastric bypass with duodenal switch is more appropriate in her case. A review of the published data shows that the duodenal switch procedure is superior to other surgical procedures, not only in terms of percentage of excess body weight loss (EBWL), but also from a quality of life perspective. Roux-en-Y gastric bypass is associated with a failure rate of more than 30% in three to five years, with a reported maximum EBWL of 60% to 70%. The duodenal switch procedure has a higher success rate and its efficacy is well established. As such, the requested procedure should be authorized. Prior to surgery it should be confirmed that the patient has obtained psychological clearance for weight loss surgery. For the reasons stated above, I have determined that the requested procedure 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 51-year-old woman with diabetes mellitus type II. She has been treated with several oral agents and Lantus insulin. Byetta was added to her regimen, resulting in maintenance of excellent control of her diabetes with an A1C of less than 6.5%. The patient has been able to discontinue Glucotrol and has experienced a 14-pound weight loss since starting Byetta. She would like to continue taking Byetta and therefore, has requested authorization for the drug. The Health Plan has denied the patients request on the basis that Byetta is not medically necessary for treatment of the patients condition.One of the goals in treating diabetes mellitus is weight loss. The submitted clinical information indicates the patient was able to achieve a 14-pound weight loss while on Byetta. Her prior treatment regimen actually resulted in significant counterproductive weight gain. Furthermore, available data suggests there is beta cell preservation with Byetta, which is in contrast to the ongoing loss that is experienced with Glucotrol and insulin. For these reasons, 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 42-year-old female who had an abnormal screening mammogram in April 2006 which led to ultrasound of the breasts in May 2006. The ultrasound showed multiple cysts bilaterally with the largest cyst in the right breast measuring up to 1.4cm. In addition, within the left breast a 5mm hypoechoic defect with internal echoes was found at the 8 oclock position near the areola. This was felt to be either a complicated cyst or a solid mass and biopsy was recommended. The patient has a family history of breast cancer with a younger sister diagnosed at age 35, the paternal grandmother having a mastectomy at age 35 and the maternal grandmother dying of breast cancer at age 63. The patient was evaluated by a surgeon who ordered breast MRI which was performed in August 2006. The study showed cysts and proliferative changes with no evidence for malignancy. The patients request for reimbursement for bilateral breast MRI was denied by the Health Plan based upon a determination that the diagnostic procedure was not medically necessary.There are several indications for MRI of the breast which include a determination of the pre-operative extent of cancer, post-operative residual cancer, the extent of lobular cancer, the identification of an occult primary cancer with positive axillary lymph nodes, the screening of high risk patients, and problem solving. An indication for non-malignant disease is the evaluation of breast implants. High risk patients are those with a personal or family history of breast cancer or a genetic predisposition for breast cancer such as a BRCA 1 or BRCA 2 gene. High risk patients also include those with biopsy proven atypia, lobular carcinoma in situ, radial scar or prior mantle radiation. This patient would be considered high risk because of her family history, which is a clinical indication for breast MRI under these circumstances. The negative MRI results however, do not change the ultrasound recommendation concerning the left breast lesion which should be followed closely or biopsied under ultrasound guidance.Based upon the information set forth above, I have determined the diagnostic procedure at issue was 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 46-year-old male with diagnoses of HIV and hepatitis C virus. He is on multiple medications. The patient reports that he experiences exhaustion and fatigue and falls asleep at his desk while at work. His provider recommended Provigil 200mg for the patients symptoms of fatigue related to HIV and hepatitis C virus. At issue is whether Provigil is medically necessary for treatment of the patients condition.Provigil is not medically necessary for this patient. There is no data to support the use of Provigil for treatment of HIV and/or hepatitis C related fatigue or to offset the effects of the patients medications. The use of Provigil in this setting is not within the standard of care or consistent with generally accepted community practice. 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 52-year-old male with no history of previous psychological evaluation or treatment. He reports experiencing anger, anxiety, decreased concentration and depressed mood. The patient has not been tried on medications and/or psychotherapy for behavior modification. He consulted a provider who recommended further evaluation. The provider has requested authorization for a total of 14 hours of psychological testing. The Health Plan indicates five hours of psychological testing are sufficient to complete the workup. At issue is whether the additional nine hours of testing are medically necessary.The Health Plans denial should be upheld. There is no evidence the proposed testing cannot be completed within five hours. Administration and analysis of the tests can be performed within the authorized five-hour timeframe and will allow the provider to establish the patients diagnosis and/or baseline. Nine additional hours of testing related services are beyond the community standard of practice in this setting and are not medically warranted. Accordingly, I have determined the requested services are 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 63-year-old female with a body mass index (BMI) of 42 and significant comorbid conditions. Additionally, she has a large hiatal hernia and previous Nissan fundoplication. The record indicates the patient completed a bariatric surgery evaluation approximately three years ago and for various reasons did not proceed with surgical weight loss. At this time, the patient is requesting authorization for the Lap Band procedure. The Health Plan has denied coverage based upon their determination that the procedure it is not medically necessary for treatment of the patients morbid obesity.With the completion of a current, favorable psychological evaluation the patient would generally satisfy the nationally accepted medical necessity criteria for consideration of weight loss surgery. However, the Lap Band procedure is contraindicated. This procedure would require the take down of her Nissan fundoplication.  As such, the reversibility benefit of the Lap Band would be lost. The patient would also have an increased risk of esophageal injury under these circumstances. While it is highly likely that bariatric surgery would be beneficial for this patient, other procedures such as the duodenal switch would avoid the esophageal problem and may be more appropriate and safer for her. The bariatric surgery consultation and re-evaluation proposed by the Health Plan is a reasonable approach. However, the patient should not require further dietary workup or independent weight loss as there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. Based upon the facts as stated above, 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 a 56-year-old male who was treated with Provigil, Paxil, and amphetamine, apparently for depression. The patient stopped his medications and reports that he feels better. He has requested reimbursement from the Health Plan for the cost of the Provigil. The Health Plan has denied his request on the basis that there is insufficient evidence Provigil was medically necessary. Although Provigil is sometimes used for augmentation of antidepressant medications, in the case of this patient he also received treatment with amphetamine, which alone would serve to augment the antidepressant. There is no literature support for the use of Provigil combined with amphetamines. The inclusion of Provigil in the patients medication regimen was not within the standard of care or clinically indicated. As such, 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: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 55-year-old male with obstructive sleep apnea (OSA) and associated cardiac arrhythmias (PACS and/or PVCS) as documented in two sleep studies at a sleep disorder center. Based on the results of these sleep studies, recommendations were made for various oral appliances, DDS/ENT surgical procedures, nasal strips, or NCPAP. The patient has been shown to be intolerant of CPAP and he has had internal nasal surgery including turbinectomies. A dental provider specializing in the fabrication and management of dental occlusal splints for a variety of medical problems has provided a repositioning device for treatment of his OSA. Sleep apneas continue to be a problem for the patient. The patients request for reimbursement for the cost of the oral device and related services was denied by the Health Plan citing a lack of medical necessity.Treatment with an occlusal splint is one of the recommendations made by the specialist at the sleep center for treatment of the patients OSA and documented cardiac arrhythmias. Anterior repositioning of the mandible with an oral appliance is a reasonable alternative to surgical repositioning of the base of the tongue or the entire mandible/maxilla complex. A review of the dental records for this patient indicates that the dental provider has attempted all of the usual fine-tuning maneuvers to obtain a satisfactory result from the splint. The occlusal device and related services provided to the patient are medically  appropriate  for management of his OSA.Based upon the information set forth above, I have determined the device and 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: Upheld Decision of Health Plan

The patient is a 13-year-old male and the full sibling of a sister with mental retardation, dysmorphic features and congenital anomalies. The sister has a chromosomal abnormality consisting of a deletion of the short arm of chromosome #8 from p22 to p terminal. Karyotypes were performed on both of the parents using peripheral blood and no abnormalities were identified. The parents were counseled by a clinical geneticist who advised them that the healthy siblings did not require chromosomal studies since the youngest childs abnormal karyotype arose de-novo as a new mutation. Nonetheless, the enrollees parent has requested authorization for genetic testing for the patient. The Health Plan denied the request based upon a determination that the testing is not medically necessary.The patients sister has congenital heart disease, mental retardation and dysmorphic features which are compatible with her abnormal karyotype 46XXdel(8)(p22). The patients mother has a normal female karyotype in blood, 46XX, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). The patients father has a normal male karyotype in blood, 46XY, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). These normal parental karyotypes support the opinion that the youngest childs chromosomal abnormality arose as a de-novo mutation. The enrollee is a normal and healthy male without any signs suggestive of a chromosomal anomaly. Chromosomal studies are not indicated for him at this time. Based upon the information set forth above, I have determined the requested testing 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 14-year-old female and the full sibling of a sister with mental retardation, dysmorphic features and congenital anomalies. The sister has a chromosomal abnormality consisting of a deletion of the short arm of chromosome #8 from p22 to p terminal. Karyotypes were performed on both of the parents using peripheral blood and no abnormalities were identified. The parents were counseled by a clinical geneticist who advised them that the healthy siblings did not require chromosomal studies since the youngest childs abnormal karyotype arose de-novo as a new mutation. Nonetheless, the enrollees parent has requested authorization for genetic testing for the patient. The Health Plan denied the request based upon a determination that the testing is not medically necessary.The patients sister has congenital heart disease, mental retardation and dysmorphic features which are compatible with her abnormal karyotype 46XXdel(8)(p22). The patients mother has a normal female karyotype in blood, 46XX, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). The patients father has a normal male karyotype in blood, 46XY, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). These normal parental karyotypes support the opinion that the youngest childs chromosomal abnormality arose as a de-novo mutation. The enrollee is a normal and healthy female without any signs suggestive of a chromosomal anomaly. Chromosomal studies are not indicated for her at this time. Based upon the information set forth above, I have determined the requested testing 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 16-year-old female and the full sibling of a sister with mental retardation, dysmorphic features and congenital anomalies. The sister has a chromosomal abnormality consisting of a deletion of the short arm of chromosome #8 from p22 to p terminal. Karyotypes were performed on both of the parents using peripheral blood and no abnormalities were identified. The parents were counseled by a clinical geneticist who advised them that the healthy siblings did not require chromosomal studies since the youngest childs abnormal karyotype arose de-novo as a new mutation. Nonetheless, the enrollees parent has requested authorization for genetic testing for the patient. The Health Plan denied the request based upon a determination that the testing is not medically necessary.The patients sister has congenital heart disease, mental retardation and dysmorphic features which are compatible with her abnormal karyotype 46XXdel(8)(p22). The patients mother has a normal female karyotype in blood, 46XX, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). The patients father has a normal male karyotype in blood, 46XY, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). These normal parental karyotypes support the opinion that the youngest childs chromosomal abnormality arose as a de-novo mutation. The enrollee is a normal and healthy female without any signs suggestive of a chromosomal anomaly. Chromosomal studies are not indicated for her at this time. Based upon the information set forth above, I have determined the requested testing is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.