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

The patient is a 48-year-old female with a history of polymenorrhea, pelvic pain, and significant fibroids. The submitted records indicate that on ultrasound the uterus is enlarged to 13.7 x 4.2 x 4.9 cm with a 3.4 cm fundal fibroid and a 6 cm pedunculated fibroid; in addition, there is present a 0.6 cm cyst adjacent to the endometrium. The records provided do not document the extent of the patients bleeding, whether she has become anemic as a result of her bleeding or whether she has experienced pelvic pain. However, based upon other documentation submitted, it appears the patient has had long-term polymenorrhea, which has resulted in anemia. In addition, the patient indicates she has pelvic pain, which causes recurrent work absences. There is no reference in the submitted records as to whether an endometrial biopsy was performed.The patient has requested authorization and coverage for a total abdominal hysterectomy. The Health Plan has determined the requested procedure is not medically necessary for treatment of the patients medical condition.ACOG criteria for the definitive surgical treatment of fibroids (i.e., hysterectomy) requires: the presence of a uterus enlarged to 12 weeks or greater; profuse bleeding lasting more than 7 days or repetitive periods of less than 21-day intervals or anemia due to blood loss; and pelvic discomfort caused by fibroids, e.g., chronic lower abdominal, pelvic or low back pain and back pressure. The patient meets the criteria for a hysterectomy. Her uterus is documented on ultrasound to be greater than 12 weeks size and she has demonstrated polymenorrhea. Furthermore, generally women of similar physical size as this patient with fibroids of similar size as this patient often experience significant symptoms. Moreover, it appears the patient is probably at or approaching menopause. The average age for menopause in the United States is 51+ years and women with fibroids often experience later onset of menopause. In light of these findings, a hysterectomy is medically appropriate and indicated for this patient. The patient should first undergo an endometrial biopsy to rule out cancer.Based upon the information set forth 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: Upheld Decision of Health Plan

The patient is a 62-year-old male with a history of coronary artery disease, chronic obstructive pulmonary disease, cardiomyopathy, AICD, sleep apnea, diabetes mellitus, Raynaud's syndrome, elevated lipids, and osteoarthritis. The results of an in-home evaluation indicate the patient is independent in stand/pivot/slide transfers, independent in ambulating 150 feet in home and can stand/ambulate for 10 minutes. The primary care provider notes document multiple medical problems and also indicate that knee surgery is scheduled. Functional skills are not documented. A power-operated vehicle (POV) has been requested for community mobility. The Health Plan has denied the request on the basis the requested equipment is not medically necessary.The patient does not meet nationally accepted medical necessity criteria for authorization of a POV. Review of the submitted records indicates the patient is ambulatory in the home and the POV has been requested only for community mobility. Furthermore, there is no indication the patient cannot operate a manual wheelchair. As such, there is no evidence a POV is medically necessary for this patient. Therefore, I have determined 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 51-year-old female who has been diagnosed with a meniscal tear and osteochondral lesion of the medial femoral condyle. She underwent arthroscopic surgery in October 2004. Post-operatively she was also diagnosed with grade 3-4 chondral lesion of the medial femoral condyle. Her physician has suggested orthovisc injections. The Health Plan has determined orthovisc injections are not medically necessary for treatment of the patients medical condition.The patient has been diagnosed with a meniscal tear and osteochondral lesion of the medial femoral condyle. Orthovisc injections are appropriate for refractory cases of osteoarthritis. There is no data to suggest or support the use of orthovisc injections with osteochondral deficits of the knee with meniscal pathology. Furthermore, there is no data to support the use of orthovisc injections as post-operative care after arthroscopy for meniscal and condyle deficits. Therefore, I have determined that the requested injections are 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

A sixty-two year-old male with stage T2, N1, M0, poorly differentiated squamous cell cancer of the right tonsil with right neck node metastases is requesting coverage for thermoradiation therapy.  Reviewers Findings:  One of the three reviewing physicians found that thermoradiation therapy has been approved by the Food and Drug Administration. It has been used at several centers for treatment of cancer of different sites with some encouraging results. Two of the three reviewing physicians found that thermoradiation therapy may be superior to standard external beam radiation therapy in select patients, but this patient does not meet the criteria that would suggest superiority of thermoradiation therapy over standard external beam radiation.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old female who was seen in May 2003 for a left foot/ankle injury. The patient noted weakness and problems with gait. The physical therapy plan of 8/25/03 notes the patient reported an inability to ambulate with her walker. In addition, edema of the right foot at the point of the fracture was noted. Per a physical therapy follow-up note of 10/8/03, the patient indicated she was doing a lot of walking with the walker. A note dated 10/15/03 indicates the patient was walking daily. The submitted physical therapy notes are not specific regarding range of motion, strength, and gait deficits, etc.A request has been made for reimbursement for physical therapy services received from 10/8/03 to 2/20/04. The Health Plan has denied this request on the basis that the therapy at issue was not medically necessary for treatment of the patients medical condition.The physical therapy notes provided include no objective data regarding strength, range of motion or improvements with physical therapy. The evaluation and follow-up notes do not give any specific information regarding the patients physical therapy evaluation or progress. Thus, there is not sufficient objective evidence to support the need for physical therapy for dates of service 10/8/03 through 2/20/04. Therefore, I have determined that 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 15-year-old male adolescent with previously diagnosed obsessive-compulsive disorder (OCD) and disruptive disorder  not otherwise specified, the former beginning when the patient was age seven. The patient has since been treated with Paxil, Topamax, and Buspar. He was admitted to residential treatment on 12/1/04 due to escalating aggressive behavior at home as well as brief experimentation with marijuana. The aggression has consisted of arguing with his mother, and later breaking her windshield with a golf club and punching some holes in the walls. The patient noted his mother as having provoked him. The patient also noted having witnessed a good deal of violence between his mother and father over the years, including his mother slapping his father in the face, thereafter grabbing the patient, putting him in the car, and leaving with him. Though his OCD affected the patient with compulsive rituals in the past (e.g., repeated hand washings and showers with prominent concerns about contamination), he denied having had such for about the past four years. The patient reported his current OCD symptoms involve obsessive thoughts, which he is simply unable to stop thinking about - such as the idea of wanting some new clothes. He has tried to engage his mother in such discussions and when she has refused he has become angry. He has had no recent checking or contamination symptoms.Review of the submitted treatment notes indicates the patient has sometimes been irritable and passive-aggressive. Paxil was maintained at 50mg CR a day, and Topamax and Buspar were discontinued in favor of supplemental Geodon. At issue is whether residential treatment services are medically necessary for treatment of the patients behavioral health problems.Though the patient has a history of OCD, the condition appears to have been relatively well controlled by the time the patient was admitted to residential treatment. The patient was admitted for aggressive behavior, not refractory OCD. The aggression appears to be localized to his interaction with his mother. Based upon the submitted treatment notes, it appears the patients mother is given to much anger and aggressive behavior. It does not appear that this family has had any sort of family therapy along the way. Though the family believes the patients problems stem from his OCD, this is clearly not the case. It appears there are entangled family dynamics that have fostered the patients aggression. As such, residential treatment is not the first-line approach to treatment and is not the standard of care in this situation. There is no indication that residential treatment is medically warranted for treatment of this patient or is likely to be of benefit. Based upon the information set forth above, I have determined that the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A forty-six year-old female with chronic myofascial pain syndrome, fibromyalgia, osteoarthritis, migraine headaches, gastritis, and bilateral elbow tendonitis is requesting authorization of Botox therapy.  Reviewers Findings:  Two of the reviewing physicians found that the patient has tried and failed numerous conventional treatment modalities, and has had success with Botox injections in the past, further treatment with Botox is medically reasonable and appropriate.  The third physician found that there isinsufficient evidence that Botox injections are likely to result in a superior clinical outcome to standard therapy.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old female who has had a long-standing history of back spasms. She has been diagnosed with torticollis. The patients provider indicates the patient has been treated with physical therapy, activity restriction, and medications such as oral analgesic, NSAID, and muscle relaxants without improvement. The patients pain management specialist has recommended the patient receive Botox injections at monthly intervals. The Health Plan has determined Botox is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence indicates the patient has not responded to conservative care for diagnosis of torticollis. Her provider has recommended Botox injections for torticollis, which is an accepted and evidence-based approach to treatment of the condition. Treatment with Botox is medically appropriate and indicated for this patient. Though development of antibodies is a possibility with monthly injections, this is not a basis on which to deny the use of Botox at this time. Therefore, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive a trial of monthly Botox therapy for a three-month period with reevaluation by her treating provider at the end of the three-month period.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 59-year-old man who has prostate cancer with a PSA of 6.3. The patient has a Gleason score of 6 (3+3) on both sides of the prostate in 3/8 needles biopsied. The majority of the remaining biopsies revealed high-grade intraepithelial neoplasia. Based on Partins Tables, the patient has a 75% chance that cancer is limited to the prostate, a 23% chance of capsular involvement, and a 2% chance of seminal vesicle involvement. The patient wishes to undergo robotic-assisted laparoscopic radical prostatectomy. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence reveals the patients cancer is essentially limited to the prostate and seminal vesicle. As such, any local form of therapy will offer him the best chance for cure. As between laparoscopic and standard radical retropubic prostatectomy, there is no widely accepted evidence currently available showing any significant difference between the two in either local control or perioperative morbidity. Though blood loss is less with the laparoscopic procedure, no blood replacement is required in either the laparoscopic or open procedure. The laparoscopic approach has not been demonstrated to be superior to the current standard, which is the open radical prostatectomy. Therefore, I have determined that 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 53-year-old male who has lymphedema and a history of renal cancer, testicular cancer, and prostate cancer. He is post nephrectomy, prostatectomy and node dissection, and cervical lymph node excision. In July 2004, the patient experienced swelling over most of his body. He has undergone a trial of compression stockings and Lasix treatment for his condition without success. He has requested a referral for a consultation and follow-up care with an out-of-network lymphedema specialist. The Health Plans denial should be upheld. Based upon the information provided, it does not appear the patient is receiving ongoing care from the out-of-network specialist. The patient has not yet consulted an in-network vascular surgeon. A consultation with an in-plan vascular surgeon should take place as soon as possible. If the in-network vascular surgeon recommends a referral to the out-of-network lymphedema specialist, the patients request should be reconsidered. As such, I have determined that the requested referral 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 62-year-old male who has requested continued chiropractic care for neck and back complaints. An MRI revealed degenerative disc and degenerative joint disease of his cervical spine. The patient sustained an injury from a motor vehicle accident approximately one year ago and found chiropractic care to be more beneficial than his experience with physical therapy and medications. The Health Plan has determined continued chiropractic care is not medically necessary for treatment of the patients medical condition.This patient wishes to receive chiropractic care beyond the eight sessions received over approximately 60 days. Chiropractic care can improve spinal degenerative complaints and is an effective alternative to medications and other physical treatment options. However, in this case the submitted documentation does not demonstrate continued chiropractic care is medically necessary. The notes provided do not adequately document symptoms intake, objective findings, and patient response to care (S.O.A.P.) and fail to justify the need for continued chiropractic care. 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 bipolar disorder, type 1 with a history of past hospitalization for frank mania as well as suicidality. The patient was later stabilized on Lamictal and Depakote following failure of Lithium due to excessive weight gain and development of acne. A chart note from her psychiatrist on 10/14/04 indicates that her mood has been somewhat difficult to control and there continues to be much stress in her life that is easily disruptive and can cause some transient mood instability. It appears that regular maintenance psychotherapy has been helpful. Chart notes of the patients psychotherapist document that due to the extent of the patients illness she went from working as a teacher to being without a job. The patient has had to return to living with her mother due to a lack of funds and is finding it difficult to obtain job interviews. Her family has also been noted as quite critical of the patient, not particularly understanding of her illness, and apt to liken her struggle to that of being lazy. This has all added to her level of depression and the focus of psychotherapy has been on how to surmount these sorts of losses and move towards a greater degree of independence.Therapy notes of 9/28/04 note the patient vacillates between a depressed giving up response and a kind of grandiose push for excellence and cite her mood as moderately depressed, highly anxious. A note of 10/19/04 cites the patient feeling herself getting agitated and her mood as mildly depressed and moderately anxious, speech somewhat fragmented. The patient has requested authorization and coverage for continued outpatient psychotherapy. The Health Plan has denied this request indicating that the requested therapy is no longer medically necessary.All told, this patient has had a very severe decline in functioning due to the extent of her illness, as she went from being employed as a teacher to living at home with her mother, unable to find another full-time job with a violence-restraining order against her from her prior work. Documentation from her psychiatrist as well as her therapist point to some stabilization in mood compared to when she was at her worst, but hardly that of genuine euthymia. To the extent that functional recovery from bipolar disorder can be quite protracted, taking place over the course of years rather than months, it can be expected that both therapy and mainstay medication treatment will need to continue. This seems particularly the case in this instance given the acrimonious environment in which the patient currently lives. Review of the medical literature including the articles cited above clearly supports continued psychotherapy for this patient. Discontinuation of therapy should be based on good, functional recovery as determined by the patients treating psychiatrist. 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

This patient is a 13-year-old male with a history of sensory motor deficits who has had multiple diagnoses associated with his developmental delays including attention deficit non-hyperactivity disorder, pervasive developmental disorder, and anxiety depressive disorder. The patients pediatric neurologist diagnosed the patient with mixed developmental disorder. He was diagnosed by neuropsychological testing with attention deficit hyperactivity disorder - predominately ineffective type; reading disorder; disorder of written expression; and anxiety disorder. A request has been made for the patient to receive speech therapy services. The Health Plan has denied the request indicating the requested therapy is not medically necessary for treatment of the patients medical condition.Review of the medical literature reveals no evidence that speech therapy is an effective treatment for attention deficit disorder. Though speech therapy is used as standard of care for pervasive developmental disorder, there is insufficient evidence in the submitted documentation to demonstrate that the patient has pervasive developmental disorder. While the patients other diagnosed learning disorders often benefit from speech therapy, treatment for such disorders is educational in nature and not medically indicated. Furthermore, there is no literature to support the use of speech therapy for treatment of anxiety disorder. 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: Upheld Decision of Health Plan

The patient is a 45-year-old male with at least a 3.5-year history of intermittent chest pain. The patient was evaluated by a cardiologist in July 2001. He was seen in March 2004 for left chest pain and the clinical impression at that time was costochondritis. A left rib series was reported to be negative. On 9/3/04, the patient returned with low back pain and a painful lump in the lower left ribs. The plan for the rib abnormality was observation. The patient was again seen on 9/13/04 for left-sided chest pain. Follow-up stress test and CT scan of the chest were ordered. There is a past history of gastroesophageal reflux with a fundoplasty in 2000. At issue is whether a CT scan of the chest is medically necessary. Based upon the clinical evidence provided, a CT scan of the chest is not clinically indicated at this time. The plan for the mass in the area of the left lower ribs was observational with a CT to be obtained if there was an increase in the size of the mass. The report from the clinical exam dated 9/13/04 did not mention a mass. The patients recurrent chest pain requires further evaluation. A chest x-ray and cardiology consult are more medically appropriate and likely to be of greater value than a CT scan. Therefore, I have determined that 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: Upheld Decision of Health Plan

The patient is a 22-year-old female with right upper quadrant pain. She has associated nausea with the pain. On physical exam, some right upper quadrant and flank pain was present. Two ultrasounds performed in June 2004 and September 2004 were negative. A CT of the abdomen and pelvis was also negative. The patient has requested coverage for a third ultrasound, which the Health Plan has denied stating the requested ultrasound is not medically necessary for evaluation of the patients medical condition. The requested ultrasound is not medically necessary for this patient. She has had two negative ultrasounds, and also a negative CT scan. All of the patients labs have been essentially negative. A repeat ultrasound in this patient at this time will not add any new information to help with her diagnosis. Therefore, I have determined that the requested ultrasound is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.