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

The patient is a 47-year-old woman who underwent gastric bypass surgery for morbid obesity with comorbid diabetes. The patient is seeking surgical treatment of hanging skin and soft tissue resulting from the weight loss. She remains an insulin dependent diabetic but is attempting further control with weight loss and exercise. The patient was examined by a plastic surgeon who recommended a panniculectomy be performed. In addition, the patient wishes to undergo an abdominoplasty and brachioplasty. The Health Plan indicates the requested abdominoplasty and brachioplasty are considered cosmetic in nature and are not medically necessary.The submitted documentation including photographs of the patients trunk reveals findings of a small umbilical hernia and some irritation beneath the pannus. The pannus does not reach the pubis. The trunk and arms demonstrate redundant hanging skin. A panniculectomy has been authorized to treat the patients large pannus. The patient has been examined by a plastic surgeon without findings of medical necessity for abdominoplasty or brachioplasty. Thus, there is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. Therefore, I have determined that the requested procedures are 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 male with a lengthy history of documented low back pain and bilateral lower extremity pain. The patient is seeking spinal decompression surgery. The information submitted provides no clinical evidence or any other objective data, which would indicate that the proposed surgery is medically necessary. The information submitted provides no evidence that the proposed surgical intervention is indicated for this patient. No objective clinical information has been provided demonstrating why the proposed surgery is indicated. In fact, based upon the information provided, it is unlikely that the procedure would provide the patient any benefit. The proposed surgery would not be considered standard of care for this patient. 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 48-year-old woman with a longstanding history of back pain following a motor vehicle accident. The patient also reports neck, arm, and hand pain. The patient reports that she has benefited from physical therapy in the past. She has requested authorization for continued physical therapy. The Health Plan has denied the patients request.The submitted documentation indicates the patient has received 20 visits of physical therapy. Review of the provided notes demonstrates that the patients condition has reached a plateau with therapy. The patients condition is chronic and is not likely to improve with continued physical therapy. Other options should be considered including additional work-up to determine the etiology of her numbness. Based upon the information set forth above, I have determined that the requested therapy 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 56-year-old female with an illness dating to mid 2001 manifested by numbness and tingling of the head, hands and feet. The patients providers notes indicate that she had EMG and nerve conduction studies, which suggested Guillain-Barre syndrome. The provider considered HSV, another neurological disease or an autoimmune illness. No documentation for any specific diagnosis has been submitted. The CDC criteria for chronic fatigue are not mentioned or demonstrated in the patients medical records. The patient is seeking authorization for Procrit.In September 2003, the patients red cell mass was 33% less than predicted and blood volume was approximately 15% less than predicted. The patients red cell count and hemoglobin have been normal.A search of medical literature reveals no evidence of any data to support the use of Procrit for this patient. The patient had normal hematological studies before she began treatment with this medication. After therapy began, the patients hematocrit began to approach a level at which there could be unwanted side effects from polycythemia. Based upon a lack of clinical and scientific evidence, there is no evidence to support authorization of the requested medication. Therefore, I have determined that the requested medication is 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 62-year-old woman with a history of osteoarthritis, insulin-dependent diabetes, neuropathy, and hypertension. She sustained a fracture of the left distal femur and is status post multiple surgical procedures. The submitted records indicate the patient has received physical therapy and as of January 2004 was ambulatory with a walker and was beginning to ambulate with a cane. Additionally, the records indicate the patient is able to get in and out of a car with difficulty. She has requested authorization and coverage for a hospital bed because her bed is located on the second floor and she is unable to climb stairs. The Health Plan indicates a hospital bed is not medically indicated.There is no medical necessity for a hospital bed in this case. The submitted evidence indicates the patient is able to ambulate with a walker and has begun to ambulate with a cane. The fact that the patients bed is located upstairs is not a medical indication for a hospital bed. In this case, a hospital bed would serve as a convenience item rather than an item of necessity. Therefore, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 64-year-old woman with a left sciatic nerve injury, which is likely related to a left hip surgery. This is a well-documented complication. The patient has experienced persistent weakness for 1.5 years associated with chronic pain. The submitted information indicates the patient has been seen by two neurologists, an orthopedist, and two pain management specialists. The patient has requested authorization for a consultation at a specialized sciatica clinic. The Health Plan indicates the requested consultation is not medically necessary for diagnosis and treatment of the patients medical condition.The patient has a traumatic sciatic neuropathy, which has shown no evidence of recovery. Unfortunately, the patients condition does not lend itself to definitive therapy. The submitted information does not provide any medical justification for the requested consultation. There is no evidence that the patient cannot receive appropriate care within network. Furthermore, there is no indication that the requested clinic offers services that would necessitate a referral to that institution. Thus, the requested consultation is not medically indicated. The patient may benefit from a neurosurgical consultation to determine if nerve exploration and neurolysis may be appropriate.Based upon the information set forth above, I have determined that the requested consultation is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 31-year-old female with a BMI of 45. She has comorbid conditions including hypercholesterolemia and elevated blood pressure. She wishes to undergo gastric bypass. She has not undergone a formal psychological evaluation to determine whether she is an appropriate candidate for weight loss surgery.With a BMI of 45 and comorbid conditions, the patient meets accepted national medical necessity criteria for consideration of weight loss surgery. Roux-en-Y gastric bypass is medically indicated and medically necessary for treatment of this patients morbid obesity. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly 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. Such an evaluation is considered standard of care prior to authorizing 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 39-year-old pregnant woman who has benefited from chiropractic care in the past.  Recently, the patients primary care physician referred her for chiropractic care to treat her neck and back pain. The Health Plan indicates chiropractic manipulation may be harmful in the third trimester. Therefore, the Health Plan has determined that chiropractic care is not medically indicated during the patients pregnancy.In January 2004, the patients primary care physician indicated the patient had scoliosis and cervicalgia, and referred her to a chiropractor. The patient has a specific coded diagnosis and one that chiropractic treats and manages as standard of practice with patients that are pregnant at various trimesters. Pregnancy is not an absolute contraindication even in the third trimester. Chiropractors apply spinal manipulation to hypomobile, dysfunctional segmental complexes and not to hypermobile areas. Those areas can be managed by postural changes and strengthening exercises. Furthermore, evidence suggests that manual manipulation may prevent back labor in those patients with low back pain during pregnancy. Chiropractic can be medically necessary to treat and manage pregnant patients during periods when neck and back complaints develop. The submitted evidence demonstrates that chiropractic is medically appropriate and indicated for this patient.Based upon the information set forth above, I have determined that the requested therapy 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 48-year-old woman who has been experiencing knee pain since at least September 2003. The patient was seen by her provider at least six times from September 2003 to March 2004, during which time the patient continued to complain of pain. The patient was given a knee brace and medication for arthritis was prescribed. Physical findings included tenderness, decreased range of motion, crepitus, and swelling. The patients provider has ordered an MRI of the knee to evaluate for a meniscal tear. The Health Plan has denied authorization for the requested MRI on the basis that it is not medically necessary.The patients persistence of symptoms and physical findings support further evaluation. MRI is the best non-invasive test to evaluate the knee. According to the article cited above, MRI of the knee is the imaging test of choice for meniscal pathology and is one of the most efficient uses of technology. Other evaluation techniques are less accurate, largely operator dependent or more invasive. The results of the MRI are necessary to determine further treatment options for this patient. Therefore, I have determined that the requested MRI 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 56-year-old woman with a several-year history of depression. The patients provider notes the patient had a positive response to individual counseling. It has been recommended that the patient receive ten weekly sessions of individual counseling. The Health Plan indicates additional individual therapy is not medically indicated.The submitted records demonstrate the patient has clearly benefited from ongoing psychotherapy. Her psychiatrist, while providing pharmacology intervention, feels continued individual therapy is medically necessary. The patients therapy sessions are well documented and clearly show ongoing benefit. It is clear from the submitted records that psychotherapy has been instrumental in preventing relapse and rehospitalization. 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 requested ten weekly sessions of individual psychotherapy should be authorized. At the end of the ten-week period, the patient should be reevaluated to determine whether additional individual psychotherapy should be authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 26-year-old female with a body mass index (BMI) of 40. She has comorbid conditions of back and joint pain. She has requested authorization for gastric bypass surgery. The Health Plan has denied the patients request. She has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery.With a BMI of 40 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. In addition, the patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly obese. Therefore, 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 seven-year-old male who has been diagnosed with autism with significant developmental delay. The patient has been receiving weekly occupational therapy to help develop age appropriate oral motor, fine motor, and gross motor coordination. The patients therapist has requested continued weekly therapy for four months. The Health Plan has approved twice-monthly occupational therapy visits for a four-month period. Review of the submitted materials indicates the patient has been receiving occupational therapy since December 2001. There are multiple clinical notes suggesting the patient has made some progress, but continues to be below age appropriate levels. However, there is no consistent baseline data. Given the subjective nature of the patients current level of function and the relatively vague goals (i.e., demonstrate increased utensil use, demonstrate increased dynamic balance, etc.), it cannot be definitively determined that weekly occupational therapy is more appropriate than twice-weekly therapy. Thus, while continued occupational therapy is medically necessary to help with the patients developmental skills, there is not sufficient evidence to determine that weekly occupational therapy is indicated. However, the patient should be re-evaluated at the end of the four-month period to assess if he requires continued occupational therapy, more frequent occupational therapy, or decreasing occupational therapy.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 58-year-old woman with visual acuity of 20/40 in each eye. She is noted to have 2+ cortical cataracts and 1+ posterior subcapsular cataract (PSC) in the right eye. The patient states that she has difficulty driving and performing job-related duties due to her vision problems. Bilateral cataract surgery has been recommended. The Health Plan indicates that the submitted information does not demonstrate that cataract surgery is medically indicated.Although the patients stated visual acuity is 20/40, she has 2+ cortical cataracts and 1+ PSC in the right eye. These types of cataracts are known for causing much worse vision under certain lighting situations. Such patients generally perform very well when tested in a dark room; however, their vision is severely impaired in the sun or when encountering the glare of oncoming headlights. Such symptoms are well documented in the case of this patient. Thus, bilateral cataract surgery is medically indicated for treatment of the patients impaired vision.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: Overturned Decision of Health Plan

The patient is a 27-year-old man with a history of open bite dental malocclusion with posterior cross bite. The patient has a history of pain in teeth and jaws with chewing, headaches, and pain in the muscles of mastication. The patients discomfort and inability to chew a wide variety of foods has increased over the last 18 months. His pain is temporarily relieved with altered (soft) diet, NSAIDS and a dental orthotic splint.The submitted medical and dental records confirm a dental malocclusion compound class III jaw relation, posterior cross bite, and anterior open bite in excess of 3mm. Periodontal records show anterior maxillary gingival recession, which is abnormal for this age group. A request has been made for orthognathic surgery. The Health Plan indicates that surgical intervention is not medically indicated.The patient exhibits chronic pain and headaches with compromised ability to masticate. The patients provider has confirmed a dysfunctional class III open bite malocclusion with an anterior open bite in excess of 3mm. The patients condition cannot be resolved with orthodontic treatment alone. Furthermore, the fact that the patients symptoms are temporarily relieved with a splint indicates an excellent prognosis for success in resolving the problem with orthognathic surgery. All of the above-mentioned factors are indications for surgical intervention. Therefore, 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 15-year-old female with a diagnosis of idiopathic scoliosis, which has progressed to 50 degrees. In 2000, the patients curve was 34 degrees and she was placed in a full-time thoracolumbosacral orthosis brace. Despite bracing, the patients curve progressed to 50 degrees. A request has been made for an idiopathic Copes Dynamic brace. The Health Plan has denied the request indicating that the requested equipment is not medically necessary for treatment of the patients scoliosis.Review of the current literature reveals no scientific evidence regarding the efficacy of the requested brace. Additionally, there is evidence indicating that if an idiopathic scoliosis progresses to greater than 50 degrees while in an acceptable brace, continued bracing will not prevent further curvature in a premenarchal patient. Also, the primary recommendation of the patients providers is surgical intervention. Given the lack of scientific evidence supporting the requested brace and the degree of curvature experienced by the patient, I have determined that 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: Overturned Decision of Health Plan

The patient is a 66-year-old male who is requesting authorization for Levitra (5 phosphodiesterase inhibitor) for the treatment of erectile dysfunction. The Health Plan has denied this request on the basis that the patient has no clear etiology for erectile dysfunction and therefore, the patient does not have an established diagnosis required for authorization of Levitra.The patients records document the patient has hypertension, elevated cholesterol and that he underwent transurethral resection of the prostate in 1999. The patient dates the onset of his erectile dysfunction to the prostate procedure. The patient initially had some success with Viagra but indicates that it is no longer effective. He is now seeking authorization for Levitra.Viagra and Levitra are accepted primary therapy for erectile dysfunction. Treatment of erectile dysfunction is goal directed. Treatment that is successful and acceptable to the patient and his partner is appropriate therapy. It is estimated that 50% of males over the age of 60 have erectile dysfunction.This patient has documented risk factors for erectile dysfunction, including hypertension and elevated cholesterol. He has also had a transurethral resection of the prostate, which has a small but definitive complication rate (less than 10%) of causing erectile dysfunction. For these reasons, the patient does have a medical diagnosis of erectile dysfunction.Given the fact that the patient no longer responds to Viagra and Viagra and Levitra have the same action mechanism, it is unlikely he will respond to Levitra. However, the patient should be provided a trial of Levitra to determine if it is effective.Based upon the information set forth above, I have determined that a one-month trial of Levitra is medically indicated for this patient. 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.