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

This patient is a 44-year-old man diagnosed with chronic lymphocytic leukemia (CLL) in April 2000. He was initially treated with chemotherapy from February through May 2002 with a good response. He was found to be ZAP-70-positive, which is an unfavorable prognostic marker and accordingly, he began more intensive chemotherapy in 2005, again with a good response. A bone marrow aspirate in November 2005 showed only minimal residual disease. The patient has sought several medical options, and now wishes to have consolidation therapy with alemtuzumab (Campath) in an effort to eradicate the minimal remaining leukemia cells in his bone marrow.  The Health Plan has denied the patients request for authorization based upon a determination that consolidation therapy with Campath (alemtuzumab) is not medically necessary.The treatment of very minimal residual disease in patients with CLL is a controversial topic and the subject of several ongoing clinical trials. A variety of treatments have been utilized in an effort to eradicate residual disease from the bone marrow.  In this particular case the treatment under consideration is alemtuzumab, a monoclonal antibody. A recent study by Moreton, et al. strongly suggests that in a small number of patients, alemtuzumab can indeed eradicate minimal residual disease and that this therapy is associated with prolonged survival. Reviews on this topic have recently appeared in Seminars in Oncology and data on the use of alemtuzumab in this setting is very encouraging. All in all there is sufficient data to conclude the patient is likely to experience meaningful clinical benefit from consolidation therapy with Campath (alemtuzumab).Based upon the information set forth above, I have determined 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 40-year-old male who underwent anterior cruciate ligament (ACL) reconstruction for a left ACL tear and medial collateral ligament sprain in November 2005. He was examined by his orthopedist in May 2006. At that time it was noted the patient had full range of motion, but some residual ligamentous laxity and significant muscle atrophy and weakness. The patients orthopedist has recommended a custom brace for use with activity to help stabilize the knee. The Health Plan has denied coverage for the requested equipment on the basis that it is not medically necessary.The submitted clinical evidence documents the presence of residual ligament instability and muscle atrophy and weakness. Use of a brace for activity is medically indicated and necessary in this setting to protect the knee from further injury in its weakened condition. Ligament instability cannot be treated by rehabilitation or any other conservative therapeutic measures. Chronic, symptomatic ligament instability is an absolute indication for use of a brace to provide external stabilization.For the reasons set forth above, I have determined the requested equipment 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 49-year-old female with a history of type 1 diabetes mellitus, bilateral carpal tunnel syndrome, goiterous thyroid, sleep apnea, hypertension, morbid obesity, degenerative disc disease and bilateral lower extremity weakness. Her need for a power operated vehicle (POV) was assessed in May 2006 by a physical medicine and rehabilitation (PM&R) and pain specialist; at that time she was able to propel a manual wheelchair. The patient indicates she is in need of various types of adaptive equipment.  She has requested authorization for a POV, hospital bed, lift chair, access ramp and automobile wheelchair lift. Her request was denied by the Health Plan based upon a determination that the requested equipment is not medically necessary.A neurological examination in February 2006 documented normal strength in the upper extremities. In May of 2006 the patient was evaluated by a PM&R specialist and was noted to have 5/5 strength and full range of motion in her upper extremities. The examiner felt the patient did not meet CMS criteria for a POV and she was observed using a manual wheelchair without difficulty. On physical exam a scar on the right wrist was noted from previous right carpal tunnel release and Tinels sign was negative. There is no documentation of symptoms that would suggest on-going carpal tunnel syndrome such as numbness in hands, wrist pain, a positive Tinels sign, or an upper extremity EMG report. The patient may be in need of other adaptive equipment, but a determination of her specific needs is not possible from the records provided.  The home care notes are not consistent and it appears the patient chose to forego physical therapy after limited intervention. A complete and objective physical assessment should be accomplished to more clearly identify the patients current functional abilities and her limitations along with a home evaluation so that her specific equipment needs might be identified.Based upon the information set forth above, I have determined the requested POV is not medically necessary for the patients mobility. Furthermore, it cannot be determined that the additional equipment is medically necessary at this time. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 55-year-old female with a history of significant back pain. She underwent a course of conservative treatment without relief. Eventually the patient underwent sacroiliac joint injection/arthrography in August 2005. The patient achieved good results from the procedure with alleviation of her pain. She is seeking reimbursement for the cost of the procedure from the Health Plan.Sacroiliac joint injection/arthrography was a clinically appropriate and indicated procedure for this patient. She had attempted a course of conservative treatment including home exercises, medication and rest. It was not until the sacroiliac injection was performed that she experienced any relief of her pain. As such, the procedure at issue was medically reasonable in this setting. Accordingly, I have determined the procedure at issue was 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 50-year-old male who was hospitalized with intracranial hemorrhage and leukemia. He had dramatically impaired consciousness. The patient was receiving IV antibiotics and PE tube feedings. An intracranial shunt was placed. He remained at an acute inpatient level of care through August 2006. The Health Plan indicates the patient could have been transferred to a sub acute level of care as of July 2006.Review of the submitted clinical evidence indicates the patient was stabilized by July 2006 and off antibiotics by July 2006. As of July 2006, the treatment plan was to discharge the patient to a skilled nursing facility. There was no change in the patients condition in July 2006 warranting continuation at an acute level of care. He was transferred to a recovery floor and was no longer in an acute medical unit. All of the patients medical issues were chronic in nature as of the last authorized date of service. All acute conditions had been addressed and stabilized by July 2006 and therefore there was no indication for continued acute hospitalization.For the reasons stated above, I have determined 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 24-year-old male with a three-year history of polysubstance abuse including cocaine, alcohol and marijuana who was admitted to inpatient treatment in May 2006 following a relapse. He was involved in outpatient treatment for substance abuse for approximately five months prior to inpatient admission, and had not used any substances from November until mid March when he and some friends used alcohol and cocaine at a party. In May 2006 the patient again used alcohol and was expelled from the outpatient program. On the recommendation of his outpatient provider, he was referred for inpatient treatment. His initial diagnoses included major depression, moderate, recurrent, personality disorder, and alcohol dependence.During his inpatient course of treatment, the patient was described as motivated for treatment, cooperative and an active participant in the various therapies and 12-step meetings. He presented as euthymic with congruent affect, linear thought processes, good insight and judgment and unimpaired perceptual and thought content. He was also noted to be able to contract for safety.  The patient continued treatment with Lamictal 250mg and Celexa 40mg without adjustment of his previous outpatient dosages; his Zyprexa was discontinued.  He was not described as significantly depressed or suicidal at any point during his inpatient stay.The patients request for reimbursement for acute inpatient substance abuse rehabilitation services provided from May 2006 through May 2006 was denied by the Health Plan citing a lack of medical necessity. The basis for the patients inpatient referral is not clear; relapses often occur in this setting and do not equate to a need for inpatient treatment. The patient did not require detoxification as his use of alcohol and cocaine was highly variable, he was a willing participant in his treatment, and his depression was quiescent. It is obviously within the purview of his former outpatient program to suspend him for noncompliance with their rules, but an alternative outpatient program should have been identified prior to May 2006. All told, I have determined 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: Overturned Decision of Health Plan

The patient is a 38-year-old woman who injured her knee. She required an anterior cruciate ligament (ACL) reconstruction. Postoperatively it was noted she had stiffness and limited range of motion. A continuous passive motion (CPM) device was prescribed. The patient has requested reimbursement for the device. The Health Plan denied coverage based upon their determination that the CPM device was not medically necessary following the patients surgery.A CPM device is often prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. In this case, the patients provider noted the patients postoperative progress was slow and she was experiencing stiffness. Subsequently, he appropriately prescribed the CPM device to attempt to regain motion and diminish stiffness in conjunction with physical therapy. Therefore, I have determined the device at issue was 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

This patient is a 43-year-old male with chronic, severe low back pain, chronic neck pain, and acute episodic pain related to Crohns disease. The patient indicates standard pain medications have not effectively managed his pain and his provider prescribed a quantity of 30 800mg Actiq for an acute Crohns flare in July 2006. Authorization was denied by the Health Plan and the patient paid out of pocket for the prescription. His request for reimbursement and prospective authorization of Actiq was denied by the Health Plan based upon a determination that the medication is not medically necessary.Actiq is currently approved by the FDA for the management of cancer-related breakthrough pain. The medication has not been approved for the management of Crohns disease or chronic neck or back pain. The use of Actiq in this context is not medically indicated and is not consistent with the community standard of care. 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: Overturned Decision of Health Plan

The patient is a five-year-old male with a history of allergies and asthma. He has had multiple ear infections resulting in insertion of bilateral PE tubes in March 2006. The patient has been receiving speech therapy for his articulation deficits with reported benefit. His therapist has recommended continued speech therapy twice a week for 12 weeks. The Health Plan has denied this request on the basis that additional speech therapy is not medically necessary for the patient.The patient has chronic asthma and recurrent otitis media with resultant articulation disorder. The submitted records document that he has had good response to tube insertion and speech therapy. His speech disorders are secondary to his physical illnesses. Speech therapy is the appropriate intervention for the patients speech deficit and should be continued. The patient should be provided the requested 12 weeks of speech therapy with re-evaluation by his provider at the end of the 12-week period to determine if additional therapy is needed.Based upon the information set forth above, I have determined 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 34-year-old man who sustained an injury to his knee requiring an ACL reconstruction. Postoperatively, the treating surgeon ordered a continuous passive motion (CPM) device, which the patient obtained and utilized. The Health Plan has denied coverage for the CPM device on the basis that it was not medically necessary.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. A CPM machine was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the device at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 58-year-old female with a history of major depression, recurrent.  She initially presented for psychiatric treatment of her depression with symptoms of anhedonia, anergia, persistent sad mood, irritability, and hopelessness. Her family history is notable for depression and bipolar disorder in first degree relatives. Previous medication trials included Effexor XR, Gabapentin, lithium and Levoxyl.  Over the next two years Effexor was discontinued in favor of Cymbalta and Abilify was added and there was improvement in the patients mood. However, she was left with a degree of anergia for which Provigil was prescribed. The patients provider reports significant gains with Provigil and a return of depressive symptoms when Adderall was substituted for Provigil. The patient again improved when samples of Provigil were provided.The patients provider has requested authorization for continued treatment with Provigil. The Health Plan has denied this request based upon a determination that the medication is not medically necessary.The addition of Provigil to the patients antidepressant regimen is a rather benign supplementation that clearly seems to have helped her. The medication was prescribed on a test/retest basis, and its benefit was far superior to Adderall. Current literature supports the use of Provigil as an antidepressant adjunct, and the prescription in this case is medically indicated. As such, 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 16-year-old male (almost 17-years old) with a weight of 508 pounds and a body mass index (BMI) of 79.6. His comorbid conditions include asthma, dyspnea on exertion, depression, obstructive sleep apnea and stress incontinence. The patient has completed a psychological evaluation and it was determined that with supportive therapy, he is an appropriate candidate for weight loss surgery. The Health Plan has denied the parents request for coverage of bariatric surgery based upon their determination that the procedure is not medically necessary.With a BMI of 79.6 and comorbid conditions such as asthma, dyspnea on exertion, depression, obstructive sleep apnea and stress incontinence, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for him. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the 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. The psychological evaluation indicates the patient is a viable candidate for the surgery with appropriate follow up.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a three-year-old male with a diagnosis of mild autism spectrum disorder. He has been evaluated by a pediatric neurologist and was referred for occupational therapy (OT). The patient has been receiving OT services from two different providers for several months and is reportedly making progress. The parent has requested continued authorization and coverage for 30 minute sessions of OT provided by Orange County Therapy Services. The Health Plan denied the request based on a determination that OT is not medically necessary for the treatment of the patients sensory processing, motor skills and body awareness deficits.Additional OT services have been requested to address overall sensory processing, feeding (oral motor and sensory processing), fine motor, body awareness, motor planning and postural control. A thorough review of two research data bases reveals no medical evidence that OT intervention to address these issues is effective. Consequently, the therapy cannot be considered 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 53-year-old woman with long-standing Anorexia Nervosa versus Bulimia Nervosa, as well as Major Depression, recurrent. She has been treated with outpatient therapy and past enrollment in partial hospitalization. Her psychiatrist feels that she has not been making progress in outpatient care. Review of the treatment notes indicates that the patient binges and purges typically 3-4 times per week, sometimes as often as daily, and is often depressed. She has been seen in weekly therapy by her psychiatrist but has continued to binge and purge with regularity. She has been underweight and often reports dizziness as a result.  The patient appears unable to comply with the treatment plan, which included refraining from excessive exercise. Her psychiatrist has referred her back to partial hospitalization. Review of the progress notes from the patients prior course of partial hospitalization treatment points to her having been enormously resistant to not focusing on her body image of being fat, often having trouble eating 100% of the meals, and having relapses of binging and purging. However, she did eventually appear to make some progress, inclusive of weight gain, with the various therapies in addition to treatment with Lexapro and Provigil, with dosages ranging from 10-20 mg and 100-200 mg respectively. By the end of the partial hospitalization program, she was able to more easily, and resist the urge to ingest carbohydrates and then purge them. Treatment notes also mention the patients inclination to cut on herself, something she has evidently done in the past, as well as wanting to leave her psychiatrist of 13 years.  At one point, she brought some of her razor blades with her to one of her outpatient appointments.  The patients provider has recommended a partial hospitalization level of care for the patient. The Health Plan has denied this request on the basis that the requested services are not medically necessary.Given that the patient has clearly not been making progress in weekly outpatient psychotherapy and is still underweight and depressed, it is eminently reasonable to intensify the approach to treatment. As such, only a program with a good deal of daily structure would be expected to be successful and, to this extent, a partial hospitalization level of care is appropriate. Furthermore, review of the patients past course of partial hospitalization indicates she did make some progress. Although the improvement was not sustained over the long term, this would not preclude a return to this level of care. In total, there is sufficient evidence to conclude that partial hospitalization is medically necessary for treatment of the patients medical condition. Accordingly, the Health Plansdenial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a four-year-old male who stutters. He has participated in school-based group therapy as well as individual private speech therapy starting in May 2006. As of July 2006 the patient had success working at the three-word imitated sentence level. A request has been made for reimbursement for the private therapy as well as prospective authorization for continued therapy. The Health Plan has denied this request citing a lack of medical necessity.The Health Plans denial should be upheld. Disfluent speech at three to four years of age is usually of short duration. There is no clinical documentation to suggest that the patients speech difficulties are associated with a medical problem. Therefore, there is no evidence to demonstrate that speech therapy is medically necessary for this patient. As such, I have determined that the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.