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

This patient is a 23-month-old female born the product of twin gestation delivery with an apparent perinatal or natal anoxic event possibly associated with an occlusion of the cord. MRI is within normal limits. Vision is intact, speech is delayed. The patient has been diagnosed with cerebral palsy with spastic quadriplegia and truncal hypotonia. She has been receiving occupational and physical therapy and has made slow gains with trunk control. The patients therapists are recommending a TheraTog garment to improve trunk control.I have reviewed the literature provided by the vendor for justification of the TheraTog garment. Most of the literature is small scale, case study on review literature, which is not evaluating treatment in hypotonia, but rather, hypotonia in the upper extremities. The only hypotonia noted is fisting of the patients hands. The article cited by the patients providers as a key reference reports the garment was abandoned by all but one of the families. Furthermore, the study does not describe the specific use of the garment.Given the lack of scientific evidence, it cannot be determined that the requested equipment is medically necessary for this patient. As the Health Plan is not required to cover this equipment the patients providers may want to attempt to have the regional center purchase the equipment.Based upon the information set forth above, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 36-year-old male with a prior history of bipolar disorder. He was admitted to inpatient treatment on 1/18/05 due to decreasing appetite with a 10-pound weight loss, increased irritability, weakness, headaches, and a great deal of oversleeping. The patient estimated the latter at 21 hours a day for about three weeks. Previously, he had been treated with Adderall, which was stopped three weeks prior. More recently he was treated with Lexapro, Trileptal, and Provigil. As of his growing more depressed and irritable, he stopped the Trileptal, but did not notice any difference in his state. Upon admission, he actually denied feeling depressed per se, but did present with the aforementioned history of neurovegetataive change.On 1/19/05, the patient later indicated he was feeling down, sad and guilty that he was unable to work and earn more money. He later indicated to staff that he was very concerned and saddened to have learned that his dog died, feeling it important to return home. He was noted as calm and pleasant on approach. Presented as mildly anxious. On 1/20/05, the patient was noted as quiet and isolative, refusing to attend groups and preferring to spend the day in his room. However, he later indicated that he was going home tomorrow, and was noted as demonstrating brighter affect. His psychiatrist noted him as devoid of suicidal ideation. Finally, on 1/21/05, he was noted as feeling much better and as looking forward to discharge. His medications were maintained as Lexapro 30 mg, amantadine 100 mg, and Trazadone 50 mg, throughout.The patient has requested reimbursement for the acute inpatient psychiatric treatment services he received from 1/19/05 through 1/22/05. The Health Plan has denied this request indicating that the services at issue were not medically necessary.Though the patient warrants ongoing treatment, there is no evidence he warranted treatment at an inpatient level of care as of 1/19/05. Clearly, his response to inpatient treatment in terms of becoming less isolative was fairly brisk and the submitted notes do not demonstrate he was suicidal. Thus, he could have been transferred back to outpatient care as of 1/19/05. Therefore, 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 15-year-old male with a diagnosis of idiopathic short stature. He is being followed by pediatric endocrinologists. He had a low IGF-1 level of 192, but normal IGFBP-3 level. His bone age at 14 years 1 month was 13 years 6 months, which showed no significant delay, giving him a predicted adult height of 53 based upon his height at that time. The mid-parental height was listed as 67 inches. It is presumed thyroid tests were normal. There is no evidence GH stimulation tests were performed. The patients puberty was advancing and he was at Tanner stage 3 more than 1 year ago. He began growth hormone therapy in October 2004. Prior to starting growth hormone therapy, the patient had grown 10.2 cm in 22 months. After beginning growth hormone therapy, the patient grew 6.9 cm in 7-8 months (as of March 2005).  The patients provider has recommended the patient continue to receive growth hormone therapy. The Health Plan has determined growth hormone therapy is not medically necessary for treatment of the patients condition.As documented in the records provided, the patient does fulfill the FDA approved criteria for growth hormone therapy for idiopathic short stature as well as the American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for Growth Hormone. The patient has had a doubling of his growth rate in height since beginning growth hormone therapy. This therapy should therefore continue until growth has ceased. Therapeutic consideration of the means to extend his growth period with advancing puberty is being appropriately considered. Accordingly, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is an 18-year-old female with a history of fatigue and sleepiness. Her psychiatrist indicates the patient was tried on a number of medications without benefit and that Provigil has been the only medication that has been effective for the patients condition. Apparently, the psychiatrist wants to increase the patients prescription to 200 mg a day. The Health Plan has denied authorization for Provigil.Although there is evidence supporting the use of Provigil as an antidepressant adjunct and for treatment of residual fatigue, no objective evidence has been submitted demonstrating Provigil is necessary or indicated for this patient. There are other approved psychostimulants available for treatment of the patients condition that have not been attempted. Furthermore, based upon the information provided, it appears other causes of the patients fatigue have not been ruled out. Because of the need to rule out other causes of the patients fatigue and the availability of other approved psychostimulants, which apparently have not been tried, I have determined the requested medication 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 31-year-old female who has a history of excessive daytime sleepiness, depression, and anxiety. It appears the patient has been on antidepressant therapy. The patient received Provigil to control her fatigue with apparently good results. There is no evidence other psychostimulants have been tried by the patient. The Health Plan has determined Provigil is not medically necessary for treatment of the patients medical condition.Although there is evidence supporting the use of Provigil as an antidepressant adjunct and for treatment of residual fatigue, no objective evidence has been submitted demonstrating Provigil is necessary or indicated for this patient. There are other approved psychostimulants available for treatment of the patients condition that have not been attempted. Furthermore, based upon the information provided, it appears other causes of the patients fatigue have not been ruled out. Because of the need to rule out other causes of the patients fatigue and the availability of other approved psychostimulants, which apparently have not been tried, I have determined the requested medication 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 53-year-old female who is seeking authorization for the medication Provigil for treatment of idiopathic hypersomnolence. Clinical findings include severe daytime sleepiness, debilitating fatigue and sleepiness associated with chronic pain, a previous episode of encephalitis, and chronic pain syndrome with severe head pain. A prior polysomnography demonstrated periodic limb movement disorder. The patient has attempted a number of medications without benefit. The patients provider has recommended Provigil. The Health Plan has denied authorization for Provigil.The patients episode of encephalitis has resulted in chronic pain leading to treatment with many different medications including analgesics and various forms of benzodiazepines. Based upon the information submitted, it is not clear that a diagnosis of idiopathic hypersomnolence has been established. For example, her sleep study actually provided a different diagnosis (restless leg syndrome) than idiopathic hypersomnolence. Furthermore, there is potential her medication regimen is responsible for the fatigue and, according to the patient, some of her sleep disturbance is related to her chronic pain. For these reasons, a diagnosis of idiopathic hypersomnolence has not been established. 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 19-year-old female with a history of major depression currently relatively stabilized on Paxil 40 mg per day but with the continued side-effect of fatigue. The patients fatigue has been successfully treated with Provigil. A number of prior medication trials including Effexor, Paxil CR, and Trazadone were not effective for her depression. While receiving treatment without Provigil the patient encountered academic difficulties; the addition of Provigil led to academic improvement. Based upon these results the patients provider has recommended continued treatment with Provigil. In addition, the provider notes Provigil does not have dependency issues found with other stimulants.There is literature supporting the use of Provigil both as an antidepressant adjunct and for treatment of residual fatigue. The patient underwent a number of medication trials prior to having success with Paxil. Furthermore, the residual fatigue she experiences has been effectively treated with Provigil. Given this success, changing the patients medication from Paxil to another antidepressant in the hopes of avoiding residual fatigue is not medically indicated. Also, because her residual fatigue has been successfully treated with Provigil, discontinuing treatment with Provigil is not medically indicated.Based upon the information set forth above, I have determined the requested medication 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 35-year-old female who has requested continuation of Provigil for treatment of idiopathic hypersomnia based upon a previous polysomnography. The patient has been on Provigil for approximately one year. The Health Plan has denied coverage for Provigil on the basis it not medically necessary for treatment of the patients medical condition.The patients clinical history contends there is a sleep study documenting narcolepsy; however, the documentation actually suggests restless leg syndrome. Thus, the recommended alternative of caffeine products may aggravate the patients underlying condition. Furthermore, the patients multi-latency sleep study indicates a short onset to sleep of 1-1.5 minutes, suggesting significant sleepiness. Clinically, there is an inference of risk of falling asleep while driving. Provigil has been an effective therapy for the patient. Given the patients therapeutic response, continued treatment with Provigil is medically appropriate and indicated. Therefore, I have determined that 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 five-year-old male with speech delay noted as early as 18 months by his parents. He has received extensive therapy from July 2004 to March 2005 and his parents are also seeking authorization for continued speech therapy three days a week. At issue in this case is whether the therapy the patient received from July 2004 to March 2005 was medically necessary and whether continued therapy three days a week is necessary.The patient has been evaluated by a number of speech therapists. The evaluations are consistent and document the patients speech delay. The frequency of speech therapy is not well established in the literature. There is no evidence supporting the need for speech therapy three times a week. Furthermore, the patient has a common diagnosis for which speech therapy once a week has been proven to be effective. Although this patient has benefited from therapy, there is no evidence he would have benefited less from less frequent therapy or that he benefited more from more frequent therapy. Therefore, although speech therapy was and is medically indicated and necessary for this patient, speech therapy multiple times a week was not and is not medically necessary.Based upon the information submitted, I have determined 24 speech therapy sessions were medically necessary for treatment of the patients medical condition from July 2004 to March 2005. In addition, I have determined speech therapy once a week from 4/1/05 to 6/1/05 is medically necessary. After 6/1/05, the patient should be re-evaluated to determine whether continued therapy is medically necessary. Therefore, I have determined the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 58-year-old male with chronic atrial fibrillation. He has been treated with Coumadin for embolic prophylaxis. He experienced a CVA at a time when his INR was sub-therapeutic. The patients treating physician has stated that control of anticoagulation has been difficult and erratic. Therefore, the patients physician has recommended a home prothrombin-monitoring device for frequent INR measurements. The Health Plan has denied coverage for the requested equipment on the basis it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. INR determinations can be performed by a lab during regular business hours. The submitted evidence demonstrates the patient is mobile and can access such services. Furthermore, the standard of care is to monitor oral anticoagulation therapy periodically rather than on a daily basis. As such, the services available from a lab are adequate. Therefore, I have determined a home prothrombin-monitoring device is not medically necessary for this patient. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 17-year-old female who, while being investigated for abdominal pain, was discovered to have an incidental hepatic mass. The hepatic mass is not thought to be related to the patients presenting symptoms. Further evaluation of the mass suggests the likely diagnosis is a focal nodular hyperplasia (FNH) tumor. The patients treating providers have suggested that the appropriate management strategy includes re-imaging the tumor in six months and defer a decision on biopsy or surgery until that time. The patient and the patients mother want to proceed with surgery immediately. The appropriate management of suspected FNH such as this tumor is watchful waiting unless there is evidence this patients tumor FNH is related to the patients symptoms. There is no evidence the tumor in this matter is related to the patients symptoms. Therefore, removal of the tumor is not indicated at this time because of the potential that biopsy or surgery would cause the patient more harm than good. Because there is greater risk than benefit to biopsy or surgery at this time, the requested procedure is not medically necessary and is, in fact, contraindicated. The Health Plans recommendation for re-imaging in six months is appropriate and standard of care.Based upon the information set forth above, I have determined the requested procedure 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 38-year-old male with a history of disc herniation at L4-5. The patient received three physical therapy treatments in September 2004. On 11/3/04, a neurosurgeon recommended further physical therapy. The Health Plan indicates further physical therapy was not medically necessary as of 12/17/04 because the patient had a level of function within normal limits and did not have pain.Review of the submitted notes indicates the patient was not pain free on 12/17/04. While a treatment note of 12/17/04 indicates the patient was independent in core stabilization on flexibility program, treatment notes through 1/25/05 show the patient was continuing to make gains. His strength improved to 4+/5. He was educated in body mechanics and posture and had increased tolerance for sitting, standing, and walking with no signs of neurologic involvement. The therapy at issue was of reasonable duration with good progress documented. Therefore, I have determined that the therapy 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 44-year-old male with a history of possible onychomycosis. He reports pain and that he has twice had a toenail removed. He further reports he has been taking Lamisil and that his condition has improved. However, there is no evidence the patient has had a fungal culture confirming a fungal infection. Because of a lack of information, the Health Plan has denied authorization for Lamisil.In order to determine whether Lamisil is necessary there must be laboratory documentation confirming fungal infection and clinical documentation demonstrating pain/functional impairment. Such information is lacking in this matter. Therefore, Lamisil cannot be considered medically necessary at this time. If the patients provider provides clinical and laboratory documentation confirming fungal infection and pain/functional impairment, the Health Plans denial should be reconsidered. However, at this time Lamisil is not medically necessary. Therefore, I have determined the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 59-year-old male with apparently a long history of mood disorder treated with various medications as well as dietary supplements. He also reportedly had experienced several falls for 18 months prior to a SPECT scan being ordered, ostensibly to evaluate possible brain trauma. Apparently, prior to the SPECT scan the patient also had a head MRI that was noted to be normal. The Health Plan has denied coverage for the SPECT scan at issue on the basis it was not medically necessary for evaluation of the patients condition. Upon review of the relevant medical literature and the submitted medical records, a SPECT scan was not medically necessary to diagnose or manage the patients condition. The patient reports none of his falls resulted in loss of consciousness or required medical evaluation or treatment. Additionally, there is no indication the patient had his vision evaluated. Furthermore, findings of the SPECT scan did not contribute to the diagnosis or treatment of the patients depressive symptomatology. Therefore, I have determined that the SPECT scan at issue was 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 54-year-old male who has celiac sprue, diarrhea, and anemia. He is OB negative. A small bowel series was negative. A colonoscopy suggested the possibility of inflammatory bowel disease. The patients mild anemia is believed to have been caused by early myelodysplastic syndrome. An IBD Prometheus test was positive for Crohns disease. The patient wishes to undergo a wireless capsule endoscopy for further evaluation of his symptomatology. The Health Plan indicates the requested procedure is not medically necessary.Review of the submitted medical records reveals no medical indication for a wireless capsule endoscopy. Based upon the information provided, it appears the patients anemia is due to myelodysplastic syndrome. The patient is OB negative. Furthermore, though the patient had a positive IBD Prometheus test, this test is not 100% sensitive. If there is a high suspicion for Crohns disease based on the colonoscopy, then a trial of empiric therapy is medically reasonable and appropriate. If the patient fails to respond to a trial of empiric therapy or if his condition worsens, further testing may then be necessary. At this time, a wireless capsule endoscopy is not medically warranted. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.