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

This patient is a 58-year-old female who has a history of Stage IIA infiltrating ductal and lobular carcinoma of the left breast. She is status post lumpectomy; sentinel lymph node biopsy showed metastasis in a lymph node (0.2cm). She had an incidental (less than 1 cm) bronchoalveolar lung cancer removed following the breast cancer diagnosis. The patient is estrogen receptor and progesterone receptor positive and human epidermal growth factor receptor 2 negative. Adjuvant chemo/hormonal therapy is clearly indicated. The patients chemotherapy protocol has included dose dense adriamycin/cytoxan followed by dose dense Taxol or Taxotere followed by radiation therapy and hormonal therapy. Neulasta was prescribed for chemo-related neutropenia.  Due to changes in the patients health plan, Neulasta was later denied, and Neupogen authorized.  The patient would like to continue with the Neulasta at two-week intervals versus eight injections per chemotherapy cycle with Neupogen. The dose dense adriamycin/cytoxan followed by dose dense Taxol protocols as originally described by the CALGB protocol employs Neulasta to allow deliverance of the chemotherapy at two-week intervals. This has produced superior results as compared to the same regimen given without Neulasta every three weeks. The use of Neulasta with this adjuvant chemotherapy regimen is the community standard of care and should be authorized. Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 31-year-old female with a two-year history of vulvar pain. She has consulted with her primary care physician as well as several OB/GYNs. She was screened for multiple vaginal infections and unsuccessfully treated. In an effort to address the possibility of neurogenic pain, the patient had been given a trial of Elavil, which she was unable to tolerate. The patients chronic pain had escalated to the point where she was having difficulty walking or sitting for any period of time and she was contemplating applying for disability since she was not able to continue working in her current state.At that point the patient was referred by her gynecologist to a pelvic pain specialist who diagnosed her with subcutaneous panniculosis and pelvic floor musculoskeletal hypersensitivity. The patient was started on a course of physical therapy and subsequently reported marked improvement of her pain.The treatment of chronic pelvic pain/vulvodynia is difficult and is often beyond the scope of a general gynecologist as is demonstrated in this case. After consulting with a number of physicians and trying all of the conventional therapies, the patient did not experience any improvement in her pain and was referred to a pelvic pain specialist.  This provider made a diagnosis of subcutaneous panniculosis with pelvic floor musculoskeletal hypersensitivity and recommended physical therapy (PT) and biofeedback.The use of PT for the treatment of chronic pelvic pain is not without precedent. The March 2004 ACOG Practice Bulletin cites observational studies that suggest various PT modalities are effective, e.g., manual treatment of trigger points in the pelvic floor resulted in improvement in pain in 65-70% of cases. In addition, there has been extensive publication on this subject in the urological literature. Given the extent of the patients disability, the failure of conventional treatments, and the lack of alternative services offered by the Health Plan, physical therapy with a pelvic pain specialist is medically reasonable and appropriate for treatment of this patients vulvodynia. 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: Upheld Decision of Health Plan

This case involves a 14-year-old male with idiopathic short stature. It does not appear GH stimulation testing has been performed. A brain MRI revealed a normal appearing pituitary. Recent serum levels of IGF-1 were normal for Tanner stage 4 of sexual development at 341. The projected adult height was 65 inches compared to a mid-parental height of 70.5 inches. Based upon the submitted records, it appears that the patients growth has always been just below the 3rd percentile. The submitted materials indicated GH was prescribed in June 2005. The endocrinologist noted that the patient had not had a pubertal growth spurt. After GH therapy, the summary indicates a growth velocity of 11.7 cm per year. The patient has requested authorization and coverage for growth hormone therapy. The Health Plan has denied this request on the basis that the requested therapy is not medically necessary for treatment of the patients medical condition.The Food and Drug Administration (FDA) approved GH therapy for idiopathic short stature (ISS) defined by the following: height of under 2 standard deviations (1.2 percentile); height velocity unlikely to permit attainment of adult height in the normal range, if they had not yet closed their epiphyses; and diagnostic evaluation has excluded other causes associated with short stature. These percentiles extrapolate to adult heights of less than 53 for men and less than 411 for women. The pivotal randomized double blind study concerned 71 children aged 9-15 years of age given GH or placebo three times weekly until final adult height was reached. Of the 33 patients who contributed final adult height measurements after a mean duration of 4.4 years of treatment, the mean final height achieved by GH treatment was +1.5 inches over placebo treated controls. In the second study where treatment was in 3 different doses for a mean of 6.5 years, mean final height exceeded final height predicted at baseline by nearly 3 inches. Though it has been proven that adult height can be increased in children with idiopathic short stature as indicated in the information cited in the FDA application, the FDA has imposed restrictions to limit usage to those destined to be short adults. The height prediction involved in this case is above that target, and the height velocity and height for age also apparently fail to meet the FDA criteria. Thus, based upon the information provided, GH therapy is not medically warranted in this case. Therefore, I have determined 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 an 11-year-old male who has a diagnosis of idiopathic short stature. He had a growth hormone stimulation test in November 2004, which had a normal response. A radiologic report found the patient had a bone age reading of 8 years at the chronologic age of 10 years 8 months. The consulting pediatric endocrinologist indicated the patient had a bone age of 9 years and 6 months at the chronologic age of 10 years 1 month. By calculating the patients predicted adult height based on each x-ray reading using Greulich & Pyles Radiographic Atlas of Skeletal Development of the Hand and Wrist, the respective final height predictions differ by less than 2 inches, (65 inches using a bone age of 9 years 6 months and 66 inches using a bone age of 8 years 10 months). The patient began receiving growth hormone therapy in February 2005. His parents are requesting coverage for continued growth hormone therapy. The Health Plan has denied this request on the basis that the requested therapy is not medically necessary for treatment of the patients condition.The patients clinical history and laboratory findings are not consistent with the accepted diagnosis of idiopathic, isolated growth hormone deficiency. However, the patients stature is below the 5th percentile and less than -2 standard deviations below the mean for his age, as well as less than 2 standard deviations below his expected mean parental height. Additionally, his growth velocity was 3.6 cm per year prior to starting therapy at around the 3rd percentile for his age. Furthermore, there is an absence of a specific conservative process. These findings suggest a diagnosis of idiopathic short stature as the most likely etiology for the patients small size, slow growth and low growth hormone dependent proteins. The Food and Drug Administration has recently approved growth hormone for the treatment of idiopathic short stature as a medically indicated therapeutic intervention to promote growth velocity and final adult height. Thus, given the available evidence-based data, it is medically reasonable and appropriate for the patient to continue to receive growth hormone therapy until he has completed a 12-month trial of therapy with close monitoring of his height response. It is essential, however, that the patients pubertal development be periodically evaluated because of his age and the potential for the onset of puberty to confound his growth velocity response to growth hormone. 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 58-year-old female who is 64 inches tall, weighing 321 pounds with a body mass index (BMI) of 55.1. She is requesting authorization for gastric bypass surgery. The patient has hepatitis C and other significant comorbid conditions. The patient outlines a significant history of family obesity and attempted weight loss both through supervised and unsupervised diet plans. The patient completed a psychological evaluation and it was recommended that she see a therapist both before and after gastric bypass surgery.  With a BMI of 55.1 and comorbid conditions, 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 this patient. 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 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 obese. Moreover, regarding the patients psychological status, the NIH recommends psychological screening for those with eating disorders. This patient has completed a psychological evaluation, which found her in good mental health, well informed about the proposed surgery, and in a stable living situation. The patient should follow through on the recommendation to see a therapist both before and after bypass surgery.Based upon the information set forth above, I have determined the requested surgery 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

This case involves a 39-year-old female who carries the diagnoses of chronic pelvic pain, neuropathy, endometriosis and bipolar disorder. She has been treated with danazol, opiates, and anti-seizure medications; the latter was used to treat the patients neuropathy. Apparently, the patient is unable to tolerate the opiates or Neurontin due to her bipolar disorder. Currently, she and her providers believe that Lidoderm patches offer her the only option for pain relief. The Health Plan does not consider Lidoderm patches medically necessary for this patients condition.The treatment of chronic pelvic pain is complex and often requires a multidisciplinary approach and a departure from more conventional therapies. Although Lidoderm is only FDA approved for post-herpetic neuralgia, its use in the treatment of chronic pelvic pain is not without precedent.  Additionally, Lidoderm is currently being used for treatment of other types of chronic pain, such as low back pain and osteoarthritis. Furthermore, it appears no viable alternative to the Lidoderm patch has been proposed in this case. Lidoderm patches appear to be the only effective option for this patient at this time. Therefore, 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

This patient is a 35-year-old male with back pain, which radiates to his legs. The patient indicates he has received chiropractic treatment in the past. X-rays of the lumbar and thoracic spine from August and December 2003 do not reveal significant bone disease. The findings show possible spina bifida occulta at S1 and loss of lordosis. Physician office visit notes from April 2005 mention coccygeal pain radiating to the patients legs for two years, which was recently aggravated. The patient is taking NSAIDs and performing home exercises. He has requested authorization and coverage for physical therapy. The Health Plan has denied this request citing a lack of medical necessity for the requested therapy.Upon review of the submitted records, it appears this patient has musculoskeletal back pain. As such, the patient may benefit from a physical therapy evaluation and instruction in pertinent exercises involving body mechanics and posture. Therefore, four to six physical therapy visits are medically indicated in order to attempt to improve this patients functional ability and decrease his discomfort. Accordingly, 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

This patient is a 36-year-old female with symptomatic mammary hypertrophy (back, neck, and shoulder pain as well as headache and intertrigo).  She sought consultation with a board certified plastic surgeon who recommended a bilateral reduction mammoplasty to relieve her symptoms. The patient had previously tried physical therapy with only short-term relief. The Health Plan has denied authorization for the requested surgery citing the small volume of breast tissue to be removed as not consistent with medical necessity.The submitted materials include clinical records and digital photographs of the patient. The evidence provided demonstrates large breasts consistent with the symptoms stated.  The proposed surgery is very likely to result in resolution of the patients symptoms. Based upon the information provided, the patient meets ASPS recommended guidelines for a bilateral reduction mammoplasty. As such, I have determined that the requested surgery 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 52-year-old male who received continued chiropractic care of prolonged duration for his low back and leg complaints. The patients pain intensity varies from 5/10 to 8/10. The stated chiropractic goals are to provide 100% reduced pain and 100% improved range of motion. The Health Plan has denied coverage for further care beyond one visit citing a lack of medical necessity. In the alternative, the Health Plan has recommended the patient consult his primary care physician.Review of the submitted records indicates the patient has chronic low back and leg pain. The stated chiropractic goals of complete pain relief and full range of motion are not likely to be achieved by any set number of chiropractic visits. Furthermore, the record does not reveal that gaps of care occurred or that a home program has been developed and practiced. Thus, there is insufficient evidence that continued chiropractic services are medically necessary at this time. The patient should receive a referral to his primary care physician for further workup.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 at this time. The Health Plans denial should be upheld at this time. The patient should follow-up with his primary care physician. If the patients primary care physician recommends additional chiropractic therapy for treatment of flare-ups, the patients request for chiropractic therapy should be reconsidered.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is an eight-year-old female born in Russia. She came to the United States at age four. Prior to immigrating, she was found to have speech delays. She began receiving speech therapy at age three. Based on the information provided, it appears the patient has been receiving speech therapy from her current therapist since May 2004.  Goals have been toward expressive vocabulary, understanding and production of irregular verbs, comprehension of grade level curriculum stories and grade level vocabulary. There is an undated report demonstrating mild progress in goals, but most goals were unmet. The patients parent has requested reimbursement for the speech therapy services the patient received from January 2005 through July 2005. In addition, authorization for continued speech therapy through the end of the year has been requested. The Health Plan has denied these requests on the basis that speech therapy services were/are not medically necessary for treatment of the patients condition.The goals as outlined in the undated report demonstrate objectives that are primarily educational. In addition, the reports provided do not develop an adequate treatment plan with short and long-term goals and documentation of each review session. Furthermore, it does not appear the patient has undergone standardized testing after the initial assessment to objectively determine if goals are being achieved. Finally, there is no evidence the patients speech delays are more than developmental delays aggravated by the fact that English is the patients second language. For the reasons stated above, 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a 42-year-old male with an apparent substance abuse disorder and sexual addiction who was admitted to a partial hospitalization program in July 2005. In August 2005 the patient was apparently diagnosed with major depression and was treated with Wellbutrin. It appears the patient responded well to treatment and was cooperative. The Health Plan indicates the submitted documentation does not demonstrate that partial hospitalization services were medically necessary beyond August 2005. The patient has requested coverage for partial hospitalization services after August 2005.Review of the clinical evidence provided indicates the patient was stable by August 2005 with his substance abuse, sexual addictive problems and depression. He was not suicidal, homicidal or psychotic. He was motivated to continue sobriety and further treatment. As such, continued partial hospitalization was no longer medically necessary for any of his psychiatric conditions. A lesser level of continued treatment was appropriate after August 2005. Therefore, I have determined the requested services 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

This case involves a 53-year-old female who suffers from migraine headaches for which she takes Maxalt and she takes Zofran for the comorbid nausea. The patient wishes to continue taking Zofran for her nausea. The patient indicates that she is also suffering from depression. She has been prescribed Adderal for an unknown reason.  The Health Plan has denied authorization and coverage for Zofran because it is only approved for nausea due to cancer treatment.This patient is taking Maxalt for her migraines, which is known to cause nausea.  The patient has not fully explored alternative medications for treatment of her migraines or her comorbid nausea according to the records provided. A trial of Zomig nose drops or another migraine medication that does not cause nausea might be beneficial. Reglan is an effective and well-tolerated anti-nausea medication. Depending on the frequency of the patients migraine headaches, prophylactic treatment with Depakote might be indicated. Depakote may also help with mood stabilization. As it appears there are other medications available that are likely to be effective for this patient, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 56-year-old male with right knee osteoarthritis who had arthroscopic surgery in February 2003. He had a series of Synvisc injections before the surgery with good results. He had two additional series of injections in April 2003 and May 2004. The patient does not tolerate anti-inflammatory medications. He had a steroid injection into the knee joint that is only expected to provide short-term relief. The patient is now requesting a fourth series of Synvisc injections. The Health Plan has denied the request as not medically necessary.At this time, there is no class I data to support a fourth round of Synvisc injections for the treatment of knee arthritis. The current literature does not support any more than two series of injections. An additional series of Synvisc injections at this point 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 three-year-old male with an expressive speech delay. He has a history of otitis media but there is no documentation of an effusion. Audiology was reportedly within normal limits. Initial speech evaluations were performed by two different providers in June 2004 and December 2004. The evaluations document mild to moderate speech delay. It appears the patient has been receiving speech therapy since February 2005. A request has been made for authorization and coverage for continued speech therapy at a frequency of three times per week. The Health Plan has denied this request on the basis that continued therapy is not medically necessary for treatment of the patients condition.In reviewing the submitted documentation, the June 2005 progress report does not demonstrate that progress has been made in this case. Additionally, the evaluations provided do not report the progress made on each goal. Furthermore, review of the relevant literature does not demonstrate that an increased frequency of speech therapy (above and beyond the therapy being provided by the school district) results in a superior clinical outcome in cases such as this. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.