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

The patient is a 14-year-old male who has been diagnosed with pituitary dwarfism. The submitted documentation indicates the patient has been receiving growth hormone therapy.  The patients height was noted as 150 cm. His weight was 38.5 kg. The patients physician has recommended further treatment with growth hormone therapy. The Health Plan has denied coverage for the requested therapy indicating growth hormone therapy is not medically necessary for treatment of the patients medical condition.Although the patients request for growth hormone therapy was submitted on the basis of a diagnosis of pituitary dwarfism (growth hormone deficiency), his laboratory evaluation failed to support such a diagnosis as classically and arbitrarily defined by a serum growth hormone level less than 10ng/mL after the administration of two standardized stimulation agents. In this context, the patient definitely fails to meet defined criteria for hormone therapy. However, growth hormone therapy is medically necessary for the patient under the FDAs latest approved indication of idiopathic short stature. As defined by the referenced articles and the FDA, the patient fits the various requirements for a diagnosis of idiopathic short stature and thus, meets medical necessity criteria for growth hormone therapy. Specifically, at initial evaluation the patient met the required characteristics of short stature (height less than 5% percentile), delayed bone age, pre-pubertal status, and normal statured parents. In this scenario, growth hormone therapy is indicated for at least a 6-12 month trial with close measurement of height response. Without detectable change in pubertal status, the patients growth during the initial 9 months of growth hormone therapy doubled from baseline to over 8 cm per year. Based upon these findings, continued growth hormone therapy is medically reasonable and indicated. 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 64-year-old man with long-standing lumbar pain and multiple medical problems including heart disease, history of disc space infection, and diabetes. A recent neurosurgeon consultation has been obtained, which found surgery was not indicated. The patient believes surgery is the most appropriate treatment option for his condition; therefore, he has requested authorization and coverage for surgical intervention. The Health Plan has denied the request on the basis that surgical intervention is not medically indicated in this case.Upon review of the submitted clinical evidence, I agree with the neurosurgical evaluation and conclusion. The patient is not a surgical candidate. The patients orthopedic condition of degenerative arthritis with no evidence of neural compression or instability does not warrant surgery. Furthermore, even if surgery were indicated, it would be an extensive procedure, which is contraindicated in a patient with heart disease such as this patient. Moreover, the patient has been offered medically reasonable alternatives for treatment. Therefore, I have determined that the requested surgery 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 38-year-old male with L1 paraplegia who has been receiving outpatient physical therapy for one year. He has requested further physical therapy to improve his level of functioning. The Health Plan has denied authorization and coverage for continued therapy indicating the requested therapy is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The patient has not recently demonstrated significant functional gain per the physical therapy note of June 2005. At this time the patient seems to have plateaued in physical therapy. The patient and his family should be independent in a home exercise program, which should be performed two times daily at minimum. Follow-up consultations with the patients spinal cord injury specialist should be performed to determine any change in rehabilitation potential. However, at this time there is no clinical indication for continued physical therapy. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 10-year-old male with issues of social integration, anger outburst and poor sensory processing and modulation. He has had multiple diagnoses from different providers including Aspergers syndrome, anxiety disorder, obsessive-compulsive disorder, and oppositional behavior. He has been seen by a speech therapist who documented that the patients classroom teacher had to give direction directly to the patient on most occasions. The therapist noted the teacher would have to say the patients name, increase the volume of her voice, and gaze at him to get a response; the therapist also noted the patient had difficulties using the restroom because of an inability to snap and unsnap his pants. The therapists evaluation of 1/27/05 noted the patient was unable to tie his shoelaces, had poor organizational skills, and had difficulties in processing modulating sensory input. The Health Plan has denied reimbursement for previous occupational therapy the patient received as well as authorization for additional occupational therapy on the basis occupational therapy is not medically necessary for treatment of the patients condition.The Health Plans denial should be overturned. It appears the processing problems described by the patients parents can be associated with Aspergers syndrome and attention deficit disorder. Sensory integration issues are also described in obsessive-compulsive disorder, but are more descriptive in nature. The patients symptoms fall on a spectrum of behavioral disorders. Additionally, the description of the patients behavior and social deficits appears to constitute sensory emotional disturbances. As such, occupational therapy including a sensory integration component is a reasonable treatment approach for this patient and should be continued. The occupational therapy should define specific goals that can be objectively quantified and these goals should be reviewed by the patients psychiatrist or primary care physician every six months. If the goals are not being met, therapy should be discontinued.Based upon the information set forth above, I have determined that the therapy at issue 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 63-year-old male with a body mass index (BMI) of 42.4. The patient has significant comorbidities. The patient reports multiple failed attempts at diets, all of which have resulted in weight regain. The patient has undergone a psychological evaluation and has obtained clearance for weight loss surgery. The patients provider has recommended the patient undergo gastric bypass with duodenal switch. The Health Plan indicates the long-term safety and efficacy of the procedure has not been established.The patient is an appropriate candidate for surgical intervention to treat his morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. 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

A 64-year-old woman with multiple non-specific symptoms had an IGF-1 test and an arginine stimulation test with GH levels. The results were suggestive but not unequivocally diagnostic of adult growth hormone deficiency (AGHD). An insulin tolerance test was normal (though barely), but no glucose levels are noted. Other hormone testing does not indicate other pituitary hormone deficiency. A request has been made for authorization and coverage for growth hormone therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the patients growth hormone deficiency.The patients symptoms are non-specific and not diagnostic of AGHD. The patient is not described as having excess central obesity. Her IGF-1 is in the normal range for her age and for the lab at which it was performed (Quest Lab). IGF-1 is not considered sensitive enough to use as a diagnostic tool for AGHD. The article cited above by Hartman et al. specifically states the presence of AGHD could be predicted with 95% accuracy by the presence of three or more pituitary hormone deficiencies (PHDs) or a serum IGF-I concentration less than 84 g/liter measured in the Esoterix assay. Furthermore, an insulin tolerance test, the gold standard for making a diagnosis of AGHD, is reported as normal though there is no indication of the adequacy of hypoglycemia achieved.Based upon the equivocal results provided, I have determined 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. However, the patient should undergo further testing including a repeat insulin tolerance test with documentation of adequate hypoglycemia (a glucose of less than 55 mg/dl) at some point during the testing. In addition, a repeat IGF-1 test should be performed under the Esoterix assay. Once these results are obtained, the patients request for growth hormone therapy should be reconsidered.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 54-year-old female who has been diagnosed with degenerative disc disease at three levels. Her physician has indicated she has tried and failed several attempts at conservative treatment including physical therapy and chiropractic care. Her physician has recommended the patient undergo artificial disc replacement at multiple levels. The Health Plan has denied this request indicating the requested procedure is experimental in nature.The patient has documented degenerative disc disease at three levels in the lumbar spine. There is no data to support artificial disc surgery at multiple levels. Additionally, there are no long-term outcomes studies. The proposed procedure is purely experimental. Given the lack of long-term data, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 54-year-old female with degenerative disc disease who has failed medications for pain and physical therapy and chiropractic manipulation. Her physician has recommended the patient undergo artificial disc replacement at multiple levels. The Health Plan has denied this procedure indicating the requested procedure is experimental and not a covered benefit.The use of multi-level artificial disc replacement in patients with degenerative disc disease is clearly investigational and without scientific merit. The existing studies do not show a major short-term advantage over fusion for one level disease. The use in this patient of multiple level disc replacement is not consistent with existing literature and cannot be recommended. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 54-year-old female with degenerative disc disease. She is requesting multi-level artificial disc replacement. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is experimental. Artificial disc replacement remains an experimental procedure without established clinical efficacy. There is no appreciable benefit conferred with the use of the artificial disc replacement. It remains an unproven procedure without established benefit. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 45-year-old female with approximately a three-year history of alcohol dependence, ingesting at least a bottle of wine per night, added to by daytime use of Sudafed, on the order of 10-15 tablets per day. Due to her increasing level of intake and inebriation, she decided to enter residential treatment. The patient had also experienced depression in the past, which was treated with Prozac. As of her admission, the patient was treated with a number of psychotherapies and was also begun on Lexapro.The patient has requested reimbursement for the inpatient chemical dependency services she received. The Health Plan indicates the submitted documentation does not demonstrate an inpatient level of care was medically necessary beyond the third day.Based upon review of the submitted documentation including the notes detailed above, it appears the patient was not appropriate for discharge from inpatient treatment. Notes point to the patient still being quite anxious such that, in the context of her background of chronic depression and sizable daily intake of alcohol, to have discharged her earlier would have predisposed her to relapse. The general drift of the treatments notes from the third-to last day onward, however, seem to point to a change in tenor such that discharge was appropriate. Therefore, I have determined that inpatient chemical dependency services were medically necessary for treatment of the patients medical condition through the third to last day.   Accordingly, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old male with residual neuropathic pain. He is status post decompression and post L3-S1 lumbar laminectomy and posterior lateral fusion at L3-4, L5-S1. His physician has recommended Lidoderm 5% patches (Lidoderm) for pharmacologic pain management. The Health Plan has denied authorization for Lidoderm on the basis it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Although Lidoderm may be used for the treatment of neuropathic pain (of any etiology), its use in this case is not medically indicated. Based upon the information provided, it appears the patients dosage of Neurontin has not been titrated to the maximum therapeutic dose. As such, prior to initiating a new medication such as Lidoderm, the patients current regimen should be optimized. In addition, low dose antidepressants may be appropriate to treat this patients post-surgical neuropathic pain. Therefore, I have determined that 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 69-year-old man who underwent resection of a lung cancer in January 2005. He was found to have a 3.5 cm well-differentiated adenocarcinoma, bronchoalveolar type. Lymph nodes were negative, and there was no evidence for lymphovascular invasion. As such, he was staged with T2N0M0 lung cancer. Initially, it was proposed that the patient be treated with adjuvant Iressa, which was denied by the Health Plan. It has now been proposed that the patient be treated with adjuvant Tarceva. The Health Plan indicates Tarceva is not medically necessary for treatment of the patients medical condition.Tarceva is a new drug that has been approved for use in locally advanced (inoperable) or metastatic non-small cell lung cancer after failure of chemotherapy. As of yet, it has not been studied as an adjuvant therapy to prevent recurrence of a resected lung cancer. Furthermore, the overall data on using adjuvant therapies in bronchoalveolar cancers is very minimal. In the absence of any data to support the use of Tarceva in this clinical setting, I have determined that 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: Overturned Decision of Health Plan

The patient is a 28-year-old super morbidly obese woman who has a body mass index (BMI) of 69. She apparently tried a short course of medically managed weight loss for 1.5 months but this was interrupted by pregnancy. She has comorbidities of hypertension, asthma, and joint pains. There is no documentation of psychiatric evaluation. The patient has requested authorization and coverage for weight loss surgery. The Health Plan has denied the request on the basis the requested procedure is not medically necessary.With a BMI of 69 and comorbid conditions such as hypertension, 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 clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not yet obtained psychological clearance for 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 15-year-old female who has a history of purging several times a day and had a 25-pound weight loss within 9 months. She has failed intensive outpatient therapy. She is restricting her intake, refusing to attend appointments and was unmotivated for treatment. Her parents are requesting residential treatment for the patient. The Health Plan has denied this request indicating the requested services are not medically necessary.This young woman clearly has an eating disorder with multiple comorbid problems including what appears to be oppositional defiant behaviors/disorder. She has a life threatening illness and is not complying with outpatient therapy. Given the severity of the patients condition and her failure to respond to less intensive treatment, residential treatment services are medically appropriate and indicated. The patient is more likely to benefit from a comprehensive treatment plan with definable goals and interventions. Therefore, I have determined that the requested services are 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 46-year-old woman who has requested reimbursement for Bi-Est, compounded capsule of estradiol (E2), estriol (E3), and progesterone (P) to treat post-menopausal hot flashes, which she has experienced for four years. She has tried a synthetic combination of conjugated estrogens with medroxyprogesterone acetate and other unnamed remedies. She has been using the compounded capsule because she is concerned about the possibility of cancer and other health problems that might arise from use of the synthetic product. The Health Plan has denied reimbursement for the medication at issue on the basis it was not medically necessary for treatment of the patients medical condition.The only synthetic estrogen on the market are the conjugated estrogens from mares urine such as Premarin and PremPro. FDA approved and regulated preparations of natural E2 and P are readily available in the market and on formularies. Compounded estrogens and P are not regulated and their actual content may vary from 0 to 150% of their stated concentrations. There are no data suggesting any clinical advantage to unconventional estrogens such as Bi-Est or Tri-Est compounded with P compared to FDA approved and regulated E2 and P, either in terms of immediate relief of hot flashes or long-term incidence of cancer or cardiovascular disease. Therefore, I have determined that the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 64-year-old male who underwent polysomnographic study in evaluation of probable obstructive sleep apnea (OSA). This revealed the presence of severe disease with an AHI of 44, and oxygen saturation nadir of 80%. CPAP was recommended for treatment of this patient, which proved to effective during titration study. However, the patient reported he was unable to tolerate CPAP therapy.  The patient then sought the care of a dentist in order to obtain a mandibular positioning device (oral appliance). At issue is whether the oral appliance was medically necessary for treatment of the patients sleep apnea.It is generally accepted that the use of oral appliances for mandible positioning in treatment of patients with moderate to severe OSA is appropriate when the patient is intolerant of CPAP. The success rate of the oral appliance is not as high as with CPAP, but the compliance rate is felt to be higher. Though oral appliances are recommended more highly for patients with milder disease, use of the appliance in this case was medically reasonable and appropriate for treatment of the patients OSA. Therefore, I have determined that the equipment at issue was 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 12-year-old female with a long history of severe anxiety, phobias and obsessive-compulsive symptoms. She has received treatment over the years with multiple combinations of medications and therapies. The patient had pervasive symptoms, which severely affected the patients normal social growth and development. A SPECT brain study was performed to clarify her diagnosis and offer treatment suggestions. The Health Plan has denied reimbursement for the SPECT scan at issue on the basis it was not medically necessary for evaluation of the patients medical condition.Review of the relevant medical literature reveals there is growing support for use of SPECT scans for diagnosis and management of psychiatric disorders. There is data demonstrating the efficacy of SPECT scanning in selected cases. Based upon the information provided, it appears the SPECT scan was of clinical value in the case of this patient as the results of the SPECT scan revealed the need for alternative therapy, which was ultimately successful. Therefore, I have determined the SPECT scan at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.