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

The patient is a 16-year-old male who received treatment for substance abuse at an acute care facility. He had been abusing alcohol, marijuana and crack cocaine prior to his admission to acute care. He reported blackouts prior to admission and conflict with school and family. The patient was diagnosed as having a major depressive disorder but was not treated for such while he was in acute care. He stepped down to an ambulatory status and relapsed on drugs after his discharge from the hospital. In February 2006 the patient was placed at the residential level of rehabilitation. He was admitted to RTC level of care utilizing the ASAM adolescent criteria.  He was started on Wellbutrin with some intolerance of this medication.  The Wellbutrin was lowered and his depression lessened.  The Health Plan determined that as of March 2006 the patient no longer met American Society of Addiction Medicine (ASAM) criteria for the residential level of care and recommended a community based treatment. The patient and his family disagreed and the patient remained at the residential level of care until his discharge in March 2006.  At issue is whether residential treatment services beyond March 2006 were medically necessary.The submitted records from the residential treatment facility report that the patient stated that he had suicidal thoughts on a daily basis in March 2006 but that he would not act on them.  He agreed to sign a safety contract on that date. A progress note dated March 2006 stated that the patient had a bright affect, was smiling and laughing, and attended all groups and activities. The patient had no signs of withdrawal symptoms as of March 2006. Furthermore, there was no indication of symptoms or behavior necessitating 24-hour monitored supervision as of March 2006. Moreover, the patients parents were supportive of his recovery and his home appeared to be conducive to his recovery. Based upon the clinical records provided, the patient was appropriate for step-down to a less intensive level of care as of March 2006. 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 54-year-old male with hypersomnia as indicated by his letter and documented by his neurologist. He reports excessive sleepiness and fatigue, which is apparently not due to medication side effects. Diagnoses of migraines and anxiety have also been made. His neurological exam was not notably abnormal. The patient was treated with a variety of medications before his neurologist initiated Provigil for his symptoms. Valium had been used at times for anxiety, but the hypersomnia persisted even when the patient did not take Valium. A previous trial of Ritalin was reportedly associated with severe side effects, although the details were not reported.  When Provigil was first prescribed there were initial side effects that are now resolved. The patient is reportedly much improved, both in regard to his sleepiness and his migraines. There was no indication in the record that a sleep study had been done.  The patient has requested reimbursement and continued authorization for Provigil. The Health Plan denied the request based on a determination that the medication was/is not medically necessary for the treatment of the patients hypersomnia.The patients diagnoses include migraine headaches, anxiety, and excessive daytime sleepiness. Although the etiology of his hypersomnolence has not been identified at present, his provider noted definite improvement with Provigil after the failure of several other medications.  Provigil is clearly effective in treating the patients hypersomnolence and has resolved his migraine headaches as well without continuing side effects. I recommend that it be continued, and that in addition, he undergo nocturnal polysomnography to evaluate for possible sleep apnea that may present with both excessive sleepiness, and headaches. Based upon the information set forth above, I have determined the medication at issue was/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 36-year-old male with a history of malignant insulinoma. The patient underwent a laparoscopic distal pancreatectomy in October 2005 and chemoembolization of a liver lesion in November 2005. According to the patients letter, the last MRI showed enlarged lymph nodes. The size and location of the lymph nodes, and the status of the liver lesion are unknown. An octreotide scan was reported negative according to a clinician note. The date of this exam is uncertain. The patients clinician has ordered a PET scan to assess surgical feasibility.At issue is whether a PET scan is medically necessary for evaluation of the patients condition.PET scan is variable in its sensitivity for pancreatic insulinomas, up to 53%. PET scan sensitivity for metastatic insulinoma is unknown. The use of standard imaging technology including CT, ultrasound, MRI, and percutaneous biopsy is appropriate to assess for recurrent metastatic disease and is likely to be of greater clinical utility than a PET scan. The use of PET scanning in this area is not the standard of care and is not medically necessary. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 53-year-old female requesting reduction mammaplasty.  There is photographic evidence of large breasts and shoulder grooving along with the typical symptoms of macromastia.  Her symptoms have been treated with physical therapy and chiropractic therapy without relief.  Additionally, the patient has lost 40 pounds.  The patients provider has requested authorization for bilateral reduction mammaplasty to treat the patients symptoms. The Health Plan has denied authorization based upon a determination that the procedure is not medically necessary.This patient has symptoms consistent with macromastia.  Her complaints of shoulder and back pain, bra strap grooving, headaches, arm numbness and paresthesias are typical for this diagnosis.  The photographs confirm large breasts and deep bra strap grooves.  Her symptoms have not improved with chiropractic treatment, which is not surprising, as symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. The medical literature provides no evidence that weight loss or conservative treatments of any type can alleviate the symptoms of macromastia.  Non-operative treatments are unlikely to improve the patients pain and surgery provides the only real chance for symptomatic relief.  The medical literature supports the concept that patients who present with the typical symptoms of macromastia and who have a confirmatory exam will benefit greatly from breast reduction surgery. The Kerrigan study identified seven physical symptoms predictive of successful surgery.  These symptoms include back pain, rashes, bra strap grooves, neck pain, shoulder pain, upper extremity numbness and arm pain.  The patient has five of these seven symptoms, suggesting she will be significantly improved with breast reduction surgery.  Kerrigan also noted that weight loss and conservative therapy do not improve symptoms of macromastia. This patients symptoms are very unlikely to improve unless she has a breast reduction.  The anticipated resection of 400 to 500 grams is greater than the amount recommended in the literature for a medically necessary reduction. The peer-reviewed literature strongly supports the concept 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: Overturned Decision of Health Plan

The patient is a 15-year-old male who has been treated with the aromatase inhibitor, Letrozole, to extend his growth period and began treatment with growth hormone therapy in November 2005 under the care of a pediatric endocrinologist. For the three months prior to the initiation of growth hormone therapy, he had grown a modest 1cm for an annual growth rate of 4cm.  The patient grew 1.6cm over the first 4 months of GH therapy for an annualized growth rate of 4.8cm. His height in February 2006 was 161.6cm (63.6). Previous testing indicated that the patient had normal IGF-1 and thyroid hormone levels and his most recent bone age of 16 years indicates that his growth period is nearing completion. The patients father has requested reimbursement and continued authorization and coverage for growth hormone therapy. This request was denied by the Health Plan based upon a determination that growth hormone therapy was/is not medically necessary.The record indicates that the patients mother is 60 tall and his father is 69 tall, which approximates a mid-parental height of 67.  The patients height in February 2006 was 63.6 and as his growth period is nearing completion, he appears to be falling short of his target in that his projected adult height estimate is between 54.2 and 55.2. The patient does have short stature and is projected to have a short adult height. As such, the previous use of growth hormone was justified under the FDA guidelines of July 2003 for the treatment of idiopathic short stature.  The therapy should be continued until epiphyseal closure and cessation of growth.Based upon the information set forth above, I have determined the therapy at issue was/is medically necessary for treatment of his medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 51-year-old female with a weight of 396 pounds and a body mass index (BMI) of 58.6 in August 2005. She is requesting authorization for bariatric surgery. She reports comorbid conditions included hypertension, osteoarthritis, insulin dependent diabetes and gastroesophageal reflux disease. She has completed a psychological evaluation and was found to be an appropriate candidate for bariatric surgery.  The Health Plan indicates a 10% weight loss requirement is a prerequisite to approval for weight loss surgery. With a BMI of 58.6 and comorbid conditions such as diabetes, 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. Therefore, 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

The patient is 62-year-old female with gastroparesis secondary to diabetes. The addition of Zofran 8mg daily to the patients regimen of Zelnorm has helped improve the patients symptoms. Previous trials of Reglan and domperidone were not as effective as Zofran. Prior to the initiation of Zofran, the patient required a prolonged hospitalization. At issue is whether Zofran is medically necessary for treatment of the patients condition.The use of Zofran in this patient is medically appropriate and indicated. She has documented gastroparesis manifested by nausea and vomiting. Traditional treatment and therapies have not been effective. Although Zofran has not been approved by the Food and Drug Administration for this diagnosis, it has proved to be effective for this patient. As such, it is medically reasonable for the patient to continue on Zofran 8mg daily to relieve her symptomatology and avoid hospitalization. Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is an 85-year-old female with a history of mitral valve repair and embolic shower. This resulted in necrosis of the fingers on her right hand, and a below the knee amputation on the right and a metatarsal amputation on the left. She also has residual eschar. Her wounds are stable and require daily dressing (application of ointment). There is no evidence the patients wounds are green or draining or require packing. She undergoes a daily dressing change only. The wound on the patients buttocks does not exceed stage II and requires no more than a duoderm dressing. A request has been made for coverage for the patients continued stay at a skilled nursing facility after April 2006.  The Health Plan has denied the request on the basis the services are not medically necessary.Review of the submitted clinical evidence demonstrates the patients wounds were stable after April 2006. Her wounds can be appropriately addressed in a variety of settings: home, assisted living, or outpatient. The patients wound care and overall medical condition do not require daily inpatient care because her wounds are stable and only require application of medicinal ointment and clean dressing. There are no medical issues of high complexity involved in this case. Therefore, I have determined that continued skilled nursing facility services after April 2006 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 17-year-old female with left thigh pain and numbness. She was referred by her primary care physician to a neurologist for further evaluation. It was the primary care physicians assessment that the patient needed to see a neurologist. There are no treatment records since the initial visit with the primary care physician in January 2006. At issue is whether a neurology consultation is medically necessary for evaluation of the patients medical condition.Based upon the information provided, the patient has not received any care regarding her left thigh pain and numbness since January 2006.  The evaluating physician determined that neurologic consultation was medically necessary. In order to provide this patient with appropriate evaluation and treatment of her left thigh pain and numbness, a neurologic consultation is medically indicated and necessary. Accordingly, I have determined the requested consultation is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a five-year-old male with a diagnosis of periventricular leukomalacia and apraxia of speech as well as dysarthria, developmental motor coordination disorder and apraxia of movements.  I have reviewed both the medical reports and speech therapy reports included in the record.  The patient has been receiving speech therapy since September 2004.  His parents have requested reimbursement for speech therapy provided from May 2005 through October 2005 and continuing authorization of speech therapy. The Plan has denied their requests based upon a determination that the therapy was/is not medically necessary.In my review of the therapy reports I found that the therapists presented objective and subjective data regarding receptive and expressive language.  A therapist in Wisconsin performed the initial objective testing when the patient was four years and seven months old.  This placed him at the first percentile for receptive language skills with an age equivalence of three years and zero months.  Subsequent testing showed an increase to the third percentile.  It is difficult to determine if this was a true increase or if it reflected a difference in his mood on a given day.  However, subsequent testing showed mild but continued progress in both auditory and expressive comprehension.  Additionally, the expressive vocabulary documented in the subjective measures of the March 2006 progress report clearly demonstrates a large increase in verbal expression as compared to previous evaluations.  The patient has a documented brain abnormality consistent with his speech and language deficits. His treatment plan is well established and it is monitored by a physician experienced in the evaluation and treatment of his condition. Therefore, I have determined the therapy at issue was/is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.  Objective testing should continue every six months and be reviewed by the pediatric neurologist.  Speech therapy services should continue as long as objective testing demonstrates continued functional gain.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 55-year-old male with severe asthma.  He has been hospitalized several times and requires frequent treatment with systemic steroids. His IgE was measured at 654 IU/mL in December 2005.  His weight is stated as 86 kg.  The providers request for authorization of Xolair was denied based upon the Health Plans determination that it was not medically necessary to treat the patients asthma.The current recommendation in the literature available on Xolair is that a patient should not be treated only if his IgE is over 700 IU/ml.  Furthermore, this recommendation is not an absolute contraindication. That is, based on the clinical situation, an asthmatic whose IgE is over 700 IU/mL could be treated with Xolair if appropriate precautions were taken and the severity of the asthma, as measured by the systemic steroid requirement, justified that course.  In summary, the patient fulfills the current criteria for Xolair administration. Therefore, 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 56-year-old male who utilized an electronic controlled thermal therapy device after knee surgery as prescribed by his surgeon. A request has been made for reimbursement for the device. The Health Plan has denied this request on the basis that a thermal therapy unit was not medically necessary for treatment of the patients medical condition. Thermal therapy units are extremely useful postoperatively to diminish pain and swelling. Use of cold therapy is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, he clearly experienced a benefit from use of the device following his surgery. 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

The patient is said to have had back, neck and shoulder pain prior to her breast reduction surgery. The record of conservative treatment attempts to resolve the patients symptoms is limited to anti-inflammatory medications and weight loss. The photocopies of photographs provided do not show severe breast hypertrophy.  The patients request for reimbursement was denied by the Health Plan based upon a determination that the reduction mammaplasty was not medically necessary.According to the pathology report, the actual breast reduction was small and unlikely to have had a significant impact on the patients symptoms.  Although the patient had the type of complaints characteristic of symptomatic macromastia, the photos do not show the severe breast hypertrophy typically seen. Symptomatic macromastia is a mechanical problem caused by the pulling forces exerted on the musculoskeletal system by heavy breasts. Although the efficacy of breast weight reduction as a treatment for musculoskeletal strain is well established, the medical literature provides absolutely no evidence that correction of breast ptosis without a significant reduction of breast weight is an effective treatment for musculoskeletal pain. The reduction of 90 grams from the right breast and 33 grams from the left breast is well below the 5th percentile on the Schnur table and would be considered a cosmetic mastopexy according to the Schnur guidelines. Regardless of the patients musculoskeletal symptoms, there is no scientific evidence that the removal of such a small volume of tissue would effectively resolve her complaints.  Based upon the information set forth above, I have determined the procedure 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: Upheld Decision of Health Plan

The patient is a 19-year-old female who is being evaluated for splenomegaly. In December 2005 she underwent a CT of the abdomen and pelvis due to abdominal pain. This exam showed splenomegaly and pericholecystic fluid.  The patient was diagnosed with cholecystitis and had a laparoscopic cholecystectomy.  The etiology for the splenomegaly is now being investigated. The patient also has several relatives with hereditary spherocytosis.  The patients provider requested authorization for a PET scan to further evaluate her splenomegaly.  The request was denied by the Health Plan based on a determination that the diagnostic procedure was not medically necessary.The differential diagnosis for splenomegaly is quite long and includes malignant and benign and infectious and non-inflammatory etiologies.  The results of a PET scan will do little towards reaching a definitive diagnosis.  In addition, splenomegaly without a specific etiology is not an approved indication for PET scan by the Centers for Medicare and Medicaid Services (CMS).  Therefore, I have determined the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.