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

The patient is a 46-year-old female who underwent a panniculectomy in 2000. Postoperatively, the patient was noted to have fullness in both sides of the lower abdomen with reported tenderness. The patient was seen and evaluated by a plastic surgeon in January 2004 for similar complaints after a stated 40-pound weight loss. The surgeon offered several options at the time and suggested that the patient wait until she reached her plateau weight before pursuing surgery. She was re-evaluated in March 2004 with essentially the same findings. The patients plastic surgeon has recommended a skin-only abdominoplasty. The Health Plan has determined that the requested procedure is not medically necessary for treatment of the patients medical condition.The submitted evidence does not demonstrate that the proposed procedure is medically indicated. There is no evidence that the patient has tried and failed conservative management of intertrigo. Thus, there is insufficient documentation of functional impairment to warrant an abdominoplasty at this time. Therefore, I have determined that the requested procedure 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 39-year-old female who started having persistent headaches in September 2003. The headaches are temporal and frontal in location, more so on the left than the right. The patient was evaluated by a neurologist and has been followed on a regular basis. Records indicate a normal neurological exam. The patient has undergone several tests including temporal artery biopsy, CT scan of the brain, MRI of the brain, MRA of the neck and brain, EEG, and lumbar puncture. All of these tests were within normal limits. The patient has been treated with several different medications with transient or no improvement in her headaches. The patients neurologist has requested an MRI of the cervical spine. The Health Plan has denied this request.The patients records provide no basis for the necessity of an MRI of the cervical spine. No history, signs or symptoms are documented indicating that a structural abnormality of the cervical spine may be the cause of the patients headaches. There is no documentation that the patient has undergone radiographs of the cervical spine. The Health Plan is correct, there is insufficient evidence to demonstrate the requested MRI is medically necessary. Therefore, I have determined the requested MRI is 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 59-year-old male with reported large right hemispheric arteriovenous malformation. He is status post treatment with gamma knife. The patient apparently experiences focal motor seizures. He has attempted treatment with Dilantin, which was unsuccessful due to adverse effects. The submitted records indicate the patient has been doing well on Trileptal. The Health Plan has denied authorization for Trileptal on the basis that it is not medically necessary since other antiepileptic drugs are available.The patient has tried and failed one antiepileptic drug for his focal seizures. Based upon the evidence provided, no antiepileptic drugs other than Trileptal have been tried by the patient. Other medications such as carbamazepine and Depakote are available and are likely to be effective. Thus, there is no medical indication for Trileptal at this time. However, if a trial of one of these medications results in failure or is intolerable, treatment with Trileptal would be appropriate. Therefore, I have determined that the requested medication 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 undergo a trial of another antiepileptic medication such as carbamazepine or Depakote. If there is documented evidence that the trial is unsuccessful, then Trileptal should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A seventy-one year-old female with peritoneal carcinoma, deep vein thrombosis, and pulmonary embolism is requesting a CoaguChek System for home use.Reviewers Findings:  The reviewing physician found that the submitted information provides no medical justification for a CoaguChek device.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old female with a BMI of 48 who is requesting a long-limb Roux-en-Y procedure for her obesity. She has comorbid conditions of hypertension and diabetes. The Health Plan has authorized standard Roux-en-Y gastric bypass.Long-limb Roux-en-Y has been shown to have greater complications and less success than other bariatric procedures and has not been established as more beneficial than other procedures. The Health Plan is offering the patient appropriate and indicated services. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1The patient is a 35-year-old female who has a history of severe intractable low back pain with radiation to the buttocks and hips bilaterally. She has undergone conservative treatment with no long-term benefit. The patient would like to undergo intradiscal electrothermal therapy (IDET), which is considered investigational by her Health Plan.IDET remains an unproven therapy without clearly defined efficacy. There is no substantial proof of its effectiveness for the treatment of low back pain. Multiple studies have demonstrated that it is not beneficial or has limited effect. Therefore, I have determined that the requested therapy 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 2The patient is a 35-year-old woman with structural discogenic lesions, which are concordantly painful. The patient has failed all appropriate conservative treatment options. She has requested authorization for intradiscal electrothermal therapy (IDET). The Health Plan has denied the request on the basis that the requested therapy is considered investigational.IDET has been demonstrated at the pain level and function/disability level to provide benefits in patients with chronic discogenic low back pain who have failed all appropriate conservative treatment. Furthermore, IDET has been proven efficacious in numerous patients. Because of the seriousness of surgical treatment available to this patient, all attempts should be made to avoid surgery. IDET has the potential to benefit this patient and prevent the need for surgery. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3The patient is a 35-year-old woman with chronic back pain. She has received numerous treatments without success. The patient has requested authorization for an intradiscal electrothermal therapy (IDET) procedure. The Health Plan has denied the patients request on the basis that the requested procedure is not medically necessary.There is no information available to warrant and support the use of IDET. No long-term prospective study has shown significant long-term benefits and the risks of the therapy are still unclear. As such, IDET cannot be recommended until the efficacy of the therapy has been established and the long-term benefits and risks are known. Therefore, I have determined that the requested procedure 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 has a history of failure to thrive and short stature. In November 2003, the patients documented height was 90cm and growth velocity was 3.7cm over seven months. The patients provider states the patient had sustained growth velocity at less than the 10th percentile and his height standard deviation (SD) score was 2.66. A request has been made for growth hormone therapy. The Health Plan has denied the request on the basis that growth hormone therapy is not medically necessary for treatment of the patients short stature.The patients stature is less than 2.5 SD for age and gender. However, it is not possible to assess whether the patients present stature is appropriate for genetic predisposition as no parental heights were included with the information submitted. The patients growth velocity between April 2003 and May 2004 was 7cm, which is between the 10th and 25th percentile for age. Growth hormone response to non-physiological stimuli was greater than 17mg/dl and thus normal by accepted standards. Considering the above information, growth hormone therapy should be delayed until a celiac panel is repeated and celiac disease is effectively ruled out and parental height and target heights are determined. Without such information there is no evidence that growth hormone therapy is medically necessary for this patient. 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. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old male with HIV-positivity since 1990. Review of the submitted medical records and photographs indicates the patient has developed moderately severe facial fat loss as a result of AIDS and the side effects of AIDS medications. The patient indicates he has had difficulty carrying out his job as a nurse due to his facial wasting. He wishes to undergo a malarplasty to correct the facial wasting. The Health Plan has denied the request indicating that the requested procedure is not medically necessary for treatment of the patients condition.Highly active antiretroviral therapy with protease inhibitors can result in facial lipoatrophy, which is demonstrated in this patient. Surgical intervention to improve this condition is not medically necessary. There is no physiologic or functional benefit to midfacial infra/submalar fat. Furthermore, the indication for restoring a normal appearance depends upon the degree to which the existing state represents a departure from normal. In the case of this patients midfacial lipoatrophy, the departure from a normal appearance is cosmetic in nature. Moreover, there is a scarcity of literature regarding large-scale studies for malar augmentation for AIDS-related lipodystrophy. One study of nine patients and another of five patients demonstrated good results at one to two-year follow-up. However, whether the procedure will result in more than a minimal improvement in appearance remains open to question. There are also inherent risks of elective surgery in the setting of AIDS.Based upon the information set forth above, I have determined that 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: Upheld Decision of Health Plan

The patient is a 15-year-old female who has a strong history of a significant axis II disorder with manipulative behaviors. She was admitted to residential treatment on 5/17/04 following partial hospitalization services. The patient was on 24-hour observation until 7/8/04. The Health Plan indicates that as of 7/6/04 the patient was appropriate for discharge to a less intense level of care. A request has been made for coverage for residential treatment center services from 7/6/04 to present.The Health Plans denial should be upheld. The submitted evidence does not demonstrate the patient required continued residential treatment for psychiatric and/or medical issues after 7/6/04. As of 7/6/04, the patient was medically stable and could have been appropriately treated with partial hospitalization and possible intensive outpatient psychotherapy. Based upon the clinical records provided, there was no medical indication for residential treatment services beyond 7/6/04. Therefore, I have determined that the services at issue were not medically necessary for the 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 17-year-old female with previously diagnosed polysubstance abuse (cannabis, alcohol, and cocaine), post-traumatic stress disorder, anorexia nervosa, and bipolar disorder versus mood disorder-not otherwise specified. The patient was admitted to residential treatment on 4/30/04 due to persistent problems with mood regulation, substance abuse, recurrent self-harm and suicide attempts, defiant behavior, and caloric restriction. She has a history of severe verbal outbursts and irritability that can last from minutes to hours, requiring isolation for stabilization. She has also been overly sensitive to noise and stress. Finally, the patient has noted visual hallucinations, reportedly seeing things such as the floor moving, blood coming out of the walls, and little people approaching her. She has also periodically heard a single male voice telling her to hurt people or that she should die, though she has never directly acted on this voice. The patient noted severe and debilitating depressive episodes, very low self-esteem, feeling irritable most of the time, wildly fluctuating energy levels, markedly decreased appetite, and significant difficulties initiating and maintaining sleep. She eventually reported having been raped some two years earlier. Treatment has included a number of psychotherapies as well as medication, the latter in the form of Effexor and Seroquel, which was latter switched to Zyprexa. This switch was thought to be more effective in helping regulate the vacillation in her mood. By 7/14/04, the patient was noted to be sleeping well, with decreased tearfulness, and was able to refrain from all self-injurious behaviors, including no oral restriction. It was further noted the patient reported feeling better overall.A request has been made for continued residential psychiatric treatment services. The Health Plan has denied this request on the basis that the requested services are not medically necessary.Though there was some uncertainty about the exact sort of mood disorder the patient experienced, i.e., whether her condition was bipolar in origin, by 7/14/04 the patient had improved from the vantage points of irritability and aggressive acting out. Additionally, as of that time the patient was not suicidal and her provider believed that she was not likely to resume substance use. Based upon the records submitted, it appears that the patient could have been appropriately treated at a less intensive level of care as of 7/14/04. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 27-year-old female with a long history of back, neck, and shoulder pain. She has been evaluated and treated by her primary care physician, her chiropractor, and her physical therapist. The patients providers believe the patients large breasts are contributing to her symptoms. She was referred to a plastic surgeon for evaluation. The plastic surgeon concurred with the patients previous examiners and recommended the patient undergo breast reduction surgery. The Health Plan indicates a breast reduction is not medically necessary for treatment of the patients medical condition.The patient is 64 inches tall and weighs 135 to 140 pounds. She wears a size 32 DDD bra. The submitted photographs demonstrate the diagnosed mammary hypertrophy as well as shoulder grooving and hyperpigmentation secondary to heavy breasts. The photographs and documentation from the patients primary care physician, chiropractor, and plastic surgeon provide medical justification for the requested procedure. Breast reduction surgery is medically appropriate and is likely to alleviate the patients symptoms. 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

The patient is a 49-year-old female status post gastric bypass for morbid obesity after an unsuccessful attempt at gastric stapling. She is nearing her pre-bypass predicted ideal weight of 134 pounds. She has undergone a panniculectomy and now wishes to undergo a brachioplasty for redundant hanging skin on her upper inner arms. The Health Plan has denied authorization for a brachioplasty on the basis that it is not medically necessary and is cosmetic in nature.The submitted medical records and photographs of the patient demonstrate hanging skin and subcutaneous fat but no indication of medical necessity for the proposed brachioplasty. There is no evidence of any skin rash or infection on the patients arms. In the absence of documented evidence of a functional impairment, such as a skin condition, which has failed to respond to conservative treatment, the requested procedure is not medically indicated and is cosmetic in nature. Therefore, I have determined that the requested procedure 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 26-year-old woman with a body mass index (BMI) of 38. In addition, the patient has high cholesterol and back pain. She has requested authorization for gastric bypass surgery. The Health Plan has denied the patients request on the basis that gastric bypass surgery is not medically necessary for treatment of the patients medical condition.With a BMI of 38 the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. Therefore, I have determined that the requested procedure 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 who has been receiving human growth hormone (HGH) treatment for almost one year for chest pain, neuropathy, and several other non-specific issues. The patient reports that his condition continues to deteriorate. He has requested authorization for continued growth hormone injections. The Health Plan has denied the patients request indicating that the submitted medical documentation provides no evidence of GHD or panhypopituitarism.The Health Plans denial should be upheld. There is no evidence in the submitted documented evidence of HGH deficiency. In fact, the patients continued reported deterioration is indicative of the lack of efficacy of the HGH therapy he has already received. Continued treatment with HGH therapy is not medically indicated and is not likely to be effective. Therefore, I have determined that the requested therapy is not medically necessary for the 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 35-year-old female teacher who is exposed to children from the Far East where hepatitis B is quite prevalent. She has requested authorization and coverage for a hepatitis B vaccination. The Health Plan has denied the patients request on the basis that the requested vaccination is not medically necessary.The Health Plans denial should be overturned. Hepatitis B vaccination is medically necessary for this patient. Although she is not at high-risk for being infected with hepatitis B, her job as a teacher requires her to be around children who may be carriers of the disease and there is a risk of exposure to the disease. As such, hepatitis B vaccine is reasonable and appropriate for this patient. Therefore, I have determined that the requested vaccination is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old woman with knee pain that persists despite an apparent course of conservative treatment. The patients provider has recommended further diagnostic studies be performed. The patient has requested authorization for knee surgery. The Health Plan has denied authorization and coverage for the requested surgery on the basis that it is not medically necessary for treatment of the patients medical condition.Based upon the submitted history and test results the exact nature of the patients problem is unclear. The patient wishes to undergo knee surgery but the exact surgical procedure at issue is not known. The patients provider has recommended further diagnostic workup. At this time there is no indication for surgical intervention. The patient should be evaluated by an orthopedic surgeon and an MRI study of her knee should be obtained. 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: Overturned Decision of Health Plan

The patient is a 42-year-old female with a body mass index (BMI) of 44. Based on the submitted information, it appears the patient has undergone a psychological evaluation and has been found to be an appropriate candidate for weight loss surgery. The patient has requested authorization and coverage for gastric bypass surgery. The Health Plan indicates the requested procedure is not medically necessary for treatment of the patients medical condition.With a BMI of 44 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 that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.