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

The patient is a 39-year-old female two years post bariatric surgery with a stated 130-pound weight loss. The patient wishes to undergo surgical removal of excess skin and soft tissue from her arms and her abdomen. She is scheduled for a hysterectomy and sought plastic surgical consultation prior to her proposed surgery to see if the procedures could be combined. The patient reports that she has controlled her intertrigo beneath her abdominal pannus with over the counter medications and therefore, has not sought help from her primary care provider for this problem. The Health Plan has denied authorization and coverage for the requested procedures on the basis they are not medically necessary.Based upon the available medical data, the procedures of abdominoplasty and brachioplasty are not medically necessary. The patient has been examined by a plastic surgeon without findings of medical necessity for abdominoplasty or brachioplasty. Thus, there is no indication that the requested procedures are medically warranted in order to treat clinical symptoms or functional complaints. Therefore, I have determined that the requested procedures 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 15-year-old female admitted to an inpatient psychiatric treatment facility on 3/17/04 with a history of recent increasing agitation and suicidal threats. Upon admission the patient was found to have healing wounds on her forearm and claimed to have self-inflicted the wounds two weeks prior. She also made harmful threats against her mother. She was placed on suicidal watch upon admission. Her behavior prior to admission began when her mother forbade the patient from having a relationship with a man she had met on the Internet. The patient claimed she had engaged in cutting behavior on her arms and thighs for the past year and had an undisclosed overdose of her mothers medications not requiring medical attention. The patient admitted to occasional use of alcohol, but denied any other drug use. The patient also claimed to find herself too fat and engaged in food restriction and self-induced emesis a couple of times during the past year. She was treated with Prozac 20mg/day in the hospital for depression. On 3/19/04, the patient admitted that she was never suicidal, but cut herself for attention due to anger at her mother. A request has been made for reimbursement for acute inpatient psychiatric treatment services received from 3/20/04 through 3/22/04. The Health Plan has determined inpatient psychiatric treatment services were not medically necessary beyond 3/19/04.The patient was acting out in a dangerous manner necessitating acute hospitalization for safety, observation, and stabilization. Review of the submitted records reveals the patient was defiant, uncooperative, and irritable and threatened to harm herself in the hospital. Thus, there was sufficient medical necessity to justify continued hospitalization through 3/20/04 to further observe the patient and ensure her stability and safety. Therefore, I have determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old female with a body mass index (BMI) of 37.3. The patients comorbid conditions include bilateral degenerative joint disease of the knee and back pain. She wishes to undergo gastric bypass surgery and has obtained psychiatric clearance. The Health Plan has denied authorization for weight loss surgery on the basis that it is not medically necessary for treatment of the patients obesity.With a BMI of 37.3 and no significant comorbid conditions such as diabetes or hypertension, 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: Overturned Decision of Health Plan

The patient is a 36-year-old female with constipation predominant irritable bowel syndrome (IBS). Although the patient has responded to therapy with Zelnorm, she quickly relapses once therapy is discontinued. Relapse of her IBS has resulted in painful perianal disease that has required surgery in the past. The Health Plan has denied authorization for Zelnorm therapy on the basis that it is not medically necessary for treatment of the patients IBS.Though it has been suggested that the Food and Drug Administration (FDA) has approved the use of Zelnorm for 4-6 weeks with one repeat, the FDA actually suggests that therapy for 12 weeks should be considered in those patients who respond by 4-6 weeks. The FDA approval never discusses repeat dosing. Furthermore, labeled indications for any drug do not necessarily reflect standard of care or prudent use. Moreover, the Health Plans suggestion of safety issues similar to those of alosetron are unwarranted as no patient of the 11,000 in the Zelnorm clinical studies has developed ischemic colitis, and the rate of ischemic colitis seen post-marketing with this component is no greater than population estimates of IBS patients suggest they should be. The Zelnorm results are very different from the alosetron data. Alosetron is a very different compound with a different mechanism of action; more importantly, alosetron is used in a different population of patients with a different disease. While Zelnorms current label dose is 6mg twice daily for up to 12 weeks and no published studies exist beyond 12 weeks, it is clear that no one dose and duration of this drug (or any drug) is the most effective dose for all patients with this disease (or any disease). As IBS is a chronic disease, it is well recognized that many patients will either relapse following cessation of therapy and therefore, require re-treatment or require maintenance in order to control their symptoms. Clinical experience with this compound in many millions of patients over the last two years is more than adequate evidence to support this pattern of use.In light of the information set forth above and given the patients good clinical experience with Zelnorm with no evidence of toxicity or side effects, continued use of Zelnorm is medically appropriate and indicated. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 38-year-old female with Crohns disease. She also has a history of multiple failed resections of the small bowel. She had a stricture on the distal small intestine and some adhesions to the small intestine. She underwent a small bowel series, which confirmed that she has 65% of her small intestine remaining. The patients physician has recommended the patient undergo a stricturoplasty to preserve her remaining small intestine. The patient has requested a colorectal specialist perform the stricturoplasty. The Health Plan has denied the patient request on the basis that the requested referral is not medically necessary. Surgery in this patient with Crohns disease should be performed by a board certified colon and rectal surgeon. Given the complexity of the patients case, it is medically reasonable and appropriate that a surgeon with a certain level of specialization perform the procedure. It is medically appropriate and reasonable for the patient to be evaluated by a colon and rectal surgeon. Therefore, I have determined that the requested referral is medically necessary for the 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 50-year-old woman who was diagnosed with ductal adenocarcinoma of the breast in January 2004. At that time, she was found to have metastatic disease in her bones and liver. She was subsequently treated with chemotherapeutic agents including Adriamycin, Cytoxan, Taxotere, and Xeloda. She has also been on Tamoxifen for many months, (her original cancer was estrogen receptor positive) as well as Iressa. The patient appears to have experienced recent progression of disease. In July 2004, the patient was given a new hormonal agent, Faslodex. At issue is whether Iressa is medically necessary for treatment of the patients medical condition. Iressa is an oral drug approved for use as a single agent in metastatic non-small cell lung cancer. Its mechanism of action is to act as an anti-epidermal growth factor receptor, which would then presumably inhibit cellular proliferation. The submitted abstracts discuss, on a laboratory basis only, a possible potentiation of hormonal therapy by Iressa. To date, there is no meaningful data in patients that this theoretical interaction would be of any clinical benefit. Thus, the use of Iressa in the case of this patient, as well as in breast cancer in general, is purely speculative and not medically indicated. 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: Upheld Decision of Health Plan

The patient is a 56-year-old female with a body mass index (BMI) of 37. She has comorbid conditions including diabetes mellitus and hypertension. She has requested authorization for gastric bypass surgery. She has undergone a formal psychological evaluation and is considered an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for gastric bypass surgery on the basis that it is not medically necessary for treatment of the patients obesity.With a BMI of 37 and no significant comorbidities, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. Although the patient has been diagnosed with diabetes mellitus, it is minimal with hemoglobin Alc of 6.3. In addition, the patients hypertension is non-severe and does not require multiple medications for control. In light of this patients BMI, 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: Overturned Decision of Health Plan

The patient is a 51-year-old female with severe allergies to inhalants. The patient has been on Allegra and Rhinocort AQ (nasal steroid) for two years. Previous medications tried and failed included Zyrtec, Claritin, Clarinex, Beconase, Nasonex, and Flonase. The submitted clinical notes indicate the patient received a prescription for a three-month supply of Allegra 180 and Rhinocort AQ in October 2002. In October 2003, a three-month supply with two refills (nine-month supply) was prescribed. The patients pharmacy records shows prescriptions for Allegra and mometasone (nasal steroid) in November 2003 and for Allegra in January 2004. In June 2004, a new prescription for Singulair was requested. The patient has requested authorization for the addition of Singulair to her regimen based on a positive response to its combination with Allegra and Rhinocort AQ. The Health Plan has denied the request on the basis that Singulair is not medically necessary for treatment of the patients allergies.Review of the submitted clinical notes indicates that a nine-month supply of Rhinocort AQ was ordered in October 2003. In spite of treatment with standard therapies this patient has not responded well. The patients provider notes the patient experienced a positive response to the addition of Singulair. In light of the patients response to Singulair and the failure of other medications including intranasal steroids, Singulair is medically appropriate and indicated for treatment of this patients allergies. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is an 11-year-old male who was born prematurely with an appropriate gestational growth for age. He received a workup for gastrointestinal causes of poor growth at the age of three. He had experienced learning and behavioral problems for which he was diagnosed with attention deficit hyperactivity disorder (ADHD) at eight years of age. The patients father indicates the patients ADHD was successfully treated with Strattera. The patient has been followed by an endocrinologist who found no evidence of growth hormone (GH) deficiency upon provocative testing. No other cause for the patients short stature has been revealed, though the patient was thought to express elements of the Russell-Silver phenotype and was reported to have a growth of 3.5cm extrapolated from a recent eight-month interval.The patients provider has recommended the patient be started on growth hormone therapy. The Health Plan has denied authorization for growth hormone therapy on the basis that it is not medically necessary for treatment of the patients medical condition.Analysis and Findings:Given the patients growth near the third percentile, his delayed bone age, and height attained to date, the patients projected adult height should place him in the normal range of at least 55. Thus, the patients most likely diagnosis would include constitutional delay. Low-normal IGF-1 levels are common in the immediate pre-pubertal period. In 2003, the Food and Drug Administration (FDA) approved the use of therapeutic GH for children who do not have GH deficiency, but are unusually short; however, the FDA approval indicated GH therapy should be reserved for boys with an adult height prediction less than 53. Since in this case the patients height prediction exceeds 53 he does not fall within FDA recommended guidelines. Thus, growth hormone therapy is not medically indicated for treatment of this patients short stature.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. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 42-year-old female with hypertension who experienced nausea and edema on Norvasc therapy. The patient was then given a trial of Cozaar, which was successful. Based upon this response, the patient has requested authorization and coverage for Cozaar. The Health Plan has denied the patients request on the basis that Cozaar is not medically necessary for treatment of the patients hypertension. There are multiple medications available for the treatment of hypertension. Common classes include calcium channel blockers, ACE inhibitors, and beta-blockers for initial therapy. Review of the submitted records indicates the patient failed a calcium channel blocker due to symptoms. It is medically reasonable to try the patient on a different class such as an ACE inhibitor or a beta-blocker. It is usual and customary practice to generally reserve angiotensin receptor blockers for those patients who are intolerant to ACE inhibitors. There are several alternative medically appropriate choices available to the patient.Based upon the information set forth above, I have determined that the requested medication is not medically necessary for the 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 58-year-old woman who has requested authorization and coverage for a bone density evaluation. There is no prior history of fracture or family history of hip fracture. There is no prior history of excess thyroid, long-term steroid use, smoking or any other factor that might suggest an increased risk for a premature fragility fracture. The submitted records indicate the patient stopped taking Premarin as of June 2004. The Health Plan has denied coverage for the requested bone density scan on the basis that it is not medically necessary for evaluation of the patients condition.There is some consensus about which post-menopausal women younger than age 65 should be screened for osteoporosis with a DEXA scan. Both the National Osteoporosis Foundation and the US Preventative Services Task Force recommend that all Caucasian women age 65 or older who are not already receiving effective osteoporosis treatment should be screened for low bone mineral density. The decision to test for osteoporosis in a 58-year-old woman should be based on the patients risk profile and is not indicated unless the test is likely to result in a treatment decision. Risk factors include previous fragility fracture, significant family history (which is usually defined as a hip fracture in mother after age 50), low weight, smoking or use of medication that might increase bone resorption such as steroids or excessive thyroid hormone. This patients records do not document any of these risk factors. However, the submitted notes indicate the patient is no longer taking Premarin. If the patients diagnosis of osteopenia in 2000 was based on a DEXA or QCT bone density scan, the fact that she is no longer on hormone replacement would warrant a repeat scan since it would influence a decision for retreatment with Premarin or another modality.Based upon the information set forth above, I have determined that the requested scan is not medically necessary for the evaluation of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. However, the basis for the patients diagnosis of osteopenia in 2000 should be ascertained. If the diagnosis was based on a DEXA or QCT bone density scan, the requested scan should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee has requested authorization and coverage for foot orthotics. Review of the documentation provided indicates the patient has a diffuse metatarsalgia and has been treated with Spenco polysorb inserts with some improvement. The Health Plan has denied authorization for the requested orthotics on the basis that they are not medically necessary. The Health Plans denial should be upheld. Review of the submitted documentation does not support the medical necessity for fabrication of a functional tri-plane corrective foot orthotic. There is no documentation as to the patients general foot structure and how an orthotic would be beneficial. In addition, though there is documentation of a moderate hallux abducto valgus deformity, no pain was noted with range of motion of the first metatarsophalangeal joint. Furthermore, while pain was noted in the second metatarsal no documentation has been provided demonstrating how the requested orthotic would be beneficial for the patients condition.Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 36-year-old female with intractable headaches and spasm of the neck and shoulders. She has requested authorization and coverage for Botox injections. The submitted documentation suggests the patient has failed Maxalt and Cox-2 inhibitors. There is no clear documentation regarding the patients current symptoms or degree of disability. The Health Plan has determined Botox is not medically necessary for treatment of the patients medical condition.The submitted medical records do not demonstrate the basis for the patients underlying disease process. It appears the patient has not undergone usual and customary treatment with physical therapy or tricyclic anti-depressants for chronic neck and head pain. The patients MRI reveals a disc herniation and possible cervical nerve root compression, which may be the primary inciting cause of this patients pain. There is minimal data concerning Botox treatment of cervical pain with or without headaches. The patient has multiple diagnostic issues, which do not appear to have been addressed. For example, the patient is being treated for migraine with Maxalt. If migraine is a component of this patients headache problem, there are many recognized medications that may be tried. The patient has not exhausted available therapies and requires further work-up. 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 29-year-old female with a history of primary hypersomnia. A sleep study revealed sleep latency of 9.25. The results indicated an alerting medication is required to prevent excessive sleepiness at work and to reduce safety risks. The patient has been taking Provigil since 1999 with excellent response documented. The patients provider, a psychiatrist and sleep study specialist, recommends the patient be continued on Provigil. The Health Plan has denied authorization for Provigil on the basis it is not medically necessary for treatment of the patients hypersomnia.Review of the submitted records demonstrates Provigil has been efficacious for treatment of the patients hypersomnia. The introduction of alternative treatments may provide more chance for abuse and possible detrimental side effects. Furthermore, review of the medical literature lends support for use of Provigil in patients such as this patient. Provigil, a putative central one adrenergic agent, has been found to result in a therapeutic benefit in patients with idiopathic hypersomnia and narcolepsy. The available documentation indicates some degree of efficacy of Provigil without any significant toxicity. The Silber article cited above indicates Provigil may in fact be better than conventional stimulating agents, which clearly have a much greater toxicity, as well as a potential for abuse. Given the established efficacy of Provigil in this patient without evidence of toxicity, continued use of Provigil is medically indicated.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.