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

The patient is a 44-year-old male who presented with left leg pain associated with varicose veins. The symptom severity is not documented; specifically there is no documentation that the symptoms interfere with activities of daily living.  There is mention of compression stocking use, but the length of time they were worn is not documented. A venous duplex exam is noted with no evidence of deep venous thrombosis, but the competency of the greater saphenous vein is not described. The patients provider has requested authorization for sclerotherapy to the left leg varicosities.  The Health Plan denied the request based on a determination that the procedure is not medically necessary.General practice guidelines in the specialty of vascular surgery dictate that symptomatic saphenous vein reflux and varicose veins warrant invasive treatment when the symptoms are severe enough to interfere with activities of daily living and are refractory to at least three months of conservative therapy with prescription compression stockings.  This patients symptom severity is not adequately documented, and there is insufficient documentation of an adequate (three month) trial of compression stockings.  The absence of proximal reflux in the greater saphenous vein is an additional generally accepted criterion for sclerotherapy.  The treatment of branch varicosities with sclerotherapy in the presence of saphenous reflux is associated with a high rate of recurrence and unproven efficacy.  No venous duplex results are submitted to document the lack of saphenous reflux.Isolated sclerotherapy of branch varicosities in the absence of saphenous reflux may be medically appropriate if the patients symptom severity, conservative therapy, and lack of saphenous reflux were appropriately documented. Based on the documentation submitted for review, 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 53-year-old female who is requesting Provigil for the treatment of her fatigue related to multiple sclerosis. Based on a review of the records, the diagnosis does not appear to be in dispute. The patient remains gainfully employed despite significant fatigue. The patient was provided with samples of Provigil in January 2006 and the medication was effective in the treatment of her fatigue. The patient has requested authorization for continued treatment with Provigil.  The Health Plan denied her request based on a determination that the medication is not medically necessary for treatment of her MS-related fatigue.There is no dispute of the patients diagnosis, nor the condition necessitating the treatment, fatigue related to multiple sclerosis. The efficacy of the medication in the treatment of the patients symptoms has been established. The Health Plan denied the treatment as an off-label application citing a peer-reviewed article that concluded Provigil was no better than placebo in alleviating fatigue.  There are other studies, as cited above, that have reached the opposite conclusion. The data from the study published in JAMA suggests that 200mg per day of Provigil significantly improves fatigue and is well tolerated in patients with MS.Fatigue is similar to pain in that it is a perception and should be treated based on the patients subjective symptoms. As MS is a disabling and chronically progressive disease, if in the patients perception her fatigue is sufficiently improved to allow her to continue working, the decision to prescribe Provigil is medically appropriate.  The study cited by the Health Plan is not persuasive in light of the patients response, and has been challenged by other studies that indicated fatigue might be alleviated by Provigil.  Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 59-year-old female with a history of chronic pelvic pain.  Her perivaginal pain has been evaluated and treated extensively. Both conservative therapies such as medications and physical therapy and interventional procedures such as surgical release of the pudendal nerves and Botox injections have proven to be unsuccessful.  The patient continues with pain and paresthesias in the clitoris, urethra, vagina, perineum and rectum.  She has been under the care of a pain management specialist and radiofrequency ablation of the pudendal nerve with hyaluronidase and steroid injections has been recommended.  The patients request for authorization of the recommended procedures was denied by the Health Plan citing a lack of medical necessity.The patient has a well-established diagnosis of chronic pelvic pain.  She has undergone multiple therapies and continues to have significant pain.  Radiofrequency ablation of the pudendal nerves is a viable option for pain control given her history of previous therapeutic interventions.  The procedure involves the use of heat to obtain neurolysis.  The benefits of this procedure include accurate target monitoring, limited need for anesthesia, precise probe placement, low incidence of mortality/morbidity, and rapid post-procedure recovery.  The procedure is accompanied by the use of a mixture of local anesthetic, steroid and hyaluronidase to maximize epidurolysis at the involved nerve site.  The patients provider has exhausted all other therapies at this point.  Therefore, I have determined the requested procedures 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

This patient is a 49-year-old woman with chronic pain due to degenerative disc disease. She is requesting ongoing and chronic nerve block and epidural injection therapy for her pain management. The Health Plan has determined the requested services are not medically necessary for treatment of the patients medical condition.The utilization of chronic and ongoing nerve blocks and epidural injections in the management of chronic discogenic pain is not medically appropriate or indicated. Such therapy is utilized primarily in radiculopathy syndromes and on occasion for acute exacerbations of pain, but not on a chronic basis. Physical therapy/rehabilitation and strengthening exercises are the standard of care long-term management tool for chronic discogenic pain that is not amenable to surgery. Nerve blocks and epidurals are utilized only on occasion for acute exacerbations. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 50-year-old female diagnosed with depressive disorder, anxiety disorder and major depression complicated by Crohns disease and hypercholesterolemia. There is no information in the record suggesting she suffers from a sleep disturbance or that she requires CPAP.  Prozac, Wellbutrin and Effexor had been prescribed in the past, and the patient is currently taking Prozac 20mg per day, Nortriptyline 20mg per day, Provigil (modafinil) 400mg per day and Xanax on average once per week.  There is no patient report of medication side effects or sedation noted in the record.  Her provider indicates Provigil was prescribed for energy and motivation approximately two years ago and it has helped the patient to be more active and less tired. The patients provider has requested authorization to continue treatment with Provigil. The Health Plan denied the request citing a lack of medical necessity.The medical literature does not demonstrate that Provigil has been found useful for extended periods of time or that it has proven to be more effective than other psychostimulants in the treatment of depression.  In this case, the medication was prescribed for the patient in 2004 and there is no record that alternative psychostimulants have been tried and found to be ineffective or not tolerated. Additionally, the record suggests that the medication is being prescribed for motivation and energy. Such vague symptoms may be indicative of factors beyond depression and this application is not consistent with the FDA approved indications for Provigil.  Finally, tri-cyclic antidepressants have a well-established profile of sedation and it has been found that the concurrent administration of a selective serotonin reuptake inhibitor with a tri-cyclic antidepressant may result in an increase in serum levels, toxicities, and or clinical effects of the tri-cyclic antidepressant.  It is not clear from the record that the current  combination of medications has been adjusted to address the energy and motivational problems.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 53-year-old female with a body mass index (BMI) of 56.2 and significant comorbid conditions. Additionally, she has motility and obstructive problems resulting from her gastric stapling over 25 years ago.  The patient has completed a psychological evaluation and was deemed an acceptable candidate for weight loss surgery. The Health Plan has denied coverage for revisional gastric bypass surgery based upon their determination that the procedure is not medically necessary for treatment of the patients morbid obesity and gastrointestinal problems.With a BMI of 56.2 and comorbid conditions such as gastric stasis, depression, gastroesophageal reflux disease, obstructive sleep apnea, hypertension, diabetes mellitus, venous insufficiency, and degenerative joint disease the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. The gastrointestinal problems described by the patient are not uncommon following vertical banded gastroplasty (VBG) or the gastric stapling operation. The patient should fully explore all of the surgical weight loss options available for the procedure, and it is probable that revisional surgery will be beneficial for her. There is no clinical data that supports a requirement of a pre-operative weight loss of 5% of total body weight.  Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly 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 morbidly obese. An anti-dumping diet has not been shown to be a factor in the success or failure of gastric bypass surgery.  The psychological evaluation indicates the patient is an appropriate candidate for the surgery.Based upon the information set forth above, I have determined 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

This patient is a 50-year-old female with symptomatic macromastia who complains of back, shoulder and neck pain.  The photographs provided in the record show moderately large, ptotic breasts. Her provider has requested authorization for the excision of 400 grams of tissue from each breast. The Health Plan denied the request based upon a determination that the procedure is not medically necessary.The patients complaints of back, shoulder and neck pain are consistent with a diagnosis of symptomatic macromastia and the photographs confirm that she has larger sized breasts.  However, the planned resection of 400 grams per breast is quite small and may not correct her symptoms. The Schnur study found that resection weights above the 22nd percentile indicated that the patients motivation was purely medical.  The planned resection of 400 grams for this patient is below the 5th percentile guideline of 401 grams.  While the question of what volume of resection is adequate to correct a patients symptoms remains controversial, the Schnur data indicates that if the planned reduction is too small, the procedure should be considered cosmetic. This patient does have functional complaints and it seems that her motivation is not cosmetic.  However, the proposed reduction is likely to be too small to correct her symptoms. This patients BSA, according to the Schnur data, would require a breast reduction of at least 628 grams to be considered medically necessary.  Therefore, a breast reduction of 400 grams per breast would not be considered 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

This patient is a 55-year-old female with a history of non-Hodgkins lymphoma treated with high-dose chemotherapy and stem cell rescue.  Low IgG levels dating back several years were reported by her provider. The patient had recurrent infections following treatment and IVIG therapy was initiated in 2002. Her provider indicates that the frequency and severity of the infections has decreased with continuing IVIG therapy.  It does not appear from the record that IgG levels were monitored regularly. The patient has requested reimbursement for previous IVIG therapy and on-going authorization.  The Health Plan denied the request based upon a determination that the therapy was/is not medically necessary in this clinical setting. Many lymphoma patients never recover in terms of immunoglobulin production even when remission is achieved. The patients baseline IgG level is not known, but was reported as below normal.  An IgG level from 2003 was in the low normal range (882) as expected and may well reflect the IVIG therapy, not the patients baseline value. It may be impossible to know if she has persistent hypogammaglobulinemia and/or if her infections would worsen if she did not receive the IVIG therapy, without placing her at substantial risk. Often patients in this clinical setting continue to receive IVIG if there is evidence of medical benefit. This patient would be in that category given her previous history of frequent infections. The dosage and frequency of her IVIG therapy are medically reasonable. Monitoring of IgG levels is possible, but it is unlikely that a below normal value will result while the patient is receiving IVIG therapy. If monitoring is done, IgG levels should be drawn at the nadir, shortly before the next dose of IVIG is due. It is reasonable to conclude that monthly IVIG therapy is a factor in the patients continued good health.Based upon the information set forth above, 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 58-year-old female who is status post gastric bypass surgery.  She has lost a significant amount of weight and had excess skin as a result, particularly in the abdominal area where there was a hanging panniculus. The patient reports a history of refractory skin rashes and/or infections.  Her primary care provider has not submitted documentation of a chronic skin condition that has persisted despite appropriate medical treatment. The patient was evaluated for panniculectomy and the procedure was performed in May 2006.  The patients request for reimbursement of the costs incurred was denied by the Health Plan due to a lack of medical necessity.While the patients history of infections may be correct, the submitted records do not document failed medical management of her intertrigo over an extended period of time such that surgery was the only treatment remaining to control her infections. Her condition did not meet the ASPRS criteria for third party coverage of skin resection following massive weight loss. According to the ASPRS Position Paper, Treatment of Skin Redundancy Following Massive Weight Loss, skin resection is medically necessary if panniculitis or uncontrollable intertrigo is present. The records do not document panniculitis or the failure of medically supervised conservative therapy to control such a condition. Surgical intervention should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient. A panniculectomy was not medically indicated.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 48-year-old female who is perimenopausal and was referred for a DEXA scan because of a positive family history of osteoporosis. This scan of the left and right hips revealed T scores of -2.3 and -2.5. The etiology of the low bone density is unknown and a presumptive diagnosis of osteoporosis was suggested by the patients provider. Based on a history of multiple sclerosis, petit mal seizures and a family history of osteoporosis, the patient was considered to be at high risk for falls. She was fitted with a hip protector and instructed to return in a year for another DEXA scan. There is no history of fragility fractures and no additional risk factors beyond her T scores and the possibility that she might fall. The patients provider indicated that her bone resorption markers (urinary NTx, and serum NTx and CTx) were below target for bisphosphonates and that her bone formation markers were low.  It appears that based on a recent extension of a combination therapy study in postmenopausal women, the patients provider has recommended a two-year course of the anabolic agent Forteo, followed by a bisphosphonate. The Health Plan denied the providers request for authorization of Forteo based upon a determination that the therapy is not medically necessary.Although the patient most likely has osteoporosis based on the dual total hip DEXA scan and her family history, she has no history of previous falls or fractures or any other risk factors. Her provider wishes to place her on Forteo due to low bone turnover imputed from low bone resorption and bone formation markers. In theory, a patient with low bone turnover would not be expected to improve bone formation by slowing bone resorption with a bisphosphonate since resorption is low to begin with and resorption and formation are coupled.  The provider indicated intent to reevaluate bone markers following three and six months of Forteo therapy to determine efficacy.  Treatment might potentially be continued for up to two years if there is significant change in bone markers. Any improvement in bone mineral density would then be consolidated with a bisphosphonate. Presently there are no definitive guidelines for the use of bone markers by reason of the tremendous variability in the values within a single agent. Values may vary with age, season and the time the specimen is taken.  The current recommendation is to reserve Forteo for those women who have failed other treatments. Failure is defined as statistically/clinically significant decreases in bone mineral density, the occurrence or recurrence of fragility fractures while on treatment, intolerance to these treatments, very severe osteoporosis (T-scores greater than -4.0) or high risk for fractures such as old age, family history of hip fractures, smoking or as assessed by various fracture risk indices.  The patient is not within the subset of women for whom Forteo therapy is indicated.  Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 24-year-old female with a diagnosis of daytime hypersomnolence. She was evaluated with polysomnography in November 2005 and the study revealed no significant abnormalities. She demonstrated essentially normal nocturnal sleep with sufficient sleep time and efficacy and consolidated sleep. There was no significant sleep disordered breathing identified. The patient also had a Multiple Sleep Latency Test (MSLT) which indicated there was no pathological daytime sleepiness nor was a diagnosis of narcolepsy likely. The patient has requested authorization for Provigil to treat her daytime hypersomnolence.  The Health Plan denied the request based on a determination that the medication is not medically necessary.The FDA approved indications for Provigil include narcolepsy syndrome, sleepiness due to obstructive sleep apnea and sleepiness due to shift work sleep disorder. Additional off-label uses include the treatment of attention deficit disorder, fatigue associated with chronic diseases, psycho-stimulant abuse, and depressive disorders. None of these indications apply to this patient as she is reportedly being prescribed Provigil for excess daytime sleepiness without an identified etiology, as narcolepsy has been ruled out.  There are other treatment modalities for hypersomnolence including sleep hygiene interventions, increased exercise, and/or dietary modifications that might be explored. The potential side effects of Provigil are significant and include cardiovascular and psychiatric symptoms. Hence the risks associated with this medication are not outweighed by the patients subjective report of symptom improvement.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 47-year-old female who had a body mass index (BMI) of 34.8 in January 2006 as well as hyperlipidemia, glucose intolerance and a family history of diabetes. She has tried various means to lose weight, but has not been successful in the long term.  Her provider recommended a bariatric surgery consultation and submitted a request for authorization to the Health Plan. Authorization was denied based upon a determination that the service is not medically necessary.The patient is a candidate for bariatric surgical evaluation based on a BMI wavering on or near 35 and hyperlipidemia. There is also real potential for the development of additional co-morbid conditions if her weight is not brought under control.  The Swedish obesity study affirms 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 morbidly obese.  Further evaluation of this patient by a specialist in the area of bariatric surgery is medically appropriate at this time. Therefore, I have determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Insurers denial should be overturned.