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

The patient is a 51-year-old woman with chronic insomnia who is requesting drug coverage for Lunesta 6mg per day. The following is a summary of her clinical course.According to the records, the patient had a severe thumb injury 10 years ago. Multiple surgical repairs resulted in chronic pain and the patient was diagnosed with reflex sympathetic dystrophy (RSD). A consult dated June 2005 by the patients sleep specialist reviewed her history including multiple bouts of depression and anxiety. The patient had been tried on various sleep aids in the past. The sleep specialist prescribed melatonin and Lunesta at 6 mg per day. The sleep specialist had noted that this dose was not FDA-approved but she found it was effective for some patients.The patients psychologist supports the use of Lunesta at 6 mg per day stating that it will help prevent future psychiatric hospitalizations. The patients psychiatrist states that the patient has depression, severe anxiety and borderline personality disorder and that lack of sleep will trigger aggressive behavior and mood instability. The psychiatrist has recommended Lunesta at 6 mg per day.The Health Plan has denied coverage for the prescribed dose because it exceeds the FDA-approved dosage of 3 mg per day.The Health Plans denial should be upheld. The enclosed prescribing information states that doses of Lunesta from 1 to 6 mg per day were tested in individuals and there were no significant issues in drug clearance and elimination. The prescribing information did include a section on Drug Abuse and Dependence. It states that the risk of abuse and dependence on Lunesta is greater for patients who have a history of psychiatric disorders. It also states that at doses two-fold or greater, a dose-related increase in reports of amnesia and hallucinations was observed.There is current evidence to suggest that a dose beyond 3 mg of Lunesta is more efficacious but there is also the question of safety. Use of Lunesta in the United States is recent and until more studies on dosing are provided, it is prudent to adhere to the FDA-approved doses. Therefore, I have determined that the requested prescription 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 44-year-old female with a body mass index (BMI) of 41. She has comorbid conditions of hyperlipidemia and sleep disturbance. She has requested authorization for gastric bypass surgery. The Health Plan has denied the patients request. She has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery.With a BMI of 41 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. In addition, the patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. Furthermore, scientific evidence does not show that structured weight management plans consisting of diet and exercise have been successful in the treatment of the morbidly obese. The study referenced above demonstrates that surgery has the best long-term outcome for the morbidly 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 36-year-old female who has a chronic condition of lower back pain with degenerative changes noted on x-ray. She received a chiropractic referral by her physician with improvement noted after the second chiropractic visit. Based upon the submitted records, it appears only six chiropractic treatments were certified between October 2004 and February 2005, a four-month span. The patient has requested authorization for continued chiropractic care. This patient has chronic lower back pain with documented degenerative changes. Six chiropractic treatments were provided between October 2004 and February 2005. A 40% improvement was stated after the second treatment. Considering the patients degenerative changes in her lumbar spine and her lack of response to physical therapy and NSAIDs, an additional six chiropractic treatments are medically appropriate and indicated to determine the patients treatment response. Based upon the information provided above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive six additional chiropractic sessions with re-evaluation at the completion of the six sessions.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old male is requesting reimbursement for a continuous passive motion (CPM) machine. The patient underwent surgical repair of a right anterior cruciate ligament (ACL) in February 2005. As part of the patients rehabilitation, his provider recommended the patient use a CPM machine for therapy and healing. The Health Plan has denied coverage for use of the CPM machine on the basis it was not medically necessary for treatment of the patients medical condition.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. A CPM machine was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 46-year-old male who had a malignant melanoma, stage 2, depth of invasion of 0.76 mm with partial regression excised by an out-of-network head and neck surgeon in June 2005. The lesion was on the left posterior scalp. Previously, he went to an in-network dermatologist in 2003. The dermatologist froze the lesion with liquid nitrogen. The spot became larger and darker. In 2004, the dermatologist froze the lesion again. In April 2005, because the spot was larger and darker, the primary care physician again referred the patient to the in-network dermatologist who wanted to again treat the lesion with liquid nitrogren. The patient requested a biopsy, which revealed a melanoma.The patient is now requesting follow-up total body skin exams from an out-of-network provider. The Health Plan has denied the patients request indicating that the proposed care is within the scope of practice of the patient primary care physician or the in-network dermatologist.The patient has malignant melanoma and is status post recent excision. It is not within the primary care providers scope of practice to access this melanoma patients skin for recurrent or new melanoma. Furthermore, the patient indicates the in-network dermatology clinic, which has treated him in the past is the only dermatology clinic available in-network. The Health Plan has not provided evidence another in-network dermatology clinic is available to provide follow-up care for the patient. Therefore, I have determined the requested referral is medically necessary for evaluation 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 nine-year-old female who has a history of bipolar disorder and narcolepsy. The patient has failed a trial of Ritalin. The diagnosis of narcolepsy is based on a polysomnogram. The Health Plan indicates there was a discrepancy in the  sleep latency results and no confirmation of any REM time. In April 2005, the patients physician recommended she try Provigil. A six-week trial of Provigil was clinically effective. The Health Plan has denied authorization and coverage for the requested medication indicating the patient does not meet Health Plan criteria for Provigil.The diagnosis of narcolepsy is based on a polysomnogram and has not been confirmed. Further, the patient is a pediatric patient. FDA approval for Provigil in children has not been established. Though there is some data to support the efficacy of Provigil for treatment of narcolepsy in the pediatric age group, the diagnosis of narcolepsy has not been confirmed in this case. Thus, there is an insufficient foundation for continuing the use of Provigil in this patient. At this time, there is insufficient peer-reviewed literature investigating Provigil for the pediatric age group. There should be further investigation to establish the patients diagnosis and a subsequent treatment plan. Accordingly, 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 62-year-old female with a recent history of breast cancer that has been treated with mastectomy and radiation. In addition, the patient underwent a hysterectomy and removal of one ovary approximately 34 years ago. Her mother and aunt evidently had breast cancer with a secondary ovarian cancer. In June 2005, the patient underwent a ventral hernia hemiorrhaphy and prophylactic oophorectomy. The Health Plan has denied coverage for the oophorectomy on the basis it was not medically necessary.While prophylactic oophorectomy after the diagnosis of breast cancer is not the standard of practice, in the case of this patient a primary operation (ventral abdominal hernia) needed to be performed. Hence, in this instance the oophorectomy can be seen as an incidental procedure similar to an incidental appendectomy. Since this was a secondary procedure to an abdominal procedure that was necessary, it would seem to be within the standard of practice of most practitioners. Considering the patients family history, her recent breast cancer, her personal anxiety, and the fact that the oophorectomy was not a primary scheduled procedure, the procedure at issue was medically reasonable and appropriate in this case. Based upon the information set forth above, I have determined the procedure at issue was medically necessary. Accordingly, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is an eight-year-old female with a history of global developmental delay with hypotonia, oral motor dyspraxia, and seizure disorder. The seizure disorder has been treated with Lamictal and she has had approximately 3-4 focal motor seizures since October 2004.  Each time the patient has jerking of the right hand and foot. The patients therapist has documented a regression in speech after each of the seizures and the neurologist and rehabilitation physician have documented weakness, right greater than left.At issue is whether continued speech therapy is medically necessary for treatment of the patients condition.Though no physician states that the patients speech deficits are directly related to the seizures, the proximity of the motor strip on the left to the speech pathways make it likely that her speech is being affected by the seizures, particularly since the therapist has documented decreased performance after the seizures. This, in conjunction with the patients significant poor oral and motor skills make it highly probable the patients condition is related to a disease state. Additionally, the patients therapist has documented steady gains with therapy from 2000-2005. Therefore, continuation of the current therapy is medically reasonable and appropriate. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old male who has a PSA of 6.55. In June 2005 he had an ultrasound-guided prostate biopsy, which revealed a Gleason score total of 6 (3+3) adenocarcinoma extensively present on both sides of the prostate. The patient wishes to undergo robotic-assisted laparoscopic radical prostatectomy. The Health Plan has denied coverage for the requested procedure but has offered radical prostatectomy, including the alternative of laparoscopic radical prostatectomy. The Health Plans denial should be upheld. The robotic-assisted laparoscopic procedure is relatively new, and while short-term results are comparable, long-term data especially with regard to survival is not yet available. While there is no medical objection to the robotic-assisted laparoscopic approach, to date there is insufficient data to demonstrate its superiority to other procedures. The open surgical approach is a well-established treatment with good long-term results regarding survival and complications and is considered standard of care for treatment of the patients prostate adenocarcinoma. 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 58-year-old male with a history of snoring, muscular weakness and constant fatigue. He also has some history of coronary artery disease, having had stints placed in the past. Because of his symptoms he was referred to and evaluated by a physician who appears to be a pulmonologist specializing in sleep disorders. His primary care provider referred him to this physician. An overnight oximetry was performed in November 2003 that indicated 407 desaturation events to have occurred during approximately a 10-hour period. Based on this result the patient was prescribed a therapeutic trial of CPAP even before polysomnography was performed. This latter study was recommended or scheduled but apparently never took place. The patient indicates he has been using a CPAP device with great success and relief of his symptoms. He has requested reimbursement for use of the CPAP device. The Health Plan has denied coverage on the basis there was no polysomnography demonstrating medical necessity for CPAP.Based upon the submitted documentation, it does not appear the patient has undergone somnography. A polysomnography is necessary to document the presence of obstructive sleep apnea. If the patient undergoes polysomnography and the results are positive, the patients request for reimbursement for CPAP therapy should be reconsidered by the Health Plan. However, based upon the evidence provided, it has not been established that CPAP therapy was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 10-year-old male with autism. There is documentation the patient has learning disabilities. He is being treated with Buspar and Lexapro. It has been recommended the patient receive occupational therapy. The Health Plan has determined the requested therapy is not medically necessary for the patients condition.The submitted information indicates the patient has difficulty processing information and has difficulty with his fine motor skills. Patients such as this patient are likely to benefit from occupational therapy. It does not appear the patient is likely to benefit from other therapies. Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should undergo a trial of occupational therapy for a three-month period.  If there are documented gains at the end of the three-month period, additional occupational therapy should be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 33-year-old male with degenerative disc disease. He has had a positive discogram at L4-5 and L5-S1. His provider is recommending a two-level artificial disc replacement at these levels. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery at two levels. There is no data to support such a procedure. There are no known outcomes at two years or more. The artificial disc is currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is no evidence supporting the safety and efficacy of a two-level disc replacement, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 33-year-old male with two-level degenerative disc disease at L4-5 and L5-S1. The patient has failed conservative management. A two-level disc replacement has been recommended. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental with no established efficacy. There are no studies supporting a two-level disc replacement. The safety profile is unknown. There is no clinical indication for the proposed procedure. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 3: The patient is a 33-year-old male with degenerative disc disease. He is seeking authorization for two-level artificial disc replacement. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding artificial disc replacement is based upon short-term follow-up in one study. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. There is no evidence for reduced long-term adjacent level disease progression compared to fusion. There are no studies that indicate long-term superiority over fusion. Artificial disc replacement is considered experimental and there is no evidence it is superior to available standard treatment. Therefore, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 58-year-old female requesting reimbursement of physical therapy services rendered from November 2004 to March 2005. The therapy at issue was provided for treatment of bilateral sacroiliac joint inflammation. The Health Plan has denied reimbursement for the therapy at issue on the basis it was not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld. The physical therapy services the patient received from November 2004 to March 2005 were primarily in the form of passive modalities for passive pain control. There is no evidence the therapy at issue was likely to result in improvement in the patients condition and ability to function in a reasonable and predictable time period. As such, it has not been established the therapy at issue was medically warranted. Accordingly, I have determined the therapy 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 four-year-old female with a diagnosis of motor incoordination. There is also some mention of speech delay. Since August 2003 the patient has been receiving occupational therapy through a hospital-based child development center for sensory issues and motor incoordination. The patients occupational therapist is recommending continued therapy once a week. The Health Plan has denied authorization for the requested therapy.The progress reports submitted show little, if any, progress has been made between February 2004 and July 2005. The patients gross motor skill goals have not been achieved. It is unclear whether the patient has met her fine motor skill goals of February 2004. Notes from February 2005 reflect the patients tendency to still hold a pen with a radial digital group. In addition, the patient is not independent in putting on pants or a jacket. The other services being offered the patient are educational and not medical in nature and should be provided through the patients IEP.Because the patient has not significantly progressed with therapy, there is little evidence that further therapy will lead to significant benefit. In addition, the patients educational services can be obtained outside of her occupational therapy milieu. 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: Overturned Decision of Health Plan

The patient is a 20-year-old male with persistent low back pain. The patient has requested coverage for chiropractic care. The Health Plan has recommended physical therapy. The patient reports he has intolerance to NSAID medication. At issue is whether chiropractic services are medically necessary for treatment of the patients condition.A persisting diagnosis of low back pain is a common presentation during a chiropractic consultation. It is also a common diagnosis treated with chiropractic care with favorable results. A trial approach of six chiropractic treatments is medically appropriate for this patient. If the patient experiences documented improvement with chiropractic treatment additional treatments should be authorized. Accordingly, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 33-year-old female with size 42DD breasts who complains of back pain. She is seeking breast reduction surgery to relieve her back pain. She has had normal x-rays of the thoracic spine and is noted to have a body mass index (BMI) of 31.9. The Health Plan has denied authorization for the requested procedure and has recommended weight loss prior to consideration of surgery.The Health Plans denial should be upheld. There is no photographic evidence demonstrating shoulder grooving and clinical notes do not document shoulder grooving. In addition, there is no evidence the patient has attempted and failed conservative therapy such as weight loss. Without such evidence there is no indication that breast reduction surgery is indicated for this patient. 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.