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

The patient is a 50-year-old female with a body mass index (BMI) of 45. The patient has multiple comorbid conditions including hypertension and hypothyroidism. 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 45 and multiple comorbid conditions 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 20-year-old female who sought correction of her developmental and congenital chest wall deformities at a breast care center. Her evaluation revealed a combined congenital anomaly (pectus excavatum) and developmental defect (tubular breasts) that has resulted in medially displaced breasts that are asymmetric and tubular. The patients provider recommended bilateral placement of breast implants and repair of the tubular breast deformity on the right side. The Health Plan has denied authorization for the requested procedure on the basis that it is cosmetic in nature.The description of the defects by the patients surgeons as well as the accompanying photographs demonstrate the complexity of the patients condition. This patient has both congenital and developmental abnormalities, which have resulted in an abnormal structure of the body. Thus, the requested procedure constitutes a reconstructive procedure under California law. Though it will be difficult to achieve symmetry and the breasts are likely to remain medially displaced due to the pectal defect, the requested procedure is medically justified. 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 34-year-old male with a body mass index (BMI) of 48. 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 48 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 43-year-old male with recurrent gout for the past two years. He had been appropriately referred to a rheumatologist for management of his gout. Once the patients acute symptoms were controlled, the Health Plan determined the patients PCP could manage the patient further. Subsequently, a change in the patients medication resulted in a recurrent acute attack of gout. The Health Plan indicates continued care with a rheumatologist for management of the patients gout is not medically necessary.Of all rheumatologic conditions, gout may be the most eminently and effectively manageable. With appropriate treatment, and in the absence of allergy to Allopurinol, gout should be suppressed well enough that no further acute episodes occur in a given patient.It can be very difficult to effectively manage gout as a chronic recurring condition. Practitioners are often unable to avoid the many pitfalls that exist in the management of gout including: lack of understanding of serum uric acid levels, which have little relevance to diagnosis, and much greater importance for monitoring treatment; incorrect timing and dosing of Allopurinol treatment; failure to maintain suppression with low-dose Colchicine until the serum uric acid level is adequately lowered; overuse of NSAIDs long-term; incomplete understanding of treatment goals; and failure to maintain long-term suppression.The patients rheumatologist correctly lowered, but did not discontinue, the patients Colchicine dose. The rheumatologist also began monitoring the patients serum uric acid level, which was apparently 7.9% at the onset. Although the patients acute episode was controlled, his serum level was not. When the patient returned to his PCP Colchicine was discontinued. Thereafter, the patient experienced another acute episode of gout, after his serum level had dropped only to 7.2mg.The submitted documentation demonstrates the patients gout is not adequately controlled and does not meet the standard of care in rheumatologic practice. The patient should continue to be followed by his rheumatologist at intervals of two to three months until his clinical gout, laboratory markers, and medication regimen are controlled and stabilized. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 57-year-old male who has been diagnosed with osteoarthritis. In addition, the patient has a history of gastroesophageal reflux disease. The patient is unable to tolerate Alleve and ibuprofen. Further, trials of Relafen and Naprosyn were unsuccessful. The patient has requested authorization and coverage for Vioxx. The Health Plan has denied the patients request on the basis that Vioxx is not medically necessary for treatment of the patients osteoarthritis.The Health Plans denial should be overturned. The patient is under age 65 and carries a diagnosis of osteoarthritis. Alleve and ibuprofen caused the patient to experience gastrointestinal upset and cramping. Additionally, the patient has failed a trial of Relafen, a low-gastrointestinal risk NSAID. As such, the medical necessity of Vioxx has been established. 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 15-year-old female who has been diagnosed with Aspergers syndrome with obsessive behavior, hair pulling, and skin picking. The patient has been tried on multiple modalities including biofeedback vision therapy, occupational therapy, and tutoring with poor results. The patient was then placed in a multidisciplinary day program, which resulted in significant benefit. It has been recommended the patient continue to receive day treatment therapy. The Health Plan has denied authorization for the requested therapy indicating it is not medically necessary.Review of the reports of the individual therapies associated with the patients day treatment program reflect a well-coordinated effort to address the outlined goals. The measured goals are attainable and realistic. Additionally, many of the patients observed behaviors cannot be appropriately treated with occupational therapy alone. Finally, these behaviors occur in the community as well as in school and therefore, are not solely educational in nature. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The patient should continue to receive day treatment therapy at least three days per week. The patients therapist should continue to document measurable objectives. Treatment should continue as long as the goals are being obtained. The patient should be reevaluated every six months. The patients therapist should provide written reports of progress to the patients neuropsychologist who should perform standard neuropsychological testing to also document the progress. These results should be reviewed by the patients psychiatrist.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 54-year-old woman with abdominal pain as a result of multiple conditions including irritable bowel syndrome, partial small bowel obstruction secondary to radiation for Hodgkins disease, and biliary dyskinesia. The patient reports Zelnorm has been effective for treatment of her abdominal symptoms. She has requested authorization and coverage for a longer duration of Zelnorm. The Health Plan has denied the request on the basis that continued use of Zelnorm is not medically indicated. Upon review of the information provided it does not appear the patient has undergone a complete gastrointestinal workup. The patient has a complex medical history and the submitted information does not demonstrate the exact etiology of the patients abdominal symptoms. Additional diagnostic testing including an EGD and/or colonoscopy is needed for further characterization of the patients pain and to determine optimal therapy. Thus, the gastroenterology evaluation and testing recommended by the Health Plan is medically reasonable and appropriate. Continued use of Zelnorm is not medically indicated at this time. Based upon the information set forth above, I have determined that 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 reports a history of anxiety/tension and menstrual cramps. She indicates she has been experiencing anxiety since her last two miscarriages. The patient has a strong desire to become pregnant and to avoid a miscarriage. She is concerned about the risks associated with anti-anxiety medications. It appears the patient has benefited from an acupuncture treatment she previously received. A request has been made for authorization and coverage for acupuncture, which has been denied by the Health Plan. Anxiety/depression is a condition that is commonly treated with acupuncture. Additionally, acupuncture has been used with success in the treatment of gynecological disorders. The patient indicates she has achieved good results from an acupuncture treatment she received in the past. It is likely that additional acupuncture treatments will improve the patients anxiety and reduce her menstrual pain. 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 receive eight acupuncture treatments followed by re-evaluation by her acupuncturist and primary care physician.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 27-year-old female with a body mass index (BMI) of 45. She has failed numerous attempts at conservative weight loss. The patient has undergone a psychological evaluation and is an appropriate candidate for weight loss surgery. The Health Plan has denied coverage for gastric bypass surgery on the basis that it is not medically necessary for treatment of the patients morbid obesity.With a BMI of 45 the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. The patient has undergone a psychological evaluation and is considered an appropriate candidate for weight loss surgery. It is unlikely the patient will be able to lose weight and maintain the weight loss through non-surgical means. Furthermore, 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 54-year-old woman with a strong family history of breast cancer. Her mother was diagnosed with breast cancer at age 46. Her paternal grandmother was diagnosed at age 48. Her maternal grandmother was diagnosed at age 80. A sister was diagnosed at age 48 and underwent bilateral mastectomies. Her oldest sister was diagnosed at age 55. The patient has had two benign breast biopsies. Her sisters have undergone BRCA testing with negative results; however, the patient indicates that her provider still believes there is a hereditary predisposition in her family. She has been on Tamoxifen as a preventive agent.  It has been recommended the patient undergo screening with MRI in addition to a mammogram. The Health Plan has denied coverage for the requested MRI on the basis that it is not medically necessary.The use of screening and diagnostic MRI of the breast is becoming increasingly used and increasingly controversial. There is little support for routine use of MRIs in screening. However, there is developing and good data that in high-risk women, particularly at a young age, MRI screening is superior to mammography. Such high-risk women include women with BRCA mutations, as well as women with family histories including two or more close relatives with breast cancer at a relatively young age. A recently published study screened 1900 high-risk women with mammography and MRI. MRI was found to be clearly superior in its ability to detect breast cancer, and demonstrated a much higher incidence of detecting smaller and node-negative cancers than mammography. In light of these results, MRI screening is medically appropriate and indicated for this high-risk patient.Based upon the information set forth above, I have determined that the requested MRI is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient was diagnosed with sleep apnea in October 2002. A CPAP machine and supplies were requested by her primary care physician (PCP). At that time, an IQ CPAP mask and headgear were requested. A nasal application device and headgear were authorized. A durable medical equipment provider supplied a nasal IQ CPAP mask as a courtesy. The patient has been tolerating CPAP well since that time, with good compliance documented in her medical visits with her PCP.The patient has been successfully using nasal CPAP for two years and does not tolerate any type of forehead pad due to forehead pressure and pain it causes. The patient attributes this to her allergy and sinus problems. The patient has now requested a nasal IQ CPAP mask and Holey Cap Headgear. The patients request has been denied by the Health Plan on the basis that the submitted documentation does not support the need for the special features of the requested equipment. A standard CPAP has been recommended.The patient has documented sleep apnea. Individual patient fit and tolerance are used to determine the best mask type to use in medically managing a patients sleep apnea. This patient clearly tolerates nasal CPAP over a full-face mask. She is not tolerant of any head strap against her forehead due to complaints of pressure and pain. She has been very compliant with CPAP use and has been tolerating it well for almost two years using a nasal IQ CPAP mask.Furthermore, special mask types may be necessary for patients who are unable to tolerate a standard nasal/face mask due to facial discomfort, sinus pain, or claustrophobia from masks. If the patient does not tolerate the type of nasal CPAP mask that is routinely supplied, then special consideration should be provided to this patient to allow her to continue to use the mask type that she has been able to tolerate and use successfully for almost two years.Based upon the information set forth above, I have determined that the requested equipment 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 woman with a history of cervical fusion 15 years ago. An MRI revealed diffuse disc bulging. Surgery has been suggested to alleviate the patients pain. The Health Plan has denied authorization and coverage for surgical intervention on the basis that it is not medically necessary.The patient has undergone prior surgery. Her symptoms at this time are not progressive. Based upon the information provided, it does not appear the patient has undergone a trial of conservative treatment. Unless there is progressive weakness, surgery should not be utilized until all other means are exhausted. The patient is not a surgical candidate until she has attempted physical therapy and/or chiropractic care, medications, and epidural injections. Therefore, I have determined that the requested procedure is 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 13-year-old male with autism, attention deficit disorder, and behavior problems. It has been suggested that the patient undergo a single-photon emission tomography (SPECT) scan to determine the cause of his neuropsychiatric problem. The Health Plan has denied coverage for the SPECT scan on the basis that it is not medically necessary for evaluation of the patients condition.Review of the medical literature reveals SPECT has not been useful in the evaluation and specific treatment of neuropsychiatric disorders. SPECT scans provide information regarding brain function by documenting changes from moment to moment as the patients brain function changes; however, SPECT scanning does not provide a more accurate diagnosis than clinical observation and testing. Further, there is no evidence that information gleaned from SPECT scanning would alter the recommended treatment. Therefore, I have determined that the requested SPECT scan 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 30-year-old male who has requested authorization for a bilateral medial thigh lift. The patient has excessive, hanging skin in the medial thigh region following a 200-pound weight loss. He reports irritation involving the overhanging skin. The patient states he must wrap the thigh in an ace wrap daily to prevent irritation and abrasions. The Health Plan has determined a bilateral thigh lift is cosmetic in nature and therefore, is not medically necessary for treatment of the patients excess skin. Based upon the submitted photographs, the patients overhang does not appear to be severe. In addition, the photographic evidence does not document a medical condition involving the medial thigh region (e.g., abrasions, irritation). In the absence of documented evidence of medial thigh irritation and abrasion there is no medical justification for the requested 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 47-year-old male with a long-standing history of neck and back pain. He participated in a computer-assisted strengthening/exercise program from September 2003 through July 2004. The patient has requested authorization and coverage for continued therapy. The Health Plan has determined the requested therapy is not medically necessary for treatment of the patients neck and back pain.Review of the submitted treatment notes indicates the patient has been using machines with computer assist to perform spinal kinetic activity. However, the submitted notes do not document a program requiring skilled therapist intervention. There is no documentation in the peer-reviewed literature, which demonstrates a computer-assisted exercise program produces superior or equal results to a self-paced gym program with weight machines. Hence, there is no evidence the requested therapy is medically necessary. 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: Upheld Decision of Health Plan

The patient is a six-year-old male with a diagnosis of attention deficit hyperactivity disorder (ADHD) and autism. He has been receiving speech therapy for treatment of autism. The patients therapist has recommended that speech therapy be continued. The Health Plan has determined the requested therapy is not medically necessary for treatment of the patients condition.There is very little literature regarding auditory processing, autism, and speech and language in the area of pragmatics. Most of the evidence involves single case studies or cohort designs with no randomization or blinding. There is still controversy regarding the existence of auditory processing as a distinct disorder. With regard to autism, the only treatment that has been shown to be beneficial is applied behavioral analysis. Furthermore, the issue of pragmatics is considered a learning disability.Upon review of the submitted speech therapy reports the goals outlined in the September 2003 report do not appear to be adequately documented. Based on this documentation, it is not possible to determine if the goals have been met, not met or abandoned because the goals from the July 2004 report in no way correlate to the previous goals.Thus, the medical need for continued speech therapy is not supported by the medical literature or by the patients prior experience with speech therapy. 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.