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

The patient is a 52-year-old woman with a variety of complaints that are documented in a letter from her physician. The letter mentions the patient has fatigue, joint pain, headaches and memory problems. At issue is the medical necessity of extended (in excess of one month) intravenous antibiotic therapy for the treatment of Lyme disease.There is no peer-reviewed support for an extended period of antibiotic therapy for patients with Lyme disease. Several studies have addressed the necessary duration of therapy for chronic Lyme disease. A study by Krupp, et al., demonstrated that a month of therapy with ceftriaxone (versus placebo) reduced perceived fatigue in a group of 55 patients with chronic Lyme disease. There are two controlled trials of long-term antibiotic therapy that do not show benefit from this treatment (Klempner, et al.). The Medical Letter review of May 2005 does not recommend more than 28 days of antibiotic therapy. Thus, there is no scientific evidence that extended antibiotic therapy has any beneficial effect on patients with this diagnosis. As such, there is no medical justification for the requested therapy for treatment of the patients condition.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 60-year-old male who has a history of severe pulmonary hypertension, diabetes mellitus, morbid obesity, and displaced left trimalleolar fractures. He was placed in a skilled nursing facility and occupational therapy and physical therapy were initiated. It appears occupational therapy was discontinued in September 2005. The Health Plan denied authorization and coverage for SNF services as of September 2005. At issue is whether continued SNF services are medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The submitted evidence indicates the patient reached a stable level with activities of daily living as of September 2005. In addition, the patient was at a stable level with physical therapy with standby assistance. Therapy notes from September 2005 indicate the patient could climb four steps with use of a quad cane. Based upon the documentation provided, the patients status as of September 2005 was such that he no longer required a SNF level of care and was appropriate for discharge. 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 58-year-old male with localized prostate cancer. He wishes to undergo radical prostatectomy. The patient has requested authorization and coverage for robotic-assisted laparoscopic prostatectomy. The Health Plan has determined the requested procedure is not medically necessary. In the alternative, the Health Plan has authorized open prostatectomy for treatment of the patients prostate cancer.The treatment of prostate cancer is effectively accomplished with radical prostatectomy. The three approaches to radical prostatectomy are the open procedure, the laparoscopic radical prostatectomy, and the robotic-assisted laparoscopic prostatectomy. The essence of the robotic-assisted procedure involves removal of the prostate and seminal vesicles and attachment of the bladder neck to the urethra. It is the same operation whether or not robotic-assistance is utilized. The differences are in the incision versus 5 lap ports. Current data do not show any benefit with using robotic assistance with respect to cure rates, continence rates or potency rates, which are the main concerns and outcome measures. Thus, there is no medical necessity for a robotic-assisted prostatectomy rather than an open surgical approach. The patients opportunity for cure and an excellent outcome are preserved with the traditional surgical approach. Based upon the information set forth above, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 52-year-old female with non-specific symptoms. She was unresponsive to L-DOPA/arginine stimulation testing and had transient symptomatic response to Mestinon. Her current status is at the baseline level of malaise or worse. The patient has requested authorization and coverage for growth hormone therapy. The Health Plan has denied this request on the basis that growth hormone therapy is not medically necessary.The submitted information lacks evidence of definitive testing for growth hormone therapy. The L-DOPA/arginine stimulation test was remarkably unresponsive. In addition, the patients symptoms are non-specific. Furthermore, the patients low estrogen and high FSH are consistent with menopause and rule out global hypopituitarism. The patients transient response to Mestinon is non-specific. Given these findings, a gold standard test of growth hormone response is indicated (e.g., insulin hypoglycemia or GHRH/arginine stimulation test). Once these results are available, the patients request for growth hormone therapy should be re-evaluated. Based upon the information provided, I have determined the requested therapy is not medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time. The patient should receive insulin hypoglycemia or GHRH/arginine stimulation testing; her request for growth hormone therapy should be reconsidered based upon the test results.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 48-year-old female with a history of arm, shoulder and neck pain, which was treated with a six-week course of physical therapy. The patient also has low back pain. The physical therapy she received during the six-week course was not focused on treatment of her back pain. The patient is still experiencing back pain and therefore, has requested authorization for additional physical therapy. The Health Plan has denied coverage for the requested therapy on the basis it is not medically necessary for treatment of the patients condition.The patient is requesting additional physical therapy for treatment of her low back pain. Review of the submitted records reveals that the patients back pain was not addressed during the course of physical therapy she previously received. As such, it is medically reasonable to assume the patient will benefit from treatment directed at her back. The requested therapy is medically appropriate and indicated for treatment of the patients low back symptoms. 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 40-year-old female with a history of chronic migraine headaches. She is currently taking Topamax, Flexeril, and Seroquel. The patient has also been diagnosed with bipolar disorder. The submitted records do not document the current number or severity of the patients headaches. The patient also has a history of neck pain and surgery, but there is no documentation regarding any current neck problems except as mentioned in the patients request for authorization of Actiq. The Health Plan has determined Actiq is not medically necessary for treatment of the patients condition.It is likely this patients headaches are associated with medication overuse secondary to daily narcotics. The records provided do not demonstrate the patient has had a thorough trial of a variety of preventative medications. Thus, it appears that the patient has not explored usual and customary modalities for the treatment of mixed migraine and chronic daily headaches including narcotic detoxification. As such, use of Actiq is not medically warranted for this patient.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: Upheld Decision of Health Plan

The patient is a 59-year-old man who is requesting coverage for continuation of growth hormone (GH) treatment to prevent a heart attack. He has been taking growth hormone therapy for three and a half years. The medical records from his endocrinologist from the 2003 to 2004 time period do not list or substantiate a diagnosis of panhypopituitarism. Pituitary function test results are not included in the submitted documentation.  The patient is being treated for diabetes mellitus type 2 and dyslipidemia. He has a normal total testosterone and above normal levels of IGF-1. Based on the information provided, it does not appear the patient is on any other pituitary tropic hormone replacement. At issue is whether continued growth hormone therapy is medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. There is no evidence of GH deficiency or any other pituitary dysfunction to sustain a diagnosis of panhypopituitarism in this patient. Patients who have documented adult growth hormone deficiency (AGHD) have an increased incidence of coronary artery disease and increased mortality. However, the use of GH to prevent an acute coronary event in patients without a diagnosis of AGHD is not the standard of care. 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 33-year-old male with a history of amphetamine abuse, smoking on average two to three times per month. His provider referred him for residential treatment. The patient is employed, married, and in no legal difficulty related to amphetamine use. In addition, the patient appears motivated for treatment. His Health Plan has declined authorization for residential treatment and has recommended outpatient therapy.The Health Plans denial should be upheld. Because of the patients rather infrequent rate of drug use as well as his motivation for treatment, outpatient therapy would be the treatment of choice for this patient. He has not previously had any concerted outpatient treatment and is otherwise a sufficiently healthy candidate for outpatient treatment. Based upon this information, there is no evidence the patients drug use warrants the intensity of residential treatment or that outpatient treatment will not be successful. 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 56-year-old man with knee pain and chondromalacia confirmed by arthroscopy. He has undergone three to four series of Synvisc injections with reportedly good results.  A request has now been made for an additional series of three injections. The Health Plan has denied this request on the basis the requested injections are not medically necessary.There is no documentation in the literature that warrants this extensive use of hyaluronic acid (Synvisc) injections. The patient has already had three to four series of injections. There is no indication or medical justification for an additional series. The patient can also try oral supplements, anti-inflammatory medications, or cortisone injections.  The proposed treatment however, cannot be recommended as medically appropriate.  Therefore, I have determined that the requested injections 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

This patient is a 57-year-old male with hepatitis C and depression. In light of the patients depression and the potential side effects of interferon, the patients provider has recommended monotherapy with ribavirin. The Health Plan has denied coverage for the requested medication on the basis it is not medically necessary for treatment of the patients condition.The use of ribavirin as a monotherapy is not medically indicated or necessary. The submitted information includes two pilot studies and four randomized double-blind placebo studies on ribavirin as a monotherapy. In general, the results indicated that the use of this drug alone for 6-12 months did not result in a sustained biochemical response and ALT levels returned to baseline within 2-3 months after discontinuing the drug. No virus was cleared and no improvement in liver biopsy was noted. Thus, the data suggests ribavirin is not beneficial as a short course therapy. A longer course of ribavirin therapy has not yet been appropriately studied. In summary, the use of ribavirin as monotherapy in patients with hepatitis C is not the standard of care and there are insufficient data to support its use in this patient. Therefore, 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 is a 50-year-old female with a past history of panic disorder. She has experienced a recent return of symptoms after experiencing stress at work. The patient notes she was successfully treated with cognitive behavioral therapy in the past, approximately 20 years ago. She has requested authorization and coverage for individual psychotherapy. The Health Plan has offered the patient group therapy for eight weeks, some adjunctive therapies including a Mind Body program, and individual therapy approximately every 4-6 weeks. The patient finds this unsatisfactory due to living too far from the sight that conducts the group therapy, which would necessitate an allotment of about three hours out of her workday. The patient also declined a medical evaluation indicating that prior use of medication caused her condition to deteriorate. The Health Plan has denied coverage for individual psychotherapy indicating the Best Practice treatment of panic disorder includes weekly symptom management in a group/class setting. The Health Plan further indicates individual psychotherapy is not usually recommended for treatment of panic disorder and is not medically necessary.Review of the relevant psychiatric literature demonstrates individual therapy, including cognitive behavioral therapy, is an effective treatment for panic disorder. Group therapy is not the community standard for treatment of panic disorder and is not a nationally recognized treatment approach. Individual psychotherapy is medically appropriate and indicated for treatment of the patients condition and should be authorized. Therefore, I have determined 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 32-year-old male with chronic knee pain. He has undergone multiple surgical procedures without sustained benefit. The patient has requested authorization and coverage for a cryosurgery procedure, which has been denied by the Health Plan.The efficacy of cryosurgery for treatment of chronic knee pain has not been established. There are no long-term, prospective studies to warrant its use at this time. The long-term benefits of the procedure, if any, are unknown. Furthermore, the risks of the procedure remain unclear. Given the lack of evidence demonstrating that cryosurgery is likely to be beneficial for treatment of this patients knee pain, it is not medically warranted and cannot be recommended at this time. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 37-year-old male who has a history of hereditary angioedema (HAE), which has been successfully treated with androgens, most recently Oxandrin. The submitted information does not indicate how the diagnosis was confirmed. Additionally, it is not known if C-1-esterase inhibitor function was measured. The patients history suggests that treatment with Oxandrin reduced and/or eliminated episodes of angioedema. Although the patient recently required urgent care for an episode of abdominal angioedema, this was most likely precipitated by his having discontinued use of the drug. At issue is whether Oxandrin is medically necessary for treatment of the patients condition.HAE is effectively treated with attenuated androgens. As one of the submitted articles suggests, Oxandrin is in the class of attenuated androgens along with danazol and stanazol. Though the latter two are more commonly utilized for treatment of HAE, Oxandrin is considered an acceptable alternative to the other attenuated androgens. While Oxandrin has not been approved by the Food and Drug Administration for this indication, the submitted evidence suggests it has been effective for this patient and has not resulted in untoward side effects. 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 a 12-year-old girl who developed Type I Diabetes Mellitus in November 2004. The patient was not over-weight and she had a goiter. The submitted blood glucose records indicate that the patient is passing her honeymoon period and is entering the stage of higher blood glucose levels. This is the stage that insulin pumps are often recommended. There is no evidence in the submitted documentation that an insulin pump has been requested by the patients provider. At issue is whether an insulin pump is medically necessary for treatment of the patients medical condition.It does not appear the patients providers have submitted a request for an insulin pump. The Health Plan indicates an insulin pump would be authorized if a request for the pump was made by the diabetes team caring for the patient. The patients mother wishes to receive an insulin pump for her daughter in order to diminish the number of sticks the patient has to receive each day. In actuality, the pump would only diminish the number of insulin shots the patient receives. In any event, approval of the request for an insulin pump necessitates that the request is made by skilled health care providers who have determined that the patient and her parent need the device and are able to operate it appropriately. In this case there is insufficient evidence an insulin pump is considered medically necessary by the patients diabetes team. Therefore, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. Accordingly, 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 apparently has a seizure disorder and another neurological syndrome known as stiff persons syndrome. The patient has been treated with intravenous immunoglobulin (IVIG) therapy and has reported some improvement in her condition. She wishes to continue to be treated with IVIG therapy. The Health Plan has denied coverage for IVIG on the basis that it is not medically necessary for treatment of the patients condition.Stiff persons syndrome is a very rare neurological condition that can be treated in several ways. In the case of this patient it does not appear the diagnosis of stiff persons syndrome has been firmly established. The patient requires further workup to establish the diagnosis clinically and by the presence of elevated anti-GAD titres. If the diagnosis of stiff persons syndrome is confirmed, available treatments include plasmapheresis, a variety of pharmacological agents, and IVIG therapy. At this time there is insufficient evidence that the patient does in fact have stiff persons disease and has failed other available treatments for the condition. However, if the diagnosis of stiff persons disease is confirmed and there is documented evidence that plasmapheresis or pharmacological agents are ineffective for this patient or cause untoward side effects, then the patients request for IVIG therapy should be reconsidered.Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 42-year-old male who underwent right knee anterior cruciate ligament reconstruction in May 2005. Initially post-operatively the patient was placed in a long brace, which was later replaced with a shorter ACL brace. The Health Plan has denied coverage for the ACL brace.The brace in question was designed for repeated use for treatment of an injury or to improve functioning or deterioration of a malformed body part. In addition, the brace in question was designed to allow for protected motion of the patients knee while keeping the knee stable. Given this patients history, the brace in question was necessary to protect the patients knee while allowing for necessary functioning of the knee. Therefore, I have determined the equipment at issue was medically necessary for treatment of the patients condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a four-year-old male who was born prematurely at 23.4 weeks. In the neonatal period he developed a bilateral grade III intraventricular hemorrhage with resulting hydrocephalus. He underwent shunt placement. The patient was diagnosed with cerebral palsy at the age of 18 months. Treatment has included physical therapy and Botox injections for lower extremity spasticity. The patients provider has recommended the patient undergo a selective dorsal rhizotomy with a single laminectomy at L1. The Health Plan has denied authorization for the proposed procedure indicating there is insufficient evidence demonstrating a difference in outcomes between a rhizotomy with single level laminectomy and a rhizotomy with double level laminectomy. A rhizotomy with a single level laminectomy has been recommended on the basis it is superior to a rhizotomy with a multiple level laminectomy. The basis for this contention is two recent articles, one by D. Speigel and the other by M. Johnson. The articles discuss spinal deformity after selective dorsal rhizotomy. Though the results indicate there was an increase in scoliosis, spondylosis, and spondylolisthesis, the Speigel article reports only one patient required a second surgical procedure and the Johnson article reports none of the patients required additional surgery. Review of the relevant medical literature does not suggest a rhizotomy with a single level laminectomy will be superior to a rhizotomy with a multiple level laminectomy for this patient. The evidence does not demonstrate a significant difference between an appropriate surgeon performing a single level laminectomy versus a multiple level laminectomy. Because there is inadequate evidence demonstrating a rhizotomy with a single level laminectomy will provide the patient with greater benefit, 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.