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

This patient is a 48-year-old female who has degenerative arthritis in both of her knees, with the left worse than the right. She has undergone arthroscopic debridement and has also tried acupuncture treatment for pain management. The patient is unable to tolerate NSAIDs and anti-inflammatory medications. She has tried Supartz injections with success and is requesting a second series of Supartz injections. The Health Plan has denied coverage for the requested injections on the basis that they are not medically necessary.Based upon the information provided, the patient has not had a steroid injection in her knee. Steroid injection is the next appropriate step in the management of the patients pain. There is no data to support the contention that a second series of Supartz injections is likely to have greater value than steroid injection or other conservative measures. A second series of Supartz injections is not standard of care for patients such as this patient. Therefore, I have determined 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

The patient is a five-year-old male with a diagnosis of speech and language delay (expressive and receptive).  He also has a diagnosis of auditory processing disorder.  He has been receiving speech therapy since July 2003.  The record provided for review includes an evaluation from January 2005 and daily progress notes from September 2004 through May 2005.  The Health Plan has denied coverage for speech therapy provided from January 2005 through May 2005 based upon a determination that it was not medically necessary.The January progress report indicates the patient was meeting all goals at that time.  However, the daily notes only document the treatment that was provided during the session and do not address functional goals.  Additionally, the therapist does not perform standardized testing to show progress toward specific goals.  In the January progress report the therapist typically reports that the goal has been met and describes the patients current level of functioning for that goal.  The progress report does not compare the current functional level with the functional level at the beginning of that evaluation period.  As a whole, the progress report only reflects the current functional level, and does not quantify the amount of change or improvement over the specified time period. For example: Goal #1 is to increase the number of communication circles in which (the patient) can participate. The progress to goal is described as (the patient) is now participating in up to 5  10 circles of communication during highly motivating activities.  There is no statement comparing the number of communication circles the patient participated in at the beginning of the evaluation period with the number of communication circles he participated in at the end of the evaluation period.  Based upon the inadequate documentation of gains, 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 12-year-old female with a history of an uncomplicated birth but global developmental delays including fine motor, gross motor (walked at 24 months) and speech delays for which she received occupational therapy, physical therapy and speech therapy as a child. She has also been diagnosed with attention deficit hyperactive disorder, anxiety and depression. She continues to have mild to moderate difficulties in language comprehension and expressive language. At issue is whether continued speech therapy for these delays is medically necessary.Upon review of the submitted therapy reports it appears little gains have been made from 2002 through 2005. Although the testing employed in each report is different, the areas of deficit are consistent between examiners. Furthermore, review of the relevant literature reveals a meta-analysis of speech and language therapy for people with primary speech and language delay. The conclusion of the meta-analysis was that the benefit of therapy on expressive syntax errors was mixed and there was less evidence that interventions are effective with receptive difficulties.Given the patients previous therapy interventions, her age, and the lack of scientific data supporting speech therapy for these types of deficits, significant improvement is not anticipated with continued speech therapy. 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 57-year-old female stated to have ankylosing spondylitis, HLA-B27 negative. She was treated with Enbrel for a period of three months, but this was stopped because of intolerance manifested as increasing rash. Her current condition is described in an office visit note from November 2005 as demonstrating synovitis of wrists, base of thumbsknees have mild crepitation and possible popliteal cystsmtps have possible synovitis, and the description of axial range of motion suggests modest limitation.At issue is whether Humira is medically necessary for treatment of the patients medical condition.The patient has been diagnosed with ankylosing spondylitis. The available records are not clear as to whether the patient has mostly peripheral involvement, or whether non-biologic DMARDs have been tried and if so, what results ensued. However, the patient was already deemed by the Health Plan as appropriate for treatment with a TNF inhibitor, and a trial of Enbrel had to be stopped because of rash. Thus, there is an acknowledged need for a TNF inhibitor for this patient, and the failure of Enbrel due to side effects would not eliminate that need. As such, the patient is an appropriate candidate for treatment with another TNF inhibitor.Standard rheumatologic practice in patients with inadequately controlled ankylosing spondylitis despite treatment with non-biologic DMARDs includes the use of TNF inhibitors. Clearly, all three available agents (Enbrel, Remicade and Humira) are very effective in the treatment of ankylosing spondylitis, and all three have been used by rheumatologists in this context. Since the patient has been deemed an appropriate candidate for TNF inhibition to treat her ankylosing spondylitis, and has already failed Enbrel due to side effects, the use of Humira is medically reasonable and appropriate for treatment of her condition.Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 57-year-old male who had a liver transplant in July 2002 for hepatitis C and hepatocellular carcinoma.  He had recurrence of the hepatocellular carcinoma in the transplanted liver in early 2004 and was treated with radiofrequency ablation.  On a CT scan of the chest, abdomen and pelvis performed in November 2005 a new enhancing 3.5 cm mass was found in the posterior portion of the liver.  The patient has an elevated alpha fetoprotein (AFP) level and the lesion is likely to be recurrent hepatocellular carcinoma.  A PET scan was ordered prior to possible surgery.  The Health Plan denied authorization for the PET scan based upon their determination that it is not medically necessary.Hepatocellular carcinoma shows variable FDG activity. This is thought to be from differing amounts of FDG-6-phosphatase activity.  PET positive activity in hepatocellular carcinoma can range from 0-64%.  For evaluation of the patients new liver lesion, a PET scan would not be helpful because a biopsy is needed to determine whether the lesion is PET positive or negative. Once the etiology of the new liver lesion is known, a PET scan would be helpful for the patients management in ways such as following the response to therapy or the detection of metastatic disease if the liver is proven to be PET positive.  However, at this time a CT-guided liver biopsy would be recommended as the next procedure for this patient. Therefore, I have determined the requested PET scan is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: This patient is a 52-year-old female with degenerative disc disease and a broad-based herniation at L3-4. She has significant radiculopathy, and conservative treatment has not improved her pain.  The patient is requesting percutaneous discectomy, and the Health Plan has denied authorization due to the experimental/investigational nature of the procedure.There is no literature to support the likelihood that percutaneous discectomy would be more effective than the standard microdiscectomy procedure. With a broad-based disc bulge, which was demonstrated in the MRI, the percutaneous procedure is not the best approach. Percutaneous discectomy would not be consistent with the standard of care in this clinical situation; the complication rate is higher and outcomes are no better than the standard procedure.  Therefore, I have determined that 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.Physician 2: This patient is a 52-year-old woman with a disc protrusion at L3-4 resulting in back pain and radiculopathy. Conservative treatment has improved the pain level somewhat, but has not resolved the radiculopathy in the right lower extremity.  The patient prefers the less invasive percutaneous discectomy over the standard microdiscectomy procedure, and has requested authorization from the Health Plan.  The Health Plan has denied this request on the basis that percutaneous discectomy is considered investigational.Despite early reports touting the benefits of percutaneous discectomy, substantiation of the overall efficacy of the procedure remains elusive. Numerous studies have shown the long-term results of this method are quite poor. The patient is likely to achieve better results with standard treatment modalities. Therefore, I have determined that 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.Physician 3: This patient is a 52-year-old woman with low back pain and pain radiating to the right thigh due to a right-sided foraminal disc protrusion at L3-4.  She has not found symptomatic relief in conservative treatment approaches and is now requesting approval for percutaneous disc discectomy at L3-4.  The requested procedure is deemed to be experimental/investigation by the Health Plan, and authorization and coverage was denied.Percutaneous discectomy is a novel and potentially effective treatment for low back pain and radiculopathy due to disc herniation. However, the long-term efficacy has not been proven in the peer-reviewed literature.  The procedure is still considered investigational, and it is not likely to be more effective than standard microsurgical and open surgical treatment of the patients disc herniation.  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 who underwent several surgical procedures at one sitting. In question is the medical necessity of liposuction of the abdomen and flanks, which was performed at the same time as her breast implant removal, capsulectomy, mastopexy, and abdominal scar revision. The Health Plan denied reimbursement for the liposuction based upon a determination that it was not medically necessary.Received and reviewed were the operative notes, history and physical examination, a color photocopy of a photograph of the patient and a note from the plastic surgeon in support of the scar revision procedure. Upon review of these documents, I find no evidence of medical necessity for the liposuction of the abdomen and flanks. The procedure at issue was cosmetic in nature and not medically warranted. Therefore, 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

This is a 58-year-old female patient who has been on Humatrope injections since 2001. In addition she is taking Cozaar, Lexapro, sotalol, Protonix and the Vivelle patch.  In September 2001 she was found to have a low IGF-1 level of 47. She appears to have had two stimulation tests with L-Dopa and clonidine. There was no growth hormone stimulation with either test. Her thyroid panel was normal. ACTH, FSH and LH levels are not found in the submitted records.  The Health Plan denied authorization for growth hormone therapy based upon their determination that it is not medically necessary.The patient has a low IGF-I level and no other pituitary abnormalities. Clonidine and L-Dopa are the least reliable tests to stimulate growth hormone, and did not evoke a positive response in this patient.  Growth hormone therapy in an adult should not be initiated on the basis of a low IGF-1 level alone. If other pituitary hormone deficiencies can be demonstrated in addition to the lack of growth hormone stimulation with a more reliable stimulation test, the patients request for growth hormone 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. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 55-year-old woman with bronchial asthma and upper respiratory tract allergies. She had been treated with allergy immunotherapy and antiallergic /antiasthmatic therapy.  It is stated that the patient occasionally required pulse steroids and was using sodium cromolyn and beta agonists. She did not want to use inhaled steroids as she was diagnosed with osteoporosis. Subsequently, the patient was experiencing mild anaphylaxis on several occasions and required short courses of pulse steroids, and did not respond to the chronic use of inhaled sodium cromolyn. The treating physician requested a trial of Xolair to determine if this would help moderate the patients asthma in the absence of inhaled steroid and reduce her dependence on the daily use of Foradil and other rescue medications. Recent spirometry and IgE levels were indicative of asthma and atopic allergy. At issue in this case is whether Xolair is medically necessary for treatment of the patients medical condition.The Health Plans drug criteria indicates the patient meets all the criteria for provision of Xolair with the exception of documented use and failure to respond to maximum inhaled steroid dose in combination with long acting beta agonist and leukotriene for three months before requesting omalizumab.  The patient is not taking inhaled steroids due to a diagnosis of osteoporosis.  The Supplement to the Journal of Respiratory Diseases published October 2005 states The potential adverse effects of systemic corticosteroid exposure have been well established and include osteoporosis it was very clear that there was a puff-for-puff relationship between the amount of inhaled corticosteroids and the loss of bone density measured at the trochanter it is important to extrapolate this loss of bone density over the life of a woman The incremental rate of bone loss imparted by continuous use of inhaled corticosteroids would confer a 2-fold increased risk of hip fracture in that woman. Therefore, as the patient qualifies for treatment with Xolair in all other categories and is avoiding inhaled steroids because of osteoporosis, 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 21-year-old female with a long and extensive history of psychiatric disorders including depression, anxiety, attention deficit disorder, obsessive-compulsive disorder and substance abuse. Her alcohol abuse began approximately nine months prior to admission. She had participated in outpatient psychotherapy with medication management, but had not been hospitalized in the past.  She was admitted for subacute psychiatric treatment in September 2005 and discharged in October 2005 with a plan for residential treatment. The Health Plan denied authorization for inpatient psychiatric services based upon their determination that the services were not medically necessary.The records from the psychiatric treatment facility are extremely detailed and include an extensive psychiatric evaluation, treatment plan (including goals and documented progress regarding attainment of goals), as well as a detailed discharge summary noting symptom improvement, prognosis and follow-up recommendations.  Given the well-documented chronic problems of this patient and worsening of her symptoms leading to admission at the facility, the admission and services rendered were clearly medically necessary and standard of care. Therefore, I have determined the services at issue were 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 16-year-old female with large pendulous breasts that, according to her chiropractor, are at least partially the cause of her back pain.  Her weight is stated as 180 pounds. The patients mother would like her daughter to undergo a breast reduction for the relief of back, neck, and shoulder pain of unknown duration. The patients primary care provider wrote a letter of support for the procedure, but submitted no additional clinical records. The Health Plan has denied the requested procedure based upon their determination that it is not medically necessary.The submitted clinical records and color photographs of the patient were reviewed. The photographs suggest that the patient may be symptomatic, but at the present time her breasts are compatible in size with her body habitus. If there is a substantial weight loss, the question of breast reduction should be revisited. However, presently there is insufficient evidence the requested procedure is medically warranted. Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 50-year-old female who has had pain in the upper outer quadrant of her right breast for several years. Mammograms of the right breast performed in October 2002, March 2003, October 2003 and November 2005 were negative and ultrasounds performed in October 2002, March 2003, October 2003 and January 2004 had benign findings. An ultrasound-guided biopsy of the right upper outer quadrant of the breast was performed in February 2004 with the pathology results showing fibrocystic changes without atypia. An ultrasound in August 2004 showed benign-appearing findings with no explanation for the patients pain. A surgical consultation dated September 2004 noted that the patients mother had lung cancer and her sister-in-law died from breast cancer. An MRI was suggested to the patient with her next mammogram.The MRI of the right breast was performed in October 2004 and showed focal enhancement at 9 oclock, which was felt to be benign microcysts or fibroadenoma. A targeted ultrasound was performed in October 2004, which showed a cluster of microcysts at 12 oclock and a cyst at 10 oclock. The MRI findings were believed to correlate with the cyst at 10 oclock.   The ultrasound findings were considered benign and a follow-up mammogram in 1 year was suggested.  The patient is requesting reimbursement for the MRI, but the Health Plan has denied coverage based upon their determination that the diagnostic procedure was not medically necessary.The indications for breast MRI include: determination of the extent of malignant disease prior to surgery, evaluation of residual tumor after lumpectomy with positive margins, to distinguish postoperative scar from tumor recurrence, detection of occult primary cancer presenting with axillary metastases, follow-up of tumor response after chemotherapy, to screen high risk patients, and to provide additional information when other tests are equivocal. Pain, which is a common breast complaint, is rarely a symptom of malignancy, and persistent pain is not an established indication for breast MRI. The patient was properly evaluated with mammography and ultrasound and after the benign biopsy, the likelihood of additional meaningful information from an MRI was low.Based upon the information set forth above, I have determined the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.