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

The patient is a 22-year-old woman who was seen by a podiatrist for thickening, discoloration, and significant discomfort of her left first toenail. She was reportedly treated for nail fungus with nail debridement and topical antifungals in the past with modest improvement. Treatment options of nail avulsion, topical antifungals, and oral antifungals were discussed. The patient opted for topical treatment because she was concerned about side effects of oral antifungals. The patients provider has recommended Penlac for the patient. The Health Plan indicates the patient does not meet medical necessity criteria for authorization of Penlac.The Health Plans denial should be upheld at this time. The submitted information does not include a record of a microscopic exam for fungus or a fungus culture. If either test is performed and is positive, treatment with Penlac should be authorized. If a three-month trial of Penlac is ineffective, oral antifungals should be considered.  Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plan denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-one year-old male with glioblastoma multiforme of the right parietal lobe is requesting continued out-of-network neuro-oncology care.Reviewers Findings:  The reviewing physician found that the patients continuity of care would be compromised by transfer from the out-of-network to the in-network facility at this point in the clinical course.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 35-year-old female with an approximate eight-year history of alcohol dependence, consisting of drinking a bottle of wine per night and apparently significantly more on the weekends. This resulted in verbally abusive (and what had been deemed manic) behavior. Her boyfriend who lives with her had noted dreading the weekends due to the extent of her drinking and subsequent unruliness. The patient also has a past history of anorexia and bulimia, though she reported this as in good control with Zoloft 200mg. She has not been formally diagnosed with bipolar disorder despite the history of becoming manic when drinking.The patient initially entered residential treatment on 12/30/04 with the request to learn how to cut down on her drinking, but still be able to drink socially. However, she was receptive to being told that this was a frequent folly of alcohol dependent individuals, noted by the clinician as she accepted this option without further question or argument. The patient did not have a history of withdrawal symptoms and none are documented in the information provided. Treatment notes from 1/2/05 indicate the patient was very congenial and friendly, seems open-minded to treatment. Maybe ambivalence, not sure. On 1/3/05, she was noted as more comfortable with residents and peers. Client utilized group process more willingly and openly today by sharing self and feelings. On 1/7/05, it was noted the patient was distraught, wanting to leave program and go ahead and relapse since hearing that insurance will not support her level of care. However, by 1/9/05, she was noted as cheerful and bouyant all morning as well as grateful for her sobriety. The submitted notes indicate the patient did sneak alcohol into residential care on two occasions, though she drank a lesser amount at those times.The patient has requested coverage for residential treatment services from 1/6/05 onward. The Health Plan has denied the patients request indicating the patient could have been treated at a less intensive level of care as of 1/6/05.All told, there appears little evidence in the submitted documentation to indicate the patient was not appropriate for transfer to a less intensive level of care by 1/6/05. Though the fact that the patient snuck alcohol into residential treatment on two occasions does indicate the patients ambivalence about sobriety, this no more argues for the need for residential treatment that it does for intensive outpatient treatment. If anything, if a patient is really that intent on drinking, neither residential treatment nor intensive outpatient treatment is likely to be successful. As such, residential treatment services were no longer medically indicated as of 1/6/05. Based upon the information set forth above, I have determined that the services at issue were 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 32-year old female with a history of chronic abdominal and pelvic pain secondary to endometriosis, protein c deficiency, status post bilateral deep vein thrombosis, and chronic nausea. Per the submitted documentation the patient has been evaluated by multiple pain management specialists. She has been receiving Buprenex via a PICC line with Phenergan and has related adequate pain control. She is requesting authorization and coverage for Buprenex for treatment of her chronic pain condition. The Health Plan has denied the patients request.The Health Plans denial should be upheld. There is no information in the documentation provided outlining the various medical treatments the patient has tried and/or failed. Therefore, there is insufficient evidence that Brupenex is warranted. The Health Plans formulary has multiple medication options and per the documentation provided, there is no documentation of any previous medication trials, failure, intolerance or contraindication to the present formulary alternatives. 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: Upheld Decision of Health Plan

A fifty-eight year-old female with chronic kidney disease and hypertension is requesting continued care related to renal transplant at an out-of-network facility.Reviewers Findings:  The reviewing physician found that the transfer to an in-network facility is considered safe because if the patient undergoes renal transplant, the transplant would not be delayed by the transfer.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 48-year-old male with hepatitis C type 1 who was previously treated with an interferon formula and did not respond. The patient was on Pegasys and Copegus and has had a one-fold drop in viral load after three months of therapy. It has been recommended the patient be continued on Pegasys and Copegus. The Health Plan has denied authorization for the proposed therapy on the basis it is not medically necessary for the patients condition.Based upon a study by Fried et al., only 3% of patients who did not experience a 2-log drop by the end of 12 weeks had sustained viral response by the end of the treatment course. This study was done in naive patients. This patient has not responded to the initial therapy. In light of these findings, there is no medical justification for continuation of Pegasys and Copegus for treatment of the patients hepatitis C virus. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 62-year-old female with a prior history of hyperplastic polyps seen on sigmoidoscopy in 1999 and 2002. She is now requesting a colonoscopy for colorectal neoplasia screening. The Health Plan has denied this request because the patient is not considered at high risk. In the alternative, the Health Plan has recommended a repeat sigmoidoscopy in 2007.The Health Plans denial should be overturned. Although colonoscopy is invasive, it is the best means of determining whether neoplasia exists and whether there is future risk. Furthermore, the clinical evidence demonstrates the patient requires a full colon screening. Sigmoidoscopy alone is not effective in decreasing proximal colon neoplasia risk and is inadequate for evaluating a normal risk individual who still has a 5% lifetime risk of developing colorectal cancer. Therefore, because this patient requires full colon screening, I have determined the requested colonoscopy is medically necessary for evaluation 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 33-year-old female who is 58 tall and weighs 280 pounds with a body mass index (BMI) of 44.1. She is requesting authorization for a consultation with a bariatric surgeon. The patient has a multitude of comorbid conditions compounding her morbid obesity. She has a history of multiple attempts at weight loss including physically supervised plans as well as plan of diet. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. With a BMI of 44 and comorbid conditions, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that weight loss surgery will be beneficial for this patient. The patient needs to be evaluated by a bariatric surgeon to determine whether the patient should proceed with weight loss surgery. A consultation with a bariatric surgeon is medically indicated and medically necessary for evaluation of this patients morbid obesity. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old male with a history of hypersomnia and depression. It appears the patients treating physician is a sleep specialist. A prior sleep study revealed mild central sleep apnea, but no evidence of obstructive sleep apnea or periodic limb movements. The patients depression has been under treatment and he ultimately achieved therapeutic success with Provigil. Ritalin was found clinically ineffective. The improvement in wakefulness was estimated at 70% after a 14-day trial of Provigil. However, absent from the patients clinical history is a definite diagnosis of refractory depression. The history also includes increased hypersomnia with two antidepressant combinations previously prescribed. The patient is also taking Paxil in combination with Provigil. The Health Plan has denied coverage for Provigil on the basis it is not medically necessary for treatment of the patients condition.The apparent diagnosis in this case is idiopathic hypersomnia. Clinically, the patient has improved with Provigil. Idiopathic hypersomnia is recognized as a sleep disorder. The patient appears to have failed Ritalin therapy and responded successfully to Provigil. Given the patients therapeutic response and the absence of a proposed alternative, continued treatment with Provigil is medically appropriate and indicated. 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 55-year-old female with a long-term history of weakness and fatigue who is requesting authorization for growth hormone for treatment of possible adult growth hormone deficiency (AGHD). Based upon the records provided, the patients presumed diagnosis of AGHD is based on nonspecific symptoms, low IGF-1 concentrations, and a suboptimal response to an arginine growth hormone (GH) stimulation test. The Health Plan has denied authorization for the requested therapy.The diagnosis of AGHD is based upon the clinical context, signs and symptoms, as well as the results of biochemical testing. This patients signs and symptoms are sufficiently nonspecific and GH stimulations tests are sufficiently inaccurate that it is possible the patient has a false positive diagnosis.There is no evidence this patient has AGHD. There are no imaging studies suggesting a structural lesion in the pituitary. Her low IGF-1 levels may be depressed for many reasons including her current medications. The rest of the patients tested pituitary hormones appear normal. Furthermore, the patient had a borderline response to the arginine GH stimulation test. Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 42-year-old female who requested reimbursement for surgical procedures she underwent on 11/18/03. The Health Plan has denied this request indicating the surgery was not medically necessary for treatment of her pelvic pain. The patient has a 20-year history of pelvic pain. She has had multiple laparoscopic procedures for excision of endometriosis without significant improvement. In addition, she has been treated with pain medication and antidepressants.Review of the submitted clinical information reveals the diagnostic laparoscopy was medically appropriate. The lysis of adhesions, left salpingoectomy, and excision of the endometriosis are within the standard of practice for patients such as this patient. The issue of a hernia repair would have been best left to a preoperative MRI and consultation with a general surgeon and was not medically necessary based upon the information provided. The pudendal nerve block was not medically necessary or appropriate since long-term benefit is not expected. The hysteroscopy and D & C were medically warranted because of a thickened endometrial on sonogram. The uterine suspension and myomectomy did not have any medical indication. Plication of the round ligaments is not an effective method to treat retroversion and myomectomy of an asymptomatic fibroid was not medically warranted.Accordingly, I have determined a portion of the procedures at issue were within the standard of practice and medically necessary for treatment of the patients condition. Specifically, the diagnostic laparoscopy, lysis of adhesions, left salpingoectomy, excision of endometriosis, hysteroscopy, and D & C are were medically necessary for treatment of the patients medical condition. The other procedures performed on 11/18/03 were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 37-year-old female who is status post surgical treatment of hallux valgus deformity with chronic capsulitis of the first MPJ and severe pes plano valgus. Her provider has requested authorization for orthotics and believes without orthotics the patient will experience complications. The Health Plan has denied authorization for the requested orthotics.The information submitted provides no objective evidence demonstrating orthotics are necessary for this patient. There is no objective evidence of the patients preoperative and postoperative condition. Furthermore, there is no objective evidence demonstrating how orthotics would benefit this patients condition. Therefore, I have determined the requested equipment 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 five-year-old male with a history of migraines, headaches, asthma, and allergies. Acupuncture has been recommended for treatment of these conditions. The Health Plan has denied this request on the basis acupuncture is not medically necessary for treatment of the patients condition.According to the California Department of Consumer Affairs, Acupuncture Board, the National Institutes of Health, and the World Health Organization, acupuncture is an acceptable and appropriate treatment for this patients condition. Acupuncture is commonly utilized to treat allergies/asthma, migraine headache, rhinitis, and sinusitis. There are controlled trials demonstrating acupuncture is an effective treatment for allergic rhinitis. Standard treatment for this patient would be acupuncture twice weekly for three to four weeks followed by evaluation to determine if further treatment is indicated.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment 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 is a 17-year-old male with an approximate three-year history of polysubstance abuse, most recently involving marijuana, cocaine, and amphetamine with daily use of all such drugs. He was noted as recently using about 2-3 grams of marijuana per day, about 0.3 grams of amphetamine per day, and an unclear quality of cocaine per day. However, he was also noted to be using the drugs amidst similarly drug abusing friends, otherwise at home alone for home schooling though his mother appears to be out of the house for 12 work hours a day. His father was also noted as out of the house due to his own drug recovery program. The patient had tried to maintain abstinence on an outpatient basis, but had been unable to stay sober for more than two days. He also briefly attended Alcoholics Anonymous, but did not persist with this to any extent. As a result of his drug use, he was on probation the year prior for possession, fearful of being put back on probation, and was behind in school credits, alongside a prior history of poor performance and truancy. Finally, he also noted that many of the family gatherings centered about substance use. A request has been made for reimbursement for residential treatment services the patient received from 2/8/05 to 3/8/05. The Health Plan has denied this request on the basis the services at issue were not medically necessary.Based on the gross quantity as well as regularity of use of drugs, with social consequences of increasingly poor academic performance and no real support at home to otherwise guide sobriety, the patient met criteria for residential treatment. The extent of his use of marijuana alone is staggering. There was no particular social support for his sobriety at home, what with a parent not at home during mainstay hours. Furthermore, there was support among his friends for his actually continuing such use. No matter his dedication to abstinence, removal from this environment to allow for a break in the cycle of his use was imperative. Lack of withdrawal symptoms also does not refute the patients need for active intervention in a secured setting if the level of drug abuse is egregious, which it was in this case. Therefore, I have determined that 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

The patient is a 45-year-old woman with chronic obstructive pulmonary disease who is requesting authorization and coverage for a portable nebulizer. She takes albuterol and Atrovent by nebulizer. She also apparently uses Combivent. The Health Plan indicates a portable nebulizer is not medically necessary for treatment of the patients condition.The clinical information provided does not demonstrate a medical need for a portable nebulizer. Metered-dose inhalers (MDI) are generally considered as appropriate as the nebulized treatment. There is no indication an MDI (with or without a spacer) will not be effective for this patient when she is outside the home. Therefore, I have determined that the requested equipment 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 36-year-old female who is status post gastric bypass in 2003. Since the surgery she lost approximately 125 pounds. A result of this massive weight loss was excessive folds of hanging skin. To treat her excess tissue, the enrollee underwent a panniculectomy, thigh lift, and buttock lift in March 2005. The patient experienced skin rashes and pain because of her excess tissue. The Health Plan has provided coverage for the panniculectomy but has denied coverage for the thigh lift and buttock lift on the basis the procedures were not medically necessary.There is no evidence to support the medical necessity of the patients thigh lift and buttock lift. These procedures are rarely medically necessary. The patient had documented skin problems due to her excess abdominal skin, which should have resolved with the panniculectomy. The submitted documentation does not demonstrate a thigh lift and buttock lift were medically indicated to resolve functional impairments. For these reasons, I have determined the procedures at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.