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

This patient is an nine-year-old female who has been receiving speech therapy for pragmatic language delay and auditory processing deficits. Specifically, the test of auditory perceptual skills showed deficits in auditory sentence memory, auditory word memory and auditory word discrimination. The test of pragmatic language put the student in the 73rd percentile with a standard score of 109 (mean standard score 100). The therapist felt however, the test did not discriminate her difficulties with describing, placement and sequencing of events. The summary recommendations from the Standardized testing deal primarily with school modification and involvement in social/pragmatic groups. School observation recommendations are also geared toward modification of the school environment. The reports do not include a formal diagnosis of speech and language deficits and neither of the summaries expressly recommend speech therapy.  The parents request for reimbursement for speech therapy provided from September 2005 through October 2005 was denied by the Health Plan based upon a determination that the therapy was not medically necessary.The establishment of a diagnosis in the area of speech and language deficits is essential to effective speech therapy.  In this case, no such diagnosis was made and the patients symptoms may be caused by deficits in other areas. Secondly, as documented, the deficits are educationally based issues and not directly related to specific speech or language deficits. Lastly, it is also essential that formal goals be developed to direct the course of the speech therapy and to measure the patients progress.  The frequency of the intervention should also be specified.  The formal reports provided here do not include goals for the improvement of speech and language skills, a measure of the patients progress to such goals, or a recommended frequency for the provision of speech therapy.  Therefore, 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 an almost two-year-old male with right torticollis and visual impairment due to right cranial nerve IV palsy as determined by a pediatric ophthalmologist in April 2004.  Corrective surgery was recommended.  The patients father has requested further evaluation by a pediatric neuro-ophthalmologist prior to surgical intervention.  The Health Plan denied the request based upon a determination that the service was not medically necessary.During her evaluation of the patient in March 2006, the physical therapist described the Bielschowsky head tilt test, which is used by an ophthalmologist to diagnose congenital superior oblique palsy (4th cranial nerve). With this condition, the rotation of the head to the side of the paretic muscle results in a greater visual disturbance because as the patient turns his head to the right, his eyes drift farther apart. If however, he rotates his head to the left, his eyes stay together and he sees better. In this case, the patient instinctively self-corrected his visual disturbance by consistently rotating his head to the left. This abnormal positioning likely resulted in the right torticollis. The referral to a pediatric ophthalmologist was appropriate as there was no history of failure to thrive or developmental delay. The diagnosis and treatment recommendations appear correct based on the record provided for review and further evaluation by a neuro-ophthalmologist is not warranted.  Based upon the information set forth above, I have determined the requested service 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 29-year-old male who carries the diagnosis of upper airway obstructive syndrome which has been interpreted as being mild to moderate.  He is noted to have responded to CPAP at a setting of 9cm H2O during a titration study.   There is no mention of whether or not an actual trial of CPAP was undertaken at home.  The consulting surgeon noted that the patient had an elongated uvula and complained that it gags him at times.  Somnoplasty was recommended and completed.  Procedure notes relate that the soft palate was treated bilaterally and in the midline.  Post-operatively there was marked edema of the uvula, but its excessive length was not addressed in the operative report.  The patient is now requesting reimbursement for the somnoplasty. The Health Plan denied the request based on a determination that the procedure was not medically necessary for treatment of the obstructive sleep apnea.The standard first-line treatment for OSA is a trial of CPAP.  If a patient fails this trial, surgery is then considered.  There is an abundance of literature available regarding the use of radiofrequency ablation for turbinate reduction, tongue base ablation for OSA and soft palate treatment in the setting of snoring.  However, there is no evidence at this time to support the use of radiofrequency ablation of the soft palate as an effective treatment for OSA and the procedure performed did nothing to reduce the length of the patients uvula and so relieve the gagging problem. In addition, it does not appear that the patient has undergone a trial of CPAP.  As such, 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: Overturned Decision of Health Plan

This patient is a 56-year-old man who has moderate to severe psoriasis over at least 20% of his body surface area. He has severe hand and foot involvement, resulting in significant pain and diminishment of function. Treatment over the past seven years has included topical medications, methotrexate, Cyclosporine, systemic and intralesional corticosteroids, Soriatane, Enbrel and Raptiva. Use of each of these medications was ineffective and/or resulted in prohibitive side effects. Although there was improvement with Cyclosporine pills, there was also significant elevation of the serum creatinine.The patients dermatologist has requested approval for Humira, which the Health Plan has denied.Humira is the only medically necessary and medically appropriate treatment for this patients debilitating psoriasis. The safety profile has been established in the studies accepted by the FDA in the approval of Humira for psoriatic arthritis. There are multiple studies supporting the drying effectiveness in treating psoriasis. Significant improvement was noted in psoriasis lesions of psoriatic arthritic patients.Humira is currently in the midst of the process for approval by the FDA for use in the treatment of plaque psoriasis. In the meantime, the off-label use of the drug is medically essential for treatment of the patients psoriasis. Therefore, 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 40-year-old male who has requested continuation of intravenous antibiotic (IV) therapy for Lyme disease.  He was started on IV ceftriaxone (Rocephin) in February 2006.  The patient stated that he was bitten by a tick in August 2004 and diagnosed with Lyme disease in February 2006.  He reported that his symptoms included tremors in the hands, numbness, weakness and cramping of the right forearm, brain fog, moderate to severe fatigue, stiff neck, migrating arthralgias, arthritis of the left hip, poor concentration and light headedness.  The patient also reported that his symptoms had improved during treatment with IV ceftriaxone.The providers notes are brief.  In February 2006 he reported the patient had fatigue and joint pain along with muscle weakness, and IV ceftriaxone was started at that time.  The patient was afebrile and the physical examination was described as normal.   In March 2006 the provider noted that the patient was 30% better and indicated positive tests for human herpes virus 6 and EBV without additional details or lab reports.  In April 2006 the provider noted that the patient was being given 4 grams per day of IV ceftriaxone four days per week.  Foggy thinking, hand tremor and joint pain are recorded as symptoms and the provider stated the patient was overall better. The providers note from April 2006 indicated the IV ceftriaxone therapy was being continued and that the patients symptoms were improving.  The Lyme IgG Western Blot is negative as is the Lyme IgM Western Blot, both done in January 2006.  The IgM is reported as positive by the testing laboratory, but noted to be negative by CDC criteria.The patient has requested authorization for continued treatment with IV ceftriaxone. The Health Plan denied his request based upon a determination that the therapy is not medically necessary.The evidence provided does not lead to a diagnosis of Lyme disease, nor is there clinical documentation of arthritis or other physical findings consistent with the diagnosis.  While the patient apparently has a photo of a bulls-eye rash, we do not have physician notes about the patients initial care following the tick bite.   The CDC approach remains the accepted route to a serological confirmation of Lyme disease.  In this case, only Western Blots were done and both were negative by the standard criteria.  Because the diagnosis was not substantiated, treatment with IV ceftriaxone for greater than 30 days is not necessary.  It is only in cases of documented cardiac or neurological disease that extended treatment is warranted.  The Krupp study cited above concluded that due to the significant adverse effects associated with antibiotic therapy, there is no indication for IV ceftriaxone therapy for patients with Lyme disease who complain of fatigue.   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 74-year-old male with idiopathic myelofibrosis. He is dependent on blood transfusions for treatment of his anemia. The patient is also on Exjade for iron chelation secondary to transfusion-related iron overload, a potentially life threatening condition. The patients provider recommended treatment with thalidomide (and prednisone) and submitted a request for authorization. The Health Plan denied the request based upon a determination that the medication is not medically necessary.There is no treatment for myelofibrosis that is universally indicated or efficacious in all patients. Myelofibrosis is very heterogeneous and certain therapies work for some patients but not for others. Although thalidomide is not a mainstream treatment for myelofibrosis, there is literature supporting the efficacy of low dose therapy in decreasing the need for transfusions and potential iron overload.  As iron overload is already a major problem for this patient, a three to four month trial of 50mg of thalidomide per day would be reasonable.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: Overturned Decision of Health Plan

This patient is a 19-year-old recurrently ill anorexic female with prior residential and outpatient treatment for her severe anorexia nervosa, with classic restricting, purging and excessive exercise. She entered acute inpatient care in January 2006, remaining until transition to residential care in March 2006. Her care was covered by the Health Plan until February 2006. At issue is whether acute inpatient services were medically necessary as of February 2006.A review of this lengthy file reveals a patient who was a very ill, depressed and obsessed anorexic patient. She did manage to cooperate and gain weight during her initial stay but was still capable of significant relapse as of February 2006. As such, she was not yet ready to leave acute inpatient care. She required extensive supervision and structured treatment management of all of her behavior and eating, if she was to improve.The submitted documentation does not demonstrate that the patient stable and ready for transfer as of February 2006. She remained manipulative around food and needed additional motivation to improve while being intensely monitored. 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: Overturned Decision of Health Plan

The patient is a 49-year-old male who has been diagnosed with Chronic Inflammatory Demyelinating Polyneuropathy (CIDP). He has moderate disability with atypical features such as dysarthria and dysphagia. The clinical records were limited to electromyography, nerve biopsy and muscle biopsy reports. The patients provider has requested authorization for treatment with IVIG. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.IVIG, while not specifically approved by the FDA for the treatment of CIDP, is the standard of care for treatment of the condition.  Furthermore, it is recommended as a first line therapy in Neurology textbooks and medical review articles alike.  The course of treatment recommend by the patients provider is medically appropriate and consistent with practice standards within the neurological community.  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

This patient is a 49-year-old female with complaints of abdominal pain, cramping, nausea and constipation. She has a diagnosis of irritable bowel syndrome (IBS) and had a negative barium enema and a negative abdominal ultrasound. The patient has previously had colonoscopies in 1994 and 1998. The results of those studies were not clear. The patient has now requested authorization for a colonoscopy.  The Health Plan denied her request based upon a determination that the procedure is not medically necessary.It appears from the record the patient has had IBS for some time with symptoms that wax and wane.  Her symptoms are consistent with the diagnosis and diagnostic studies performed thus far have all been negative. It is not clear that any additional information would be gained from a colonoscopy at this time. Therefore, I have determined the requested procedure 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 50-year-old female who initially presented to her doctor with urinary incontinence. She was treated with anticholinergics, Detrol and Imipramine and underwent a bladder neck suspension in July 2004.   The surgery resolved her stress incontinence but her urgency persisted. Repeat urodynamic studies suggested that the patient still had an element of bladder instability with uninhibited contractions. She was again treated with Vesicare and Detrol, which were not completely effective.  In addition, the patient was involved in a bus accident resulting in a disc herniation at C6. Discotomy with bone grafting was recommended for treatment of the back injury. The patient noted that since the accident her bladder symptoms have been worse. Her provider recommended Botox injections into the base of the bladder to reduce the unstable bladder contractions. The patients request for authorization was denied by the Health Plan based upon a determination that the requested therapy is not medically necessary.Botox bladder injections to reduce instability remain an interesting but investigational use of the drug. The therapy is not yet a commonly accepted medical practice and the manufacturer is currently conducting investigational studies to determine the efficacy of this treatment for bladder instability with urgency incontinence. Additionally, the patient had a spinal disc injury this year, which she states has exacerbated her bladder problems and she awaits corrective spinal surgery. It is possible her bladder symptoms may improve when the neurological problem is treated.   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 51-year-old woman who was involved in a motor vehicle accident in July 2005. She has continued to have pain since the accident occurred and still requires analgesic medications. The patient has tried conservative measures to alleviate her pain for almost one year without complete symptom relief.  Her provider ordered MRIs of the cervical and thoracic spine.  The patient proceeded with the MRIs and is now requesting reimbursement for the cost of the diagnostic procedures.  The Health Plan denied her request based on a determination that the MRIs were not medically necessary.The MRI studies were indicated in this case. The patient was involved in a motor vehicle accident, which resulted in pain and weakness.  Despite some improvement, she has continued to have discomfort. The MRI studies were a reasonable means of evaluating for neural impairment, disc herniation, or other causes of the patients pain and weakness.  Therefore, I have determined the diagnostic procedures at issue were medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 44-year-old female diagnosed with hepatitis C. Her liver biopsy from January 2006 was negative for significant inflammation or fibrosis. The patients liver function tests are normal and although her PCR was negative, HCV RNA was detectable.  There is no genotype information available. The patients provider has requested authorization for treatment with Peg-Intron and ribavirin. The Health Plan denied the request based upon a determination that the requested therapy is not medically necessary.The purpose of a liver biopsy in a patient diagnosed with hepatitis C is to help make a determination regarding appropriate treatment based on the condition of the liver. This patients biopsy showed no evidence of liver disease from the hepatitis and there would be no clinical value in the proposed treatment. In the event a patient does receive treatment for hepatitis C, the response is typically determined by a 2-log drop in the viral PCR after 12 weeks. This patient had a negative PCR, and if treatment was provided, there would be no way of measuring her response.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: Upheld Decision of Health Plan

The patient is a 14-year-old male who was placed in the High Top School following his stay in a residential facility in Hawaii. His placement in this program has the stated goals of improving his attention, improving his impulse control, taking his medications, helping parents set clear firm limits, improve his self-esteem and to develop positive social skills to help maintain lasting peer friendships.He started in the program in February 2006 with a projected graduation in February 2007. He currently is fully participating and taking his medications. At issue is whether these residential treatment services are medically necessary for treatment of the patients medical condition.The patient is an intelligent 14-year-old male with a history of ADHD, conduct disorder, depression and anxiety. He has had difficulty with peers and was sent to a residential treatment facility in Hawaii prior to his placement at the High Top Ranch School by his parents. He started at the facility in February 2006 with the plan to attend school, and to participate in the programs that they offer.Although the program does offer access to psychiatry and to health care, it is on a limited basis. A review of the submitted records reveals that the psychiatrist comes to the school approximately twice per month. Each student is assigned a counselor who sees the students individually. The counselor for this student is a LCSW. The students also participate in groups with other students. The record reveals that the medications prescribed for the student are continued. The notes from the consulting psychiatrist document changes in the dosages of his medications. The primary function of the residential program is a therapeutic school. The services being provided do not appear to be consistent with a medically supervised residential program in accordance with psychiatric community standards. As such, the medical necessity of these services has not been established. Accordingly, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 28-year-old female with a history of hyperthyroidism. The medical records make note of thyrotoxicosis but there is no evidence of this in the information provided. Elevated TFTs do not equate to a diagnosis of thyrotoxicosis, which is apparent in only 1% of all pregnant patients with hyperthyroidism.The patients hyperthyroidism is controlled on fairly standard dosing of PTU with no evidence of fetal goiter or IUGR documented on any fetal ultrasound reports. The patient has requested authorization and coverage for fetal non-stress tests and biophysical profiles twice per week until delivery. The Health Plan has denied this request indicating that the requested services are not medically necessary. Despite the patient's assertion that she is taking a large dose of PTU, the dose she is receiving is a very standard dose in the range of 100-150 mg twice daily. None of the documented physical exams reveal symptomatology or findings suggestive of either thyrotoxicosis or thyroid storm. None of the fetal ultrasounds in the third trimester suggest IUGR, and the reports specifically describe the absence of a fetal goiter.While PTU does cross the placenta, the stated goal by the providers is to keep the patient's thyroid tests at the upper range of normal to avoid the risk of fetal hypothyroidism, which is medically reasonable and appropriate. ACOG Practice Bulletins list `poorly controlled` maternal hyperthyroidism as an indication for antepartum surveillance. This is not the case in the situation in question. Fetal testing would also be indicated for evidence of IUGR, fetal tachycardia or maternal deterioration, any of which can occur (though rarely) with treated hyperthyroidism in pregnancy. None of these conditions have occurred during this pregnancy.Serial fetal surveillance in the form of scans for fetal growth and monitoring of both maternal and fetal heart rates during the pregnancy are indicated. However, routine twice-weekly fetal non-stress tests and biophysical profiles in the presence of controlled maternal hyperthyroidism and in the absence of fetal impact are not medically warranted or supported by the existing medical literature.Based upon the information set forth above, I have determined the requested services are not medically necessary. The Health Plans denial should be upheld.