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

The patient is a 43-year-old male with cardiomyopathy. He has an ejection fraction (EF) of 35% and is stable on his current medications, which include Avalide, a combination medication containing irbesartan and HCTZ. The patients provider recommends the patient continue taking Avalide, and has submitted a request for authorization to the Health Plan. The medication was not considered medically necessary, and the request was denied.There is no current data to suggest any clinical advantage for prescribing Avalide as compared to other angiotensin receptor blocking agents.  A trial of a similar formulary medication in the same drug class as Avalide is medically reasonable. Should the alternative medication not have medical effectiveness similar to Avalide, reconsideration of the patients request would be warranted.  Based upon the clinical record provided for review, 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: Overturned Decision of Health Plan

The patient is a 54-year-old female with a history of long-standing knee pain. She has tried numerous modalities to alleviate her pain. She received Synvisc injections a year ago with reported benefit. At issue is whether another course of Synvisc injections is medically necessary for treatment of the patients medical condition.The patient received a series of Synvisc injections in May 2005 with good results.  In light of her previous response to the therapy, a repeat series of Synvisc is likely to be beneficial. The patient is relatively young to have severe arthritis and appears to be in eventual need of knee replacement. A repeat series of Synvisc injections is appropriate to alleviate pain and postpone surgical intervention. Therefore, I have determined the requested injections are 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 42-year-old female with chronic low back pain due to degenerative disc disease. She has tried conservative measures including pain medication, muscle relaxants, antidepressants, neuroleptic medications, SI joint injections and physical therapy, without lasting relief. Her provider has recommended a spinal cord stimulator. The Health Plan has denied authorization for the device on the basis that it is not medically necessary.There is no Class I data to establish the efficacy of spinal cord stimulators for the treatment of discogenic or non-specific low back pain. The device is not within the mainstream of care for orthopedic practice. Available data does not demonstrate an advantage to spinal cord stimulators over standard pain management modalities. Therefore, I have determined that the requested device 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 52-year-old female who underwent a matrixectomy of the right hallux toenail in December 2004. In early January 2005 she was seen in follow-up and placed on antibiotics. During the December 2004 visit she related experiencing right hallux pain for four months. In March 2006 she again reported right hallux toenail pain from an ingrown nail beginning approximately six months earlier. She reported that a pedicurist was not able to resolve the problem. At this visit she requested a right hallux matrixectomy. The Health Plan denied her request indicating the requested procedure is not medically necessary.The submitted clinical information demonstrates that this patient has had chronic painful ingrown toenails since well before December 2004. It is certainly medically appropriate to attempt to stop the recurrent ingrown toenail with a phenol matrixectomy procedure. It is not the standard of care to have a pedicurist treat/remove ingrown toenails. The procedure requested by the patient is medically appropriate and indicated and should be authorized. For the reasons set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 64-year-old male with a history of chronic daily headaches.  He has been under the care of a pain management specialist and has received conservative therapy with medication and interventional therapies including Botox injections, trigger point injections, and a trial of a spinal cord stimulator.  The patient has requested authorization for continued follow-up with the pain management specialist. The Health Plan denied his request indicating that specialty services are not medically necessary.A review of the medical documentation indicates that on the patients last visit to the specialty provider his treatment regimen was changed and the medications Neurontin and Robaxin were prescribed, with increasing doses as tolerated. There were no interventional therapies recommended or scheduled at that time. Presently, the patients chronic pain condition is being managed with medical therapy only. It is appropriate for his primary care provider to follow his condition and to continue titration of his medication regimen.  His primary care provider can also determine when additional pain management specialty services might be indicated and make the appropriate referrals at that time.Based upon the information set forth above, 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: Overturned Decision of Health Plan

The patient is a seven-year-old male with low levels of IGF-1 and IGFBP-3, a bone age delayed by two and a half to three years and a height well below the third percentile.  The brain MRI was negative for pituitary abnormalities and thyroid tests were within normal limits. Based on these findings the patients provider diagnosed growth hormone deficiency and requested authorization for growth hormone therapy. The Health Plan denied authorization based upon a determination that the therapy is not medically necessary.The clinical history and evaluation of this patient served to rule out the vast majority of etiologies for his small size with the exception of benign constitutional delay, idiopathic short stature and idiopathic growth hormone deficiency. The first two possibilities are unlikely as growth hormone deficiency/dysfunction is classically suggested by the presence of biochemical and clinical findings supportive of the diagnosis. The patient had abnormally low insulin growth factor 1 and binding protein 3 levels, both of which are growth hormone dependent, along with slow growth, delayed skeletal age and genetically inappropriate short stature. With this evidence, growth hormone stimulation tests are unnecessary for a definitive diagnosis of growth hormone deficiency.  Based upon the information set forth above, 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 six-year-old boy who has been diagnosed with idiopathic short stature.  When seen in August 2005 at the age of 5 years 5 months he was below the third percentile for height and at about the tenth percentile for weight. His growth rate over the past year was documented as 2.8cm per year.  A bone age study completed in the same timeframe was read as 2 years and 8 months. Thyroid tests were normal as was an MRI examination of the pituitary gland.  It appears that growth hormone was prescribed in October 2005 and the patients parents have requested authorization for the therapy. The Health Plan determined the therapy is not medically necessary and denied their request.The records provided for review do not suggest a diagnosis of growth hormone deficiency.  The blood levels of growth hormone dependent IGF-1 and IGFBP-3 were normal and the brain MRI study showed a normal pituitary gland. Similarly, there is no indication from the record the patient was small for gestational age and has failed to achieve appropriate catch-up growth. The patients growth rate has been modest, but that in it self is not a basis for growth hormone therapy at this age. It appears likely from the clinical data that the patient has a constitutional delay in growth. The delayed bone age will provide additional opportunity for growth.   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 30-year-old female who has a complex history of low back pain due to a motor vehicle accident, but also has upper back, neck and shoulder pain that may be due to her large breasts. She has requested authorization and coverage for breast reduction surgery. She is obese and her request was denied on the basis that her body mass index (BMI) exceeds 30. At issue is whether breast reduction surgery (reduction mammoplasty) is medically necessary for treatment of the patients medical condition.This patients musculoskeletal symptoms may or may not be due to macromastia, but referral to a plastic surgeon to make this determination is warranted.  The patients request for a breast reduction was denied on the basis that the patient is obese.  Weight loss however, does not improve the symptoms of macromastia. A study by Collins and Kerrigan confirms that weight loss is unlikely to be of any benefit for this patients upper body musculoskeletal symptoms.Since obesity is a known cause of back pain, musculoskeletal symptoms due to macromastia are often inappropriately attributed to body weight rather than breast size.  Macromastia causes a unique set of upper musculoskeletal symptoms separate and distinguishable from those caused by obesity alone. Multiple studies have confirmed both that obese patients benefit from breast reduction and that weight loss is ineffective as a treatment for symptomatic macromastia.As the patient has not yet undergone a plastic surgeon consultation for consideration of a reduction mammoplasty, the requested surgery may or may not be appropriate for this patient. Therefore, I have determined that the requested surgery is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. A plastic surgery referral should be authorized. If the plastic surgeon determines the patient is an appropriate candidate for a reduction mammoplasty, the surgery should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is 57-year-old female with a history of chronic low back pain, lumbar spondylosis, and degenerative joint disease. She received 122 physical therapy visits over approximately a three-year period and reports that traction helps with her pain. She would like to continue with physical therapy including traction. The Health Plan has determined additional physical therapy is not medically necessary for treatment of the patients chronic pain.Review of the submitted clinical information including the physical therapy notes and physician records indicates the patient has reached a plateau in her rehabilitation. Continued physical therapy is therefore not likely to result in any further clinical benefit. The patient can incorporate a traction unit into her home program if she so desires. Based upon the clinical information provided, there is no medical necessity for additional physical therapy in this case. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 35-year-old male who has been diagnosed with Type I Diabetes since the age of 17. He is injecting Lantus, 25 units every day and Humalog insulin before meals. The patients labs in November 2005 showed a blood glucose level of 425. According to the physicians note the patient forgot to inject his Lantus. The patients hemoglobin A1c was 7.9% in June 2005, 7.8% in May 2004, and 7.7% in June 2002. According to the providers note, the patient has frequent hypoglycemia and rebound hyperglycemia and his diabetes is described as uncontrolled. There was no blood glucose log contained in the record provided for review.  The patients provider has requested authorization for an insulin pump to achieve better glycemic control. The Health Plan denied authorization based upon a determination that the device is not medically necessary.This patient fulfills the medical necessity criteria for authorization of insulin pump therapy.  He has had Type I Diabetes since the age of 17, his provider has documented poor glycemic control with Lantus and Humalog insulins, his hemoglobin A1c levels have been between 7.7% -7.9% for over three years, his provider documented episodes of hypoglycemia and hyperglycemia, and the range of hemoglobin A1c values (7.7% -7.9%) would indicate the patient is generally compliant with his regimen and injects insulin the majority of the time. Poorly compliant patients usually have a hemoglobin A1c in a much higher range.  It has been shown that insulin pump therapy reduces blood glucose fluctuations and severe hypoglycemia. Most patients demonstrate improvement in their hemoglobin A1c with insulin pump therapy. Prior to receiving the insulin pump, the patient should be encouraged to keep a diabetic log and to document self-glucose monitoring at least four times daily along with the amount of insulin injected. Based upon the information set forth above, I have determined the requested device 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 56-year-old male with a long-standing history of polycythemia vera (PCV) and thrombocytosis, with both ischemic and bleeding complications. He has non-healing lower extremity ulcers that may be secondary to hydrea and/or exacerbated by his diabetes. The patients request for authorization of Gleevec was denied based upon the Health Plans determination that it is not medically necessary to treat his PCV.There are relatively few treatment alternatives available for this patient.  He is at greater risk for ischemic or thrombotic complications due to his diabetes and the difficulty he has had controlling his PCV with conventional treatment. Alpha-interferon is useful for some patients, but is associated with many side effects that would be dangerous in a diabetic and might additionally worsen the patients depression.  Gleevec has been shown to be effective for patients with PCV, and is a reasonable option at this juncture in the course of the patients treatment. 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 21-year-old female with a prior history of bulimia and anorexia, difficulty with concentration, and severe mood vacillation in the direction of anger, who was referred for psychological evaluation and treatment. She was interviewed in November 2005 and was noted to have not responded to medications such as Topamax, Zoloft, Concerta, Strattera with Lexapro, Effexor, Prozac, and Paxil. The patient indicated there had been a prior response to Lexapro 10mg per day for a couple of years. The initial mental status exam revealed a neatly dressed, friendly, cooperative, and restless young woman.  The patient commented she was really self-deprecating and I think thats the primary source of the depression.  I feel like I get really angry at things but I dont express it so then I get depressed.  She was diagnosed with major depression with possible bipolar tendencies, ADHD, anorexia and bulimia nervosa.  SPECT (and CT) scans were employed to aid in diagnosis.  It was recommended that the patient restart Lexapro, 5-10mg per day, and begin Lamictal, Adderall XR, and Omega-3 fatty acids (fish oil).The patient has requested reimbursement for the cost of the SPECT (and CT) scans.  The Health Plan denied the request based on a determination that the diagnostic procedures were not medically necessary for diagnosis or treatment of the patients psychiatric condition.The patients history and clinical exam were sufficient to formulate a meaningful differential diagnosis and to establish an effective treatment plan.  Notably, her provider ultimately recommended Lexapro, which the patient herself had indicated was effective at the start of her evaluation.  In total, I find the diagnostic procedures at issue were not medically necessary for evaluation 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 male with erectile dysfunction. Upon examination the patient was overweight with a height of 56 and weight of 179 pounds. Blood tests included normal PSA, glucose and testosterone, but lipids were not measured. His treating physician noted that the patient had benefited from a trial of Viagra and therefore authorization for the medication was requested from the Health Plan. The Health Plan denied this request on the basis that Viagra is not medically necessary for treatment of the patients condition.Review of the submitted clinical evidence indicates the cause of the patients erectile dysfunction has not been fully determined. The patient is overweight and may have a problem with lipid metabolism. He may also have peripheral vascular disease, either arterial on the basis of abnormal lipids or venous due to a leak from the corpora cavernosa of the penis. In any event, his provider has already initiated appropriate treatment of the erectile dysfunction with an oral PDE-5 inhibiting medication, Viagra. This medication has been effective treatment for his dysfunction. Furthermore, regardless of the presumed source of erectile dysfunction, Viagra is considered a first-line therapy. Based upon this information, the patient should continue to receive Viagra for treatment of his erectile dysfunction. Therefore, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 53-year-old male with knee pain. The patient has undergone surgery, and has attempted treatment with medications and steroid injections. Hyalgan has been recommended by his provider. The Health Plan denied authorization for the requested therapy on the basis that Hyalgan is not medically necessary.The patient is an appropriate candidate for Hyalgan therapy. Anti-inflammatory medications and cortisone have failed to alleviate his pain. Studies have shown Hyalgan is clinically effective in this clinical setting. As such, it is likely that Hyalgan will be beneficial for this patient and it is the best alternative to surgery at this time. 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: Overturned Decision of Health Plan

The patient is a 64-year-old male with multiple myeloma and diabetes. He has a several year history of a whole body dysesthesia, which he describes as itching, but also has characteristics of pins and needles. He tried Neurontin up to 800 mg twice daily with only slight improvement. He was recently tried on Lyrica with moderate improvement at 150 mg twice daily, but more substantial improvement at 200 mg twice daily. At issue is whether a dosage of Lyrica 200 mg twice daily is medically necessary for the patients condition.Lyrica has been shown to be safe at doses of 300 mg twice daily. In dealing with painful neuropathy, patients experience a vast difference in response to medication due to metabolic and genetic factors. Some patients respond better to higher doses. Since this patient has shown a better response to Lyrica 200 mg twice daily without significant adverse effects, and safety has been shown in doses up to 300 mg twice daily, the requested prescription is medically reasonable and appropriate and should be authorized. Therefore, I have determined the requested prescription 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

A 53-year-old female patient has requested authorization and coverage for extracorporeal shock wave therapy (ESWT) for the treatment of chronic plantar fasciitis. Review of the documentation provided indicates the patient has an eight-year history of pain. She has been treated with orthotics, night splints, oral medications and steroid injections without sustained relief of symptoms. The Health Plan has denied authorization for ESWT on the basis that its efficacy has not been established in peer-reviewed literature. ESWT is an FDA approved treatment modality for chronic proximal plantar fasciitis. However, current scientific literature provides no evidence that ESWT for treatment of plantar fasciitis is more effective than current conservative treatment or minimally invasive surgical treatment. Endoscopic plantar fasciotomy demonstrates about a 90% cure rate, which exceeds the cure rate of ESWT (70-80%). As there are other treatment modalities with greater efficacy available for treatment of the patients condition, ESWT is not medically necessary.As 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 54-year-old man with a long history of bruxism and facial pain. He is currently being treated with a dental occlusal splint. Botox injections into the masseter muscle were added to his treatment regimen and the patient reported subjective improvement in bruxism and pain. A request has been made for reimbursement and continued authorization and coverage for Botox injections. The Health Plan has denied this request on the basis that Botox therapy is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Botox injections into the muscles of mastication to control bruxism is not within the standard care. Botox has not been approved by the Food and Drug Administration for treatment of temporomandibular joint dysfunction and bruxism or myofascial pain syndrome. Furthermore, review of the medical literature does not reveal sufficient evidence that Botox is efficacious in this clinical setting. Therefore, I have determined that the therapy at issue was/is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.