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

The patient is a 60-year-old male who has had symptoms of gastroesophageal reflux disease (GERD) since 2001. There is documented evidence that the patient has Barretts esophagus. He has been taking Nexium 40mg twice daily for the past three years and has requested authorization and coverage for this dosage. The Health Plan has denied the patients request on the basis that the requested prescription is not medically necessary.The Food and Drug Administration (FDA) approved dosing for Nexium is 40mg once a day. With the presence of Barretts esophagus, this patient requires Nexium on a chronic basis. The submitted evidence demonstrates that Nexium 40mg twice daily relieves the patients symptoms. Additionally, there is evidence that the patient has tried Aciphex and Protonix in the past without relief. Based upon the proven success of the requested dosage for treatment of this patients GERD, as well as the failure of other medications, the requested prescription is medically appropriate and indicated. Therefore, I have determined that 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

The patient is a nine-year-old male who has been diagnosed with autism. He has received speech therapy since 1998. Documented speech testing results reveal the patient continues to be approximately two years behind in language skills with receptive language and expressive language at less than 1 percentile in most categories. Clinical evaluation of language (CELF) testing shows the patients overall language in most categories is less than the 25th percentile. At issue is whether continued speech therapy is medically necessary for treatment of the patients medical condition.Current medical literature fails to establish the efficacy of speech therapy in the treatment of autism. Furthermore, because the loss of speech and other behavioral issues are related to communication and social issues associated with autism there is no medical indication for speech therapy for patients such as this patient. In cases such as this, speech therapy can typically be appropriately provided through means other than individual therapy. 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: Upheld Decision of Health Plan

The patient is a 47-year-old woman who has been diagnosed with rheumatoid arthritis, osteoarthritis, lumbar spinal stenosis, and fibromyalgia. The submitted information indicates the patient has a standard wheelchair. The patient reports she does not have sufficient strength in her hands and shoulders to operate a manual wheelchair. She has requested authorization for a POV. The Health Plan has denied the request on the basis that a POV is not medically necessary for the patients mobility.Review of the submitted medical records demonstrates the patient had normal strength, sensation, and reflexes in her upper extremities upon examination on 2/19/04. The exam notes from 2/19/04 and 4/26/04 reveal no evidence of any deformities, swelling, joint effusions or impairment in range of motion in the arms. Thus, the provided documentation does not demonstrate the patient is precluded from operating a manual wheelchair. Furthermore, there is no indication in the submitted information as to the extent to which the patients gait is limited. As such, the medical necessity of a POV has not been established. Therefore, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old female who has a body mass index (BMI) of 38.1. She has joint pain, hiatal hernia, and GERD. She has requested authorization for gastric bypass surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary.With a BMI of 38 and no significant comorbid condition, the patient does not meet nationally accepted medical necessity criteria for consideration of weight loss surgery. There is potential that further attempts at conservative weight loss will be successful. Furthermore, as the patient has the potential for further weight loss through conservative means, the risks of weight loss surgery outweigh the potential benefits of the procedure. Therefore, 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: Overturned Decision of Health Plan

The patient is a 20-year-old man with a two-year history of low back pain. The patient has undergone conservative treatment yet his symptoms persist. He has not received epidural injections. The patient appears to have congenital spondylolisthesis. It has been recommended he undergo surgery in the form of spinal fusion. The Health Plan has denied authorization for lumbar spine surgery on the basis that it is not medically necessary for treatment of the patients back pain.In light of the patients persistent pain the treatment of choice is surgery. Though the patient has not yet undergone epidural injections, such treatment is not definitive and at the most would provide only temporary relief. For definitive treatment of the patients condition a spinal fusion is medically appropriate and indicated. Given the failure of conservative treatment it is not likely that continuation of conservative measures will alleviate his pain. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 60-year-old man with blood in his stool. The results of an EGD only showed some linear erosions. Apparently the patient has abdominal pain and has experienced a change in bowel movements. He has never undergone a colonoscopy. His last flexible sigmoidoscopy was performed in 1997. The patient has requested authorization for a colonoscopy. The Health Plan has denied the request on the basis that the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned. The patient has never undergone a colonoscopy. The results of the EGD do not completely explain the patients symptoms. In light of the unknown etiology of the patients abdominal pain and change in bowel movements, as well as his age, a colonoscopy is medically appropriate and indicated. Therefore, I have determined that the requested procedure is 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 52-year-old woman with a history of morbid obesity, diabetes mellitus, asthma, and osteoarthritis. The patient has poor coordination and has difficulty ambulating. She reports that she wears wrist braces. The patient has requested authorization for a power-operated vehicle (POV). The Health Plan indicates the submitted documentation does not demonstrate a POV is medically necessary for the patients mobility. The Health Plans denial should be upheld. Review of the submitted medical records fails to provide confirmation of any impairment, weakness or decreased range of motion involving the arms. Thus, the provided documentation does not demonstrate the patient is precluded from operating a manual wheelchair. Furthermore, the submitted medical records do not define the patients current ambulatory abilities. Hence, the medical necessity for a POV has not been established. Based upon the information set forth above, I have determined that the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 45-year-old woman purported to have a primary hypogammaglobulinemia and adult growth hormone deficiency (AGHD). The patient reports fatigue, malaise, lethargy, cognitive deficits, and a history of thrush and other body sores. Two Candida species grew in a sputum culture dated 6/17/04. A workup for the hypogammaglobulinemia has not been submitted but the patient is said to have mannose-binding globulin deficiency. There are no immunoglobulin or T cell CD 4+/CD8+ ratios to suggest a mannose-binding lectin defect. It appears the patient has been receiving IV gammaglobulin. A multitude of laboratory tests have been submitted including a series of growth hormones dated 11/12/03, which appear to represent some sort of stimulation test. The results appear normal, as do IGF-1 and IGFBP3 concentrations and all other pituitary function tests.The patient has requested authorization for chronic Diflucan and Humatrope. The Health Plan has denied the request on the basis that the requested medications are not medically necessary for treatment of the patients medical condition.The submitted records include no documented evidence that the patient has a primary hypogammaglobulinemia. Candida species are common commensals in the oral pharynx, and are present in 50% of a persons normal flora. Chronic prophylaxis or treatment with Diflucan is not medically indicated in the absence of opportunistic infection in immunosuppressed patients.Furthermore, the patient has no evidence of AGHD. The diagnosis is based on the clinical context, signs and symptoms, and the results of biochemical testing. The patients signs and symptoms are sufficiently non-specific, and the stimulation tests sufficiently inaccurate, that it is possible to have a false positive diagnosis. The patients multiple medical problems and medications could account for her symptoms. Humatrope is not medically indicated in the treatment of patients with primary hypogammaglobulinemias. Based upon the information set forth above, I have determined that the requested medications 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 62-year-old female with a history of depression, gastroesophageal reflux disease, post-polio syndrome, and excessive daytime sleepiness. No evidence of narcolepsy or obstructive sleep apnea has been provided. The patient is being managed with Provigil 200mg as recommended by her pulmonologist. The patients documented weight is 229 pounds. The submitted medical records do not include documentation of polysomnography or multi-sleep latency testing to determine if the patient has hypersomnolence due to narcolepsy or obstructive sleep apnea. The patient reports her fatigue has improved with Provigil. The Health Plan has denied authorization for Provigil on the basis that it is not medically necessary for treatment of the patients medical condition.Provigil has generated a wide variety of clinical and prospective trials for fatigue-associated illnesses. Though the patient reports that Provigil has improved her fatigue, Provigil has not been approved for treatment of post-polio syndrome. Provigil is indicated for treatment of narcolepsy and obstructive sleep apnea. The submitted information does not include documentation of polysomnography or multi-sleep latency testing to determine if the patients hypersomnolence is due to narcolepsy or obstructive sleep apnea. Based upon the information set forth above, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time. However, the patient should undergo polysomnography and multi-sleep latency testing in order to determine if she has narcolepsy or obstructive sleep apnea. If the results of the sleep studies are consistent with narcolepsy or obstructive sleep apnea, the patients request for Provigil should be reconsidered.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 49-year-old female with a history of depression and generalized anxiety disorder, inclusive of low energy, loss of appetite, crying spells, poor concentration, loss of pleasure, periods of hopelessness, and withdrawal. She was previously unresponsive to courses of Zoloft, Prozac, Celexa, Lexapro, Effexor, Remeron, Desyrel, Doxepin, and Wellbutrin. She also suffered from significant sleep disturbance with sleep interruption, restless legs, and inability to stop thinking. She either did not respond to the aforementioned medications or had side effects she found intolerable. Her psychiatrist eventually tried her on a combination of Prozac 20 mg and Provigil 200 mg in November 2003 and the patient reported feeling happier and more productive by her next visit of 12/16/03. By her next visit of 1/20/04, the patient noted that her mood was better, sleep was fair but she doesnt stress about it and she wanted to travel more. This improvement appeared sustained such that by her next visit of 2/17/04, she was noted as more available for new experiences with little severe insomnia and her feeling clear headed most of the time. By her visit of 5/18/04, she was noted as still sleeping better and less depressed, cited as feeling like her normal self again.The information submitted demonstrates the patient not only responded to the combination of Prozac and Provigil but the improvements themselves were sustained over months. To the extent the benefit of this therapy exceeded that which she experienced with other antidepressants, in conjunction with there being support in the literature for utilizing Provigil as an antidepressant adjunct, it must be concluded that Provigil is medically necessary for treatment of the patients depression. 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 47-year-old woman with a history of non-specific back and neck pain. The patient underwent cervical fusion in February 2004. She continues to experience leg and low back pain. The patients provider has recommended L5-S1 fusion surgery. The patient has requested authorization and coverage for spinal fusion surgery and a discogram. The Health Plan has denied the request on the basis that the requested services are not medically necessary for treatment of the patients medical condition.There is no clear indication for either a spinal fusion or discogram at this time. The submitted evidence reveals no evidence of disc degeneration or any other abnormality. Without conclusive identification of the etiology of the patients pain, surgery is not indicated. Continuation of conservative treatment is medically reasonable and appropriate. Therefore, I have determined that the requested services are not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1The patient is a 36-year-old man with a long history of back pain. It has been recommended the patient undergo artificial lumbar disc surgery. The Health Plan has denied authorization for the requested procedure on the basis that the efficacy of artificial disc replacement has not been established.Lumbar disc replacement is in its infancy at this time. Several studies are currently being undertaken to investigate the risks, benefits, and outcomes of replacement. However, at this time there are no long-term studies to warrant use of the procedure. In fact, the surgery itself has only been performed sporadically by very few surgeons. Thus, at this time there is no evidence that artificial lumbar disc surgery is likely to be of greater benefit than standard treatment. 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 2The patient is a 36-year-old male with degenerative changes since the age of 16. The patient wishes to undergo artificial lumbar disc surgery. The Health Plan has denied authorization for the requested procedure on the basis that it is considered experimental.At this time, artificial lumbar disc surgery is an unproven procedure. There is no substantial proof of its effectiveness for treatment of chronic back pain. The benefits and efficacy of artificial disc replacement have not been shown. Thus, the requested procedure is not likely to provide greater relief than 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 3The patient is a 36-year-old male with a long-standing history of chronic back pain. The patients MRI demonstrates facet degenerative disc changes. He has undergone conservative treatment without long-term success. The patient has requested authorization for artificial lumbar disc surgery. The Health Plan has denied the patients request on the basis that the requested procedure is considered investigational for treatment of the patients medical condition.Artificial disc replacement is of unproven efficacy. There are not sufficient long-term studies to establish the effectiveness of the procedure. There is no literature from the United States with more than one-year follow-up. The FDA study remains ongoing at this time. Thus, it is not known how the requested procedure will affect long-term outcomes. Furthermore, the patients MRI demonstrates facet degenerative disc changes, which is a contraindication to artificial lumbar disc surgery.Based upon the information set forth above, 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. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 58-year-old male diabetic with onychomycosis involving the nails in his hands and feet. The patients provider notes the patient was unable to tolerate Lamisil due to gastrointestinal upset. A request has been made for Penlac. The Health Plan has denied authorization for Penlac on the basis that it is not medically necessary for treatment of the patients onychomycosis. In light of the patients immunosuppressed status and increased risk for secondary bacterial infection, his onychomycosis should be treated. Both Lamisil and Sporanox appear to be contraindicated secondary to the patients concomitant medical problems and medications. Though topical Penlac is generally less effective it is an appropriate alternative in this case pending laboratory confirmation of fungus with KOH, CX or PAS stain.Based upon the information set forth above, I have determined that the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. Laboratory confirmation of fungus should be obtained prior to authorization of Penlac.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 58-year-old man with small cell lung cancer diagnosed in April 2003. He was aggressively treated with chemotherapy and received cranial irradiation. Chemotherapy continued on and off until May 2004, when during chemotherapy he developed trouble speaking. Following chemotherapy, a CT scan revealed four lesions in the cerebrum. An MRI scan revealed a few more lesions with the largest measuring 17mm. Because of previous cranial irradiation the patient was referred for gamma knife radiosurgery. The Health Plan has denied authorization for gamma knife radiosurgery due to the multiplicity of the cranial lesions. The patient consulted another provider who concurred with the recommended gamma knife radiosurgery. Meanwhile, the patients central nervous symptoms have returned and are poorly controlled with steroids and Dilantin. The patient has stage IV small cell cancer of the lung. He has received prior cranial irradiation with good response. He now has new intracranial metastases with the largest lesion measuring 17mm. The choices of radiation management are between gamma knife radiosurgery and external beam cranial irradiation. Gamma knife radiosurgery is a proven therapy and has been recommended by two of the patients providers. The fact that the patient has multiple lesions is not a contraindication to the procedure. Gamma knife radiosurgery is a medically appropriate and indicated procedure. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 39-year-old man with plantar fibromatosis. He has undergone prior procedures involving surgical excision of the masses. In May 2004, the patients provider indicated the patient had developed recurrent aggressive fibromatosis involving the right foot. The patients provider has recommended surgical excision of the right foot masses followed by radiation therapy. The Health Plan indicates the requested procedure is not medically necessary for treatment of the patients medical condition.The requested procedure is medically necessary for treatment of the patients right foot masses. As of May 2004, the patient had not developed a recurrence of masses in his left foot after undergoing surgical excision. It is medically reasonable to proceed with surgical excision of the right foot masses. The treatment as outlined by the patients provider is medically appropriate and is indicated at this time. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.