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

The patient is a 27-year-old woman who underwent an ACL reconstruction. Postoperatively she utilized a CPM machine as prescribed by her orthopedic surgeon.  She is requesting reimbursement for the rental cost of the CPM device. The Health Plan denied coverage based upon their determination that the CPM device was not medically necessary following the patients surgery. A CPM device is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. The purpose of the device is to help patients regain their range of motion.  The use of the device is not experimental; it is a matter of surgeon preference.  In this case, the patient exhibited decreased range of motion (ROM) for several months and the CPM device was needed so that she could regain full ROM with the injured knee.  Based upon the information set forth above, I have determined the device at issue was 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 14-year old female who injured her left wrist in an indoor rock climbing accident.  She fractured her radius and ulna and was in a cast for about three weeks. The patient had persistent pain after cast removal and was ultimately diagnosed with a triangular fibrocartilage complex (TFCC) tear.  Her parents took the patient to a non-plan orthopedic surgeon for a second opinion and he recommended arthroscopic wrist surgery with laser debridement of the TFCC.  The Health Plan is willing to provide arthroscopic wrist surgery performed by a hand surgeon, using the Arthrocare technique.  The Health Plan has denied authorization for the laser debridement procedure performed based upon their determination that it is not medically necessary.  TFCC debridement via wrist arthroscopy is essentially the same as laser debridement.  The expected outcomes are similar regardless of whether an Arthrocare radiofrequency probe is utilized or a laser technique. As such, the procedure recommended by the Health Plan is medically reasonable and appropriate. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old woman with a diagnosis of Crohns disease who is suffering from frequent diarrhea.  She has been treated with several different medications, but they did not remedy her symptoms. The patient has been using Sandostatin for the past three years and believes that it decreases the frequency of her diarrhea.  She is requesting that the Health Plan authorize continued usage of the medication. The Health Plan has denied her request based upon their determination the Sandostatin is not medically necessary for the treatment of Crohns disease.The submitted records do not include much detail as to the character of the patients diarrhea. The FDA however, has not approved Sandostatin for the treatment of diarrhea related to Crohns disease, nor is it indicated according to the community standard of care. As such, based on the clinical information provided, the use of Sandostatin is not medically warranted in this case. Accordingly, 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: Upheld Decision of Health Plan

This patient is a 63-year-old male who has significant osteoarthritis of both knees.  He has greater severity on the right side with bone on bone articulation. The medical records provided indicate the patient has had various treatments for this including medication and a series of Synvisc injections to both knees. He next received a series of prolotherapy injections to his knees from June 2005 through October 2005. The patient reports he has been pain free since the therapy, but the clinical records do not document this outcome.A critical review of prolotherapy in the treatment of osteoarthritis, low back pain and other musculoskeletal conditions reveals that the clinical efficacy of the therapy remains inconclusive.  Although the patient reported pain relief, the use of prolotherapy for pain control is still considered investigational and it is not consistent with the current standard of care.  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

This patient is a two-year, eleven-month old female with a diagnosis of Rhetts syndrome. Associated with the Rhetts syndrome is a seizure disorder and cognitive/developmental delay, which includes significant motor delay. The patient is able to stand independently while holding onto furniture, but cannot stand independently without support. She requires maximum assistance to ambulate and is currently taking two to three steps using a Rifton Pacer Gait Trainer. When ambulating, she does not respond to commands and does not walk with intention toward an object. The patient requires moderate to maximum assistance to walk with the ambulatory assistance device.  The Health Plan has denied authorization for the device based upon their determination that the patient cannot use it for its intended function. In this case the ambulatory assistance device is being used as exercise equipment and cannot yet be used as a functional mobility device. Consequently, by community standards it is not medically necessary.  The patients medical therapy unit can continue to provide the device during therapy sessions. If, at some point, the patient starts to use it independently in therapy, then the medical necessity of the ambulatory assistance device should be reassessed at that time.  Based upon the information set forth above, I have determined 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 20-year-old woman who has severe bilateral axillary hyperhidrosis. Treatment courses of Xerac AC and Drysol have been ineffective. The patient stated that the hyperhidrosis has been so severe that she experiences large areas of clothing stains that are noticed by others. She received Botox injections in February 2005 and her provider has recommended a repeat course of the therapy. The Health Plan has denied coverage for additional treatment with Botox on the basis it is not medically necessary for treatment of the patients condition.Review of the submitted clinical evidence demonstrates the patients hyperhidrosis is severe. Erosion, maceration or ulceration of the skin is not the sole criterion for assessing whether treatment of this condition is medically necessary. Interference with daily functioning and impact on quality of life are also valid standards and should be considered. Treatment of the patients severe axillary hyperhidrosis is medically warranted. Initial therapy with Xerac AC and Drysol has been ineffective. Therefore, Botox therapy is the next appropriate treatment step and should be authorized. Based upon the information set forth above, I have determined that 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 51-year-old female who fell onto wet concrete in January 2005.  Since her fall she has experienced headaches, back and neck pain, and pain/weakness in the extremities.  She was evaluated by a neurosurgeon, but her injuries were not deemed amenable to surgical intervention.  She was referred to physical therapy (PT) for symptomatic relief.  She participated in PT for five to six months and is requesting coverage for continued therapy.   The Health Plan denied the patients request for additional PT based upon their determination that it is not medically necessary.The patient participated in PT from April 2005 through September 2005.  When she began therapy, her cervical pain was assessed at 4-6/10 and her headaches at 8-10/10.  The patients pain continued to flare with pain levels still reaching 8-9/10 in August after several months of therapy.  In September, her pain levels were 7-9/10 and her therapist reported that none of the initial treatment goals had been met.  In fact, it appeared her headaches were worsening in frequency and intensity.  Additionally, there is little documentation of improvement in functional abilities. The patient remained unable to cook or perform household tasks and experienced severe pain while washing her hair.  The PT treatment records lead to the conclusion that overall, there is no objective documentation of improvement with this treatment modality. The patients therapist appropriately recommended further medical evaluation.  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 40-year-old female who has undergone rhinoplasty and is requesting reimbursement for the stated functional septoplasty portion of the surgery. The patient states that she has been told in the past that her septum was deviated and that rhinoplasty would be necessary to correct this. She further indicates that her nose was obviously not straight and blocking her airway passage. There is no documentation of problems with nasal airway restriction. The plastic surgeons notes indicate that the patients nose had a prominent tip and wide nostrils. Pre-operative photos show that the patient had a bulbous nasal tip that was fuller on one side than the other. There was a hanging columella that was deviated to one side as well, resulting in asymmetry of the nostrils. The patient underwent open rhinoplasty in November 2004. The dictated operative note demonstrates that a reduction of the dorsal septum was performed. There is no other mention of septal work having been performed during the procedure.At issue is whether any portion of the surgery at issue as medically necessary for treatment of the patients condition.There is no evidence the surgery at issue was performed for functional purposes. The submitted records do not include any discussion of septal deviation or airway restriction. Furthermore, there is no mention of a septoplasty having been performed other than reduction of the dorsal aspect of the septum. This would lower the height of the septum and, in turn, the dorsum of the patients nose, but would not affect a deviation of the septum. As such, I have determined the surgery at issue was cosmetic in nature and therefore, 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 59-year-old male with pulmonary fibrosis induced end stage lung disease and coronary artery disease. It is felt that both procedures are necessary to be performed simultaneously. The patient was evaluated on paper by USC Transplant Center and it was determined he is not an appropriate candidate for the proposed procedure. At issue is whether concurrent lung transplantation and CABG surgery is medically necessary for treatment of the patients condition.Transplantation provides patients with traditionally fatal diseases the opportunity for survival. As transplantation success improves, the potential recipient base will be expanded. Though randomized controlled trials will not be feasible, procedures will be adopted by individual centers based on their expertise. In the case of this patient, although USC Transplant Center determined he was not an appropriate candidate for the proposed procedure, it does not appear that this center has experience in simultaneous lung transplantation and CABG surgery. The submitted literature indicates there is evidence of reasonable success associated with the requested procedure. Though the scientific literature provides sufficient evidence of feasibility, the patient has not yet been evaluated by a center that specializes in the proposed procedure. As such, the patient should be referred to a center that has appropriate expertise in concurrent lung transplantation and CABG surgery (i.e., University of California Los Angeles) for further evaluation. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 36-year-old female with a history of chronic migraine headaches at a frequency of eight to ten per month. She has been treated with a number of medications including Imitrex, Fiorinol and propranolol. She has also received acupuncture treatment, which she states has reduced the number of headaches she experiences a month and has enabled her to reduce her medication use. She is requesting authorization and coverage for continuation of acupuncture at a frequency of once weekly. The Health Plan has denied this request on the basis that weekly acupuncture therapy is not medically necessary.The patient began treatment with an acupuncturist in April 2005 and continued to receive therapy on an irregular basis (e.g., three weeks apart, weekly, five to six weeks apart, etc.) through November 2005. All of the visit notes indicate the patient was slightly better with the exception of the note dated August 2005. On this visit an increase in pain was noted; the patient had hit her head on her cars trunk. Because of the debilitating nature of the patients migraine headaches and her less than favorable response to prescribed medications, she should continue to receive acupuncture treatments; however, the requested frequency of therapy is not medically necessary. Weekly therapy is appropriate in the beginning of treatment when symptoms are most severe or uncontrolled. The patient has been receiving acupuncture therapy since April 2005 and no longer requires weekly visits. She can be appropriately treated at a frequency of twice monthly with, depending upon her response, an eventual reduction in frequency to once monthly. In addition to acupuncture, Headache classes would be medically appropriate and may be helpful.Based upon the information 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: Overturned Decision of Health Plan

The patient is a 13-year-old male diagnosed with pervasive developmental disorder, depressive disorder and intermittent explosive disorder.  He was treated emergently in October 2005 and held for acute psychiatric hospitalization due to gross violence against his mother.  While at home, he became angry about what she was preparing for dinner and grabbed her by the throat and shoved her head against the kitchen cabinets. He had a prior history of violence inclusive of punching and biting his mother two weeks prior and an episode of choking her one-year prior when he was again upset about what she was preparing for dinner. The patient had also been admitted for inpatient psychiatric treatment four years prior due to behaviors that included charging at family members with a knife. His mother reported that although he had a long history of depression and low self-esteem, the severity of his behavioral disruptions had grown significantly in the past four years. He frequently refused to attend school and had explosive outbursts on the subject of food. The family also noted him to be preoccupied with fast food, wanting to be taken there each night. If his parents did not comply with his demands, he became angry, threatening, and/or violent. At that time of admission, the patient was attending a modified public school program and beginning in June 2005, his depression was successfully treated with Cymbalta 60 mg.With regard to his hospitalization, he was described as concrete in his reasoning with difficulty in his expression of feelings, having difficulty with change, having only a few close friends, and being hypersensitive to smells and tactile sensations. He was begun on Depakote and his dosage was gradually titrated upwards. Though he was initially a bit placid, by October 2005 he was noted to have grown increasingly rude and very resistant to any interaction when a change in his diet was related to him. At issue is whether the acute inpatient psychiatric care the patient received from October 2005 through November 2005 was medically necessary.As noted in the aforementioned notes, the patient did not appear appreciably improved by October 2005.  There is ample documentation pointing to his irritability, intolerance, and provocation.  These behaviors were of great concern and particularly problematic in light of his pattern of violence at home. Safe and appropriate discharge required that the treating clinician be as sure as possible that the patient had improved before sending him home.  He was assessed as sufficiently stable for discharge as of November 2005.  All told, I have determined that the acute inpatient care at issue was 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 fifty year-old male with end-stage liver disease due to hepatitis C and cirrhosis is requesting authorization and coverage for inpatient methadone detoxification.  Reviewers Findings:  The reviewing physician found that the medical literature demonstrates methadone detoxification can be performed safely on an outpatient basis with a decrease of methadone, as tolerated, coupled with treatment of associated symptoms.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 19-month-old male with plagiocephaly and congenital torticollis. The plagiocephaly has been treated since the age of eight months. He outgrew the first band and subsequently received a second band. The family is requesting reimbursement for the continued orthosis treatment with a second DOC band. At issue is whether continued treatment with a second DOC cranial band was medically necessary for treatment of the patients medical condition.Review of developmental medicine and child neurology literature shows that DOC bands can benefit patients with plagiocephaly if initiated before the age of one year, as was the case with this patient. Although there is no level I or II literature available on the results in older children, there is some evidence that continuation of band therapy may be beneficial up to age two. The use of DOC banding in patients who have plagiocephaly with torticollis is medically reasonable and appropriate. Since torticollis is the underlying cause of plagiocephaly in this patient, aggressive treatment for the torticollis should also occur. Based upon the information at this time, I have determined the device at issue was 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 woman who has psoriasis covering approximately 30% of her body surface area and has had the condition for at least 20 years. Appropriate topical therapies have been tried as well as UVA and cyclosporine; all have been ineffective. The patient has also been treated by a neurologist for recurrent diplopia and was advised that Enbrel is contraindicated because she may have demyelinating disorder. The patients dermatologist prescribed Raptiva and outlined the reasons why other medications are ineffective and/or contraindicated for her.  The Health Plan denied authorization for Raptiva based upon their determination that it is not medically necessary.The patient is of childbearing age and because the possibility of pregnancy exists methotrexate and Soriantane should be eliminated as alternatives to Raptiva. With regard to cyclosporine, the increased risk of serious side effects with long-term use should be considered in addition to the fact that it did not work well for this patient. Enbrel is contraindicated in patients with possible demyelinating disorders, as indicated by the neurologist. This is related to the effect of tissue necrosis factor (TNF) on such disorders. Enbrels method of action involves TNF.  Raptiva is the only appropriate and effective medication remaining for the treatment of this 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: Overturned Decision of Health Plan

The patient is a 42-year-old male with an anterior mediastinal mass and pulmonary nodules; his diagnosis is unknown.  A needle biopsy was not sufficient for diagnosis and he requires a resection for a tissue sampling and biopsy.  The patient requested the video-assisted thoracoscopic surgery (VATS) procedure because he believes it is less invasive.  The Health Plan has denied authorization and coverage for the VATS procedure on the basis it is not medically necessary.VATS is the procedure of choice for lung biopsies, pleural biopsies, resection of mediastinal masses, etc. unless there is a clinical reason not to use this approach. This mediastinal mass, by CT description, can be resected via a VATS approach.  The VATS procedure is much less invasive than the sternotomy and should be utilized in this clinical context.  Based upon the information 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 57-year-old male with osteoarthritis of the right knee. An arthroscopy performed in August 2005 revealed Grade III chondromalacia on the medial side of the knee and Grade II-III chondromalacia on the patellofemoral joint. Appropriate surgery was performed. Because of persistent symptoms, the patient returned for follow-up and his surgeon recommended Synvisc. The Health Plan has denied authorization for Synvisc on the basis it is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld. The submitted evidence does not document a trial of acetaminophen for pain relief. Furthermore, it does not appear the patient has tried and failed treatment with different non-steroidal anti-inflammatory medications (NSAIDs). Nor is there evidence the patient failed treatment with intra-articular steroid injections. If the patient undergoes a trial of these therapies without relief, then Synvisc may be medically indicated. However, at this time the therapies recommended by the Health Plan are medically reasonable and appropriate. Therefore, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.