Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 45-year-old male with degenerative disc disease at L5-S1. The patient is status post a discectomy in 2003. His provider is recommending a single level disc replacement. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement as the best available treatment for this patient. Artificial discs are currently being investigated for single level disc replacement in the treatment of degenerative disc disease in the lumbar spine. Current data for single level disc replacement demonstrates a 63% short-term success rate; however, long-term outcomes are unknown and complications may be severe. Because there is no evidence supporting the safety and efficacy of artificial disc replacement, I have determined 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.Physician 2: The patient is a 45-year-old male with degenerative disc disease at L5-S1. Artificial disc replacement has been recommended. The patient is status post discectomy in 2003 and has persistent pain. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined 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.Physician 3: The patient is a 45-year-old male with degenerative disc disease. He is seeking authorization for artificial disc replacement utilizing the Charite III disc. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300 patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a three-year-old male diagnosed with autism at the age of 20 months. His treatment has consisted of an applied behavioral analysis program three hours per week, speech therapy three hours per week, and occupational therapy one hour per week. Occupational therapy has primarily been sensory based. The most current reports reflect gross motor skills within functional limits except for handling a ball and poor arm swing while running. Fine motor skills are within functional limits. Activities of daily living are delayed in dressing, especially for fasteners, though fasteners are not an age appropriate activity of daily living for a three-year-old child. The patient requires scheduled toileting. He has difficulty with circle time in group when other children sing.Language skills are age appropriate with receptive language when engaged and attending, but much of this appears to be from rote learning. The patients receptive vocabulary is within functional limits. His expressive language is still significantly delayed. The patients parents have requested authorization and coverage for continued speech therapy and occupational therapy services. The Health Plan has denied this request on the basis the requested services are not medically necessary for treatment of the patients condition.Review of the relevant medical literature reveals no data on individualized speech therapy in the treatment of autism. Given that pragmatic speech, auditory processing, social communication, and expressive speech are the primary deficits, group speech with normal peers and speech within the educational setting are more appropriate. This should be done as part of a coordinated interdisciplinary program.Furthermore, review of the literature regarding occupational therapy in autism reflects mixed findings especially with regard to specific therapies such as sensory integration therapy. All studies regarding sensory integration therapy are small scale and at least one of those studies reports no benefits.Though the submitted records indicate multiple physicians have recommended speech and occupational therapy for the patient, these therapies have been recommended in an educational context and do not imply such services are medically necessary.The only treatment validated through scientific research to be beneficial for treatment of autism is applied behavioral analysis (ABA). The gains achieved by autism patients in speech and communication are usually a product of an ABA program. Historically, ABA programs after the age of three have been offered through IEP and the Individuals with Disabilities Education Act. Deficits such as pragmatic speech, auditory comprehension, and expressive speech delay fall primarily under educational issues and coordination of care is required. Thus, treatment is best provided through the student IEP.Based upon the information set forth above, I have determined that 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: Upheld Decision of Health Plan

The patient is a 53-year-old male who is requesting ongoing growth hormone replacement therapy. He has an undocumented history of childhood growth hormone deficiency, which apparently was never treated. He has been diagnosed with adult growth hormone deficiency based on inadequate growth hormone response to clonidine, though the dosage of clonidine involved appears to have been inadequate. The patient began growth hormone therapy in late 2001 or early 2002 and treatment was discontinued or interrupted in August 2004. Based upon the information provided, it is not known how often the patient has been receiving growth hormone therapy in the last six months. The Health Plan has denied coverage for continued growth hormone therapy on the basis it is not medically necessary.The Health Plans denial should be upheld. The submitted records do not provide sufficient evidence to support a diagnosis of adult growth hormone deficiency. The patients response to treatment was subjective with an equivocal biochemical response. The Health Plans recommendation of further diagnostic studies is medically reasonable and appropriate in the case of this patient. An insulin hypoglycemia test should be undertaken by the patients endocrinologist. At this time, there is no medical indication for continued growth hormone 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

This case involves an 18-year-old male with severe short bowel syndrome due to complications of a gunshot wound to the abdomen in November 2004. He is now TPN dependent and experiencing significant complications. The patients treating physicians have recommended a living related small bowel transplant. The Health Plan indicates the requested procedure is not medically necessary and has authorized a cadaveric small bowel transplant for the patient. While a living related small bowel transplant is a reasonable alternative to cadaveric small bowel transplant, there are no scientific data to show that the former is superior to the latter. In fact, there is more risk associated with a living related small bowel transplant than with a cadaveric small bowel transplant. In addition, a cadaveric transplant allows more flexibility with the length of the transplanted intestine. The only potential benefit of a living related small bowel transplant is immediate availability of the bowel for transplantation. However, this is not an emergency situation and there is no shortage of donor small bowel in the United States. 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 39-year-old female with neck pain that radiates to the right shoulder and arm. She has evidence of cervical disc disease. The patient has had symptoms for many years and has had a course of conservative treatment that has included medications, splints, and therapy. She has continued pain. A request has been made for anterior cervical discectomy and fusion. The Health Plan has determined the requested procedure is not medically necessary.While the MRI does not reveal a large disc herniation, the patient has radicular complaints and chronic pain. The patient has elected to proceed with surgery. The patient has attempted and failed conservative therapy. It is unlikely that further conservative therapy will be beneficial for the patient. It is likely that she will continue to have pain. Furthermore, she meets accepted criteria for consideration of cervical discectomy and fusion. 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: Upheld Decision of Health Plan

The patient is a 16-year-old female who apparently has discrete spots of vitiligo of the hands, trunk, and face. Treatment with topical medications including Elocon, Protopic, and Temovate has been ineffective. A request for authorization for treatment with ultraviolet blue light therapy has been denied by the Health Plan on the basis the requested therapy is not medically necessary for treatment of the patients condition.Ultraviolet blue light therapy is an accepted therapy for treatment of vitiligo. However, the submitted documentation does not indicate the extent, severity, and location of the patients vitiligo. As such, there is no evidence the patients condition has resulted in a functional impairment thereby necessitating ultraviolet blue light therapy. Based upon the information provided, there is no medical justification for ultraviolet blue light therapy. Therefore, 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

This patient is a 52-year-old man who has hepatitis C genotype 1A. He was once treated in 1997 with regular IFN and apparently did not respond. It appears that he had a six-month course of therapy at that time. More recently, the patient was treated with Pegasys and ribavirin for 48 weeks and his last primary clearance rate was apparently undetectable. Another six months of therapy has been requested by his provider. The Health Plan has denied this request on the basis it is not medically necessary for treatment of the patients condition.Review of the submitted records reveals that continuation of Pegasys and ribavirin therapy is not medically indicated for treatment of this patients hepatitis C virus. It is not the community standard to treat genotype 1 patients for 18 months with increased dosage of ribavirin. The requested therapy is not likely to be of benefit. The submitted evidence indicates the patient failed one course of therapy. Furthermore, with the more recent course of therapy the patient did not have a 2-log drop in his viral count after 12 weeks of therapy. Based upon a study by Fried, et al., only 3% of patients who did not experience a 2-log drop by the end of 12 weeks had sustained viral response by the end of the treatment course. In light of these findings, there is no medical justification for continuation of Pegasys and ribavirin therapy for treatment of the patients hepatitis C virus. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 13-year-old female who has been diagnosed with obsessive-compulsive disorder with delusions and attention-deficit hyperactivity disorder. The patients medication regimen includes prescribed Lexapro and Focalin. The Plan has denied coverage for Focalin on the basis it is a non-formulary medication and is not medically necessary.Since the patient is stable it would be inappropriate to stop her current medication regimen in order to give a trial of formulary medications, which may or may not be effective. Furthermore, Focalin has a unique mechanism of action (receptor binding affinities, etc.) and generic equivalents do not exist. 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 13-year-old female who has been diagnosed with obsessive-compulsive disorder with delusions and attention-deficit hyperactivity disorder. The patients medication regimen includes prescribed Lexapro and Focalin. The Plan has denied coverage for Lexapro on the basis it is a non-formulary medication and is not medically necessary.Since the patient is stable it would be inappropriate to stop her current medication regimen in order to give a trial of formulary medications, which may or may not be effective. Furthermore, Lexapro has a unique mechanism of action (receptor binding affinities, etc.) and generic equivalents do not exist. 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 50-year-old female who has a skin tag on her left lower eyelid. She indicates the skin tag changes in size, itches all the time, and sometimes is very painful and tender. Her physician referred her to an opthalmologist who recommended she undergo removal of the skin tag. The Health Plan has denied this request indicating the procedure is cosmetic in nature and not medically necessary.Skin tags are common, benign, and seldom require removal for other than cosmetic purposes. Though the eyelids are an area subject to skin cancers, no evidence has been presented demonstrating that an excisional biopsy is warranted at this time. Furthermore, there is no evidence the skin tag results in a functional impairment. As such, there is no medical indication for the requested 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: Upheld Decision of Health Plan

This patient is a 10-year-old female with global developmental delay. Specifically, the patient has had significant delay in activities of daily living including dressing and brushing teeth. She also has difficulty with fine motor skills. She received occupational therapy in the first half of 2003 and then went to China to try alternative treatment. The patients provider is now requesting occupational therapy to address the patients self-help skills and fine motor skills. The Health Plan indicates additional occupational therapy is not medically necessary.In reviewing the previous occupational therapy summary from January to March 2003, it does not appear the patient was making functional gains. The goals provided in the most recent evaluation are similar to the goals from 2003 reflecting a lack of progress since that time. Therefore, functional progress would not be anticipated in an appropriate amount of time. Progress will likely come through significant repetition, which can be accomplished through community-based services. There is no clinical indication for additional occupational therapy at this time. 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 21-year-old female with chronic pain who is requesting Actiq for pain control as several other pain medications have not been effective. The patient has been taking Actiq since 2002 and indicates it is the only medication that has provided her with relief. The Health Plan has denied coverage for Actiq on the basis that it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. Actiq is not indicated in this patients condition and it is generally utilized for cancer pain refractory or tolerant to long-term opioids. No documentation has been provided demonstrating medical necessity for the use of Actiq. The patients chronic pain condition is related to cervical facet syndrome. Though the patient has a significant chronic pain syndrome, there are other established medications for non-cancer related breakthrough pain. Therefore, I have determined that the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 41-year-old female who underwent a cervical discectomy and fusion at C5-6 and C6-7. Her physician has recommended she receive a Spinal Logic bone growth stimulator post-operatively. The Health Plan has denied this request indicating the efficacy of the requested equipment has not been established.Bone growth stimulators are of proven efficacy as is demonstrated by the studies provided. They have been used for nearly two decades to increase bone growth for fractures and other orthopedic ailments. Numerous studies, including those that have been provided, have shown increased bone growth with the use of bone growth stimulators. There is sufficient data demonstrating that use of the requested equipment is likely to result in a superior outcome to standard treatments. Therefore, I have determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned. Physician 2: The patient is a 41-year old woman who underwent cervical fusion in November 2004. Her physician has recommended she use a bone growth stimulator to improve bone healing. The Health Plan has denied coverage for the requested equipment on the basis it is considered experimental for treatment of patients such as this patient.There is inadequate data to support the use of a bone growth stimulator in this patient. Use of the device for patients who have undergone cervical surgery has not been shown to be beneficial in peer-reviewed literature. Given the lack of evidence-based literature involving post cervical fusion patients, a bone growth stimulator cannot be recommended. Accordingly, I have determined that the requested equipment 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 3: The patient is a 41-year-old woman who, after a long history of neck, shoulder, and arm pain, underwent an anterior cervical disc excision and fusion at C5-6 and C6-7. Her physician has recommended she use a bone growth stimulator to expedite healing of her fusion. The Health Plan has denied coverage for the requested equipment on the basis that it is considered experimental.There is no prospective data establishing the efficacy of spinal bone growth stimulation. All evidence of its efficacy is anecdotal at best. There is no evidence of clearly established benefit resulting from use of the device. As such, there is no clinical indication for use of the requested equipment in this patient. Therefore, I have determined that the requested equipment 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.