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

The patient is a 58-year-old female with a history of back, neck, and shoulder pain. She was seen by a chiropractor who suggested the patients symptoms would probably benefit from breast reduction surgery. The patient was previously seen by a physical therapist and a neurosurgeon for other back pain in the past. It appears from the submitted documentation that the board certified plastic surgeon who requested authorization for breast reduction surgery agreed the patient would benefit from the requested procedure. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is not medically necessary.The submitted photocopies of photographs are of poor quality. Therefore, it is not possible to confirm that the patients breast size results in medical complications. Furthermore, the submitted consultation notes are insufficient to support medical necessity for breast reduction surgery. As such, it has not been established the requested procedure is medically warranted at this time. 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

The patient is a 51-year-old morbidly obese female who underwent simultaneous gastric bypass and panniculectomy.  She subsequently underwent revision of the panniculectomy scar and excision of thigh skin with suction assisted lumpectomies (thighplasties). The patients postoperative course was marred by the anticipated cellulitis of the right thigh. Because of persistent bulging of the thighs and lateral trunk, the patients plastic surgeon has requested authorization for liposuction of these areas. The Health Plan has denied authorization for the requested procedure on the basis it is cosmetic in nature and therefore, not medically necessary.The submitted medical records and photographs do not demonstrate medical necessity for suction assisted lipectomy of the legs and chest. There is insufficient objective evidence of a functional impairment resulting from the patients excess skin. The requested procedure is cosmetic in nature and is not medically indicated. 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 64-year-old male status post anteroapical myocardial infarction (MI). He underwent stent implant with persistent ST elevation and abnormal flow post procedure. He also underwent a repeat angiogram demonstrating occlusion of the distal LAD with an ejection fraction of 32%. The patient has requested reimbursement of an in-home external defibrillator, which was provided prior to internal defibrillation. The Health Plan has denied authorization for the equipment at issue indicating an external defibrillator was not medically necessary. The patient met criteria for implant of an internal defibrillator by MADIT III criteria, post myocardial infarction with an ejection fraction of 32%. This was discovered at the time of cardiac catheterization. The evidenced based approach would be to implant an internal defibrillator after recognition of having criteria met for malignant arrhythmia risk. If there is concern over risk of sudden death after recognition of risk by catheterization, it is not uncommon to perform defibrillator implant before discharge, or to transfer to a facility that has implant capacity. As the patient met criteria for internal defibrillation, there was no medical indication for an external defibrillator, which has not been proven to reduce mortality. Therefore, I have determined that the equipment at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old male with symptoms suggesting sleep apnea, with no evidence of special risk factors (such as obesity, hypertension, cardiac disease) and mild daytime sleepiness with an Epworth score of 9. Sleep study documents mild sleep apnea with an apnea-hypopnea index of 11.9/hr, no significant oxygen desaturation, and no documented apnea.Review of the relevant medical literature reveals no benefit of CPAP in mild cases of sleep apnea when compared to placebo. An apnea-hypopnea index of 11.9 is compatible with mild apnea and does not meet criteria for treatment. A threshold of 15 or 20 is usually invoked unless there are additional risk factors. This patient has no documented additional risk factors. Therefore, I have determined that the requested equipment 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 58-year-old male with a large radiolucent lesion in the ramus of the left mandible. The lesion may be associated with a malposed and impacted third molar. The patients treatment plan includes exploration of the mandible, excision of the lesion, and extraction of the lower left molar. The Health Plan indicates excision of the lesion is dental and not medical in nature and has denied authorization for excision. The patient has a radiolucent lesion of the left mandible without tissue diagnosis. Most of these types of pathologic lesions are odontogenic in origin even though they approximate teeth. Therefore, the differential diagnosis would have to include the following pathology:1. Odontogenic cystFollicular cystDentigerous cystOdontogenic keratocystOdontogenic keratocyst with intraluminal malignancy such as squamous cell carcinoma;2. Odontogenic neoplasmBenignMalignant;3. Vascular neoplasm;4. Vascular defect;5. Non-odontogenic cyst;6. Non-odontogenic neoplasmBenignMalignant; or7. Other radiolucent mandibular lesions.Osteolytic lesions in the region of the mandible can lead to pathologic fracture of the mandible. The patient needs to have the lesion excised and submitted for microscopic tissue diagnosis. For the reasons set forth above, excision of the lesion is medical and not dental in nature. The only difference between this patients lesion and maxillofacial lesions is the tissue of origin.Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is an 11-year-old male with a history of attention deficit hyperactivity disorder (ADHD), and inconsistent and erratic school performance. In 2005, the patient was tried on Strattera, apparently with good results. The patients parents have requested authorization and coverage to allow the patient to continue on Strattera. The Health Plan has denied coverage for Strattera on the basis the patient does not meet criteria for use of a second-line drug.At issue is whether Strattera is medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The submitted clinical information does not establish that Strattera is medically necessary for this patient. There is no evidence the patient has been tried on a long-acting stimulant or that use of a long-acting stimulant is contraindicated. As such, there are alternative therapies available that are likely to be beneficial for the patient. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 43-year-old female who has a history of depression and alcohol abuse. She began inpatient hospitalization in 2005. At the time of her admission, the patient was suicidal as evidenced by an emergency room visit secondary to taking excessive Xanax and alcohol. In the psychiatric history and evaluation, the patients chief complaint was constant thoughts of not wanting to be around. A request has been made for coverage for continued inpatient psychiatric treatment services. The Health Plan indicates the submitted documentation does not demonstrate the requested services are medically necessary.Although the patient had symptoms consistent with active suicidality upon admission, these symptoms were most likely precipitated or exacerbated by active alcohol intoxication. There is scant evidence in the medical record to suggest ongoing suicidality. It would have been medically reasonable and appropriate to transfer the patient to partial hospitalization or outpatient chemical dependency program, at which point the patient was stable. There is no evidence of acute alcohol withdrawal symptoms at the time of admission. Detoxification was optimal and certainly could have been completed. Therefore, I have determined that inpatient psychiatric treatment services were medically necessary. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 40-year-old male who underwent gastric bypass in 2002. He has back pain and has been diagnosed with degenerative disc disease. The patient has excess skin in the abdomen, thighs, buttocks, and hips and reports skin rashes in the folds. The Health Plan has authorized an abdominoplasty for treatment of the patients excess abdominal skin. The patient has requested authorization and coverage for surgical removal of the excess skin in his thighs, buttocks, and hips. The Health Plan indicates the requested surgery is not medically necessary for treatment of the patients condition.There is no documented evidence to support the medical necessity of surgical removal of excess skin from the patients thigh, buttock, and hip regions. These procedures are usually considered cosmetic in nature. The patient has documented skin problems due to his excess abdominal skin, which should resolve with the abdominoplasty. The submitted documentation does not demonstrate the requested surgery is medically indicated to resolve functional impairments. For these reasons, I have determined the requested surgery 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 an eight-year-old male diagnosed in April 2000 with autism. He has been receiving speech therapy since 2001. He continues to have significant speech delays. As documented by his therapist, the patients vocabulary is between 40-50 words. The patient and his therapist have also been working on who statements with some success. At issue is whether continued speech therapy is medically necessary for treatment of the patients medical condition. Upon review of the submitted therapy notes since September 2004, there has been some improvement primarily in vocabulary and receptive and expressive language skills. However, in reviewing the most recent progress reports dated March 2005 and May 2005 there is no documentation showing discrete functional goals. In addition, the March 2005 evaluation relies on testing performed three months earlier. Similarly, the May 2005 progress report relies on testing performed six months earlier. Thus, no standardized testing has been provided which documents improvement. Based upon the information provided, a well-defined treatment plan and goals have not been established for this patient. Furthermore, individualized speech therapy has not been well documented in the medical literature to significantly improve autism. As such, continued speech 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 31-year-old male with generalized social phobia disorder. Based upon the information provided, it appears the patient does not wish to pursue pharmacotherapy. He has been receiving individualized psychotherapy since 2003. The patients provider indicates that although the patients symptoms have improved, he continues to require individualized psychotherapy. The Health Plan has determined additional psychotherapy is not medically necessary for treatment of the patients condition.Though it appears the patient has been making progress with psychotherapy, the acceptable and appropriate treatment for the patients social phobia also includes pharmacotherapy. The patient has declined pharmacologic treatment. The submitted evidence demonstrates the patient has already received 42 sessions of psychotherapy. There is no evidence the patient is experiencing acute adverse symptoms or comorbid medical problems. As such, there is insufficient evidence continued psychotherapy is medically indicated. 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 57-year-old female with a documented and accepted diagnosis of obstructive sleep apnea. Although she has used CPAP and felt better with its use, she has trouble with the mask fit and has had significant difficulty in the past tolerating a fixed pressure unit. She was given an APAP (auto-CPAP) unit as an alternative and reports increased compliance with this device. Authorization for payment of the APAP unit has been denied as not medically necessary.The issue of APAP vs. CPAP is being debated in the current literature. At this time APAP has not been found to be more efficacious than CPAP in the medical treatment of obstructive sleep apnea (OSA). Furthermore, the patient does not meet accepted criteria for consideration of APAP. As such, I recommend upholding the Health Plans denial because the disputed service is not medically necessary. This patient does meet criteria of intolerance of CPAP making her a candidate for a trial of BiPAP, which would be recommended as an appropriate alternative in this case.Based upon the information set forth above, I have determined the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a six-year-old female who has been receiving occupational therapy since 2001 for sensory integration and fine motor delays. A progress report from November 2002 reflects moderate sensory integration difficulties and mild fine skill deficits including difficulty buttoning and drawing shapes. Subsequent reports document poor trunk control. The patients therapist indicates the patient experienced improvement from moderate to mild deficits in sensory integration from 2002 to 2004.At issue is whether the therapy the patient received from September 2003 to May 2004 was medically necessary.In reviewing the literature regarding occupational therapy utilizing sensory integration for treatment of developmental delay, there are no controlled studies in support of the therapy. Though relevant papers describe theories, the authors conclude there is a lack of evidence supporting these theories. Thus, although sensory integration therapy is the primary tool used by occupational therapists in the developmental delay population, it is not evidence based. Furthermore, in the case of this patient, the goals defined in the submitted progress reports are not medically based. Most of the goals are educational in nature (e.g., stringing beads, picking up pennies, attention tasks, bouncing balls) and are not very objective. Moreover, the evaluations are one year apart and do not demonstrate significant gains over that year. The gains achieved could just as easily be explained by practice. Therefore, I have determined that 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: Overturned Decision of Health Plan

The records provided describe a now 30-year-old female managed by her rheumatologist for fibromyalgia. It is stated that the patient has failed various agents intended to improve her sleep. Because of unacceptable daytime drowsiness, the patient has been using Provigil since 2001 with apparently good results, improving her daytime energy, though fibromyalgia continues.The records provided demonstrate the patient was earlier treated with various appropriate agents, including Flexeril, Zanaflex, and trazodone, but daytime drowsiness and fatigue continued to interfere with work and school activities. It is stated that the patient has had significant improvement in daytime energy using Provigil 200 mg daily. Provigil is employed by many rheumatologists as a standard part of the approach to the fatigue associated with fibromyalgia. Furthermore, Provigil is also often utilized for fatigue associated with depression, which is similar to fibromyalgia-associated fatigue. Therefore, given the patients history of lack of benefit with the more usual agents for fibromyalgia, and her apparent long-term benefit, the use of Provigil 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 47-year-old male with chronic back pain and a history of opioid dependence. He has requested authorization and coverage for Subutex for pain control. The Health Plan has denied the patients request indicating the requested medication is not medically necessary for treatment of the patients condition.Review of the submitted clinical records documents a significant pain condition requiring treatment. There is documented evidence Subutex has been beneficial for this patient. Based upon the patients history and documented response to Subutex, continued use of Subutex is medically reasonable and appropriate and should be authorized. 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 58-year-old male who has advanced osteoarthritis in both knees. He has been treated with Synvisc injections and obtained significant pain relief. He has requested authorization and coverage for further Synvisc injections. The Health Plan has denied this request indicating the requested therapy is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. The patient has already received two courses of Synvisc injections. There is no medical justification for greater than two courses of Synvisc injections. There is no peer-reviewed medical literature supporting additional Synvisc injections in this clinical setting. Furthermore, additional injections of Synvisc are contrary to FDA recommendations. 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 54-year-old male with a diagnosis of ulnar neuropathy who had failed to respond to anti-inflammatory medications, physical therapy and time. Chiropractic care ensued and relief was slow but, nonetheless, reported by the patient. The Health Plan has denied coverage for the chiropractic therapy the patient received on the basis it was not medically necessary for treatment of the patients medical condition.As this patient failed to improve with a course of anti-inflammatory medication and a course of physical therapy, chiropractic care was medically reasonable and indicated. Chiropractic care is an appropriate treatment modality for a diagnosis of ulnar neuropathy. Furthermore, the submitted documentation demonstrates the patient experienced gradual improvement with chiropractic treatment. As such, I have determined that the therapy 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 44-year-old female with constipation predominant irritable bowel syndrome (IBS). She has responded to Zelnorm therapy and is seeking continued authorization for Zelnorm. The Health Plan has denied this request. As part of its denial the Health Plan has referred to the patient not meeting Rome II criteria.IBS is a clinical diagnosis based on subjective symptom assessment. The patient has altered bowel habits with abdominal discomfort  the hallmark of IBS and its diagnosis. The patient has responded to and benefited from Zelnorm therapy. The Rome II criteria were developed for and are used in research studies to ensure a uniform patient population is enrolled in a study. The Rome II criteria have not been recommended for everyday clinical practice or shown to be applicable/effective in everyday clinical practice. As such, they are not applicable or relevant to this case.The patient has received effective, beneficial therapy with Zelnorm. There is no evidence such therapy should be discontinued. Therefore, I have determined the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.