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

The patient is a 54-year-old male with a prolactin-secreting macroadenoma who is status post trans-sphenoidal resection several years ago. He has a residual tumor measuring 2.7cm in size with no apparent increase in size since the surgery. He is taking Dostinex 2mg twice a week to control prolactin secretion.  The patients prolactin level was 242 in June 2004. His prolactin level rose to 376 in November 2004 possibly due to non-compliance in taking the Dostinex as prescribed. The patients prolactin level dropped to 189 in March 2005 but rose again to 294.8 in August 2005 and 346.6 in November 2005. The patient was found to have blurriness in his right eye and galactorrhea when last seen by his endocrinologist. The treating physician recommended increasing Dostinex to 2mg three times a week and referred him for visual field testing.  The Health Plan has denied the patients request for Dostinex 2mg three times per week based upon medical necessity and has indicated it will not continue to authorize the medication at a frequency greater than once per week.This patient has fluctuating prolactin levels. His highest level of 376 in November 2004 was probably due to non-compliance. In March 2005 his level dropped to 189, which appears to be his baseline according to the treating physicians notes. Although the patient has a large residual tumor it has not grown and is unlikely to be the cause of his high prolactin level in November 2005. Because of the large residual tumor Dostinex should be continued at 2mg twice weekly for an additional 12 months. If the dosage is decreased to 1mg twice per week before the reason for the high prolactin levels is clear, it will introduce an additional variable and confound the clinical evaluation.  The treating physician should closely monitor compliance during the next 12-month period so that non-compliance can be ruled out as the cause of the recently high prolactin levels.  If the patients prolactin level returns to his baseline at this dosage and he can be maintained at the lower level, a cautious trial of 1mg twice per week would be indicated.  If the prolactin level continues to rise or if a visual field defect is present, the patient should continue at the dosage of 2mg twice per week and be referred for the appropriate neurosurgical evaluation.Based upon the information set forth above, I have determined although the requested dosage of Dostinex 2mg three times per week is not medically necessary for treatment of the patients medical condition, Dostinex 2mg twice per week is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This patient is a 50-year-old male who had a colonoscopy at age 49 because of his family history (his father had colon cancer at age 72). The patient was not symptomatic and had no complaints. The Health Plan has denied reimbursement for the colonoscopy on the basis it was not medically necessary.As set forth in the 2003 American Gastroenterological Association (AGA) guidelines for colorectal cancer screening, a colonoscopy was medically indicated in this case. The patients father was diagnosed with colorectal cancer at age 72. The AGA guidelines recommend colonoscopy screening at age 40 for patients with a first-degree relative affected with colorectal cancer at or above the age of 60. Therefore, I have determined the colonoscopy at issue was 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 59-year-old woman with right-sided foot drop apparently as a complication of total hip replacement surgery in March 2005.  There is no documentation of upper extremity weakness in the record provided. The patient has difficulty maneuvering a standard wheelchair in the home and has requested a power wheelchair.  The Health Plan has denied the request based upon their determination that it is not medically necessary.The patient contends that she needs a power wheelchair because it is difficult to turn the standard wheelchair.  Generally, a manual wheelchair has the same turning radius as a power wheelchair, and in some cases the turning radius of the standard chair is tighter. The patient apparently has a severe right foot drop, but according to the records she has the ability to ambulate within the home for a distance of up to 70 feet with the AFO and a walker. It is anticipated that ambulation would improve with time and practice. There is no documentation of upper extremity weakness, which would preclude the use of a manual wheelchair.  Therefore, I have determined 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: Upheld Decision of Health Plan

The patient is a 55-year-old female who has requested reimbursement and continued authorization and coverage for vitamin B12 and hormone therapy injections. The Health Plan has denied this request stating that the therapy at issue was/is not medically necessary for the treatment of the patients condition.Review of the submitted clinical information indicates the patient has been experiencing fatigue, headaches, sleep disorder, anxiety and depression. There is no documentation in the records that she has had any hot flashes or night sweats, which usually occur in patients who have symptoms due to menopause. In the absence of such symptoms, it is less likely that the patients condition is related to menopause. Additionally, this would explain why oral medication, patches and the vaginal ring have not been effective.Current standard of practice for patients such as this patient is to give hormone replacement therapy for a limited amount of time in order to improve the quality of life. It is considered undesirable to continue such therapy for an extended period. Furthermore, the use of estrogen in an injectable depot form is not recommended because it does not administer the lowest dose necessary. Moreover, there is no indication for depot testosterone, which may have some side effects such as liver problems. Finally, there is no indication for vitamin B12 injections in the management of this patients symptoms. Based upon the information set forth above, I have determined the therapy at issue was/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 55-year-old man with a diagnosis of end-stage arthritis of the ankle joint. He has requested authorization and coverage for fresh osteochondral allografting to alleviate his pain. The Health Plan has denied this request on the basis that the requested procedure is not medically necessary for treatment of the patients medical condition.Fresh osteochondral allografting is not within the standard of care for treatment of the patients condition. End-stage arthritis of the ankle joint is treated with medications, injections, bracing, and eventual arthrodesis if the pain persists. For some patients, arthroplasty is an option. While allograft procedures have been helpful for smaller lesions, severe arthritis requires significant coverage. There are no long-term, prospective studies available outlining the risks, benefits, complications or outcomes of fresh osteochondral allografting in this clinical setting. 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 47-year-old woman who reports that she has Lyme disease complicated with infections of Mycoplasma and Babesiosis diagnosed in March 2005. There is no stated history of a tick bite or rash.  One of the patients providers noted that she was deteriorating off IV Rocephin.  Another of her providers indicated that her symptoms include fatigue, poor stamina, muscle pain, headache, blurry vision, poor balance, confusion, forgetfulness, poor short term memory, poor attention, problems absorbing new information, disorientation, mood swings and disturbed sleep. Her treatment was documented to include Doxycycline, Biaxin, hydroxychloroquine, Cipro, IV Rocephin and Zithromax.  The records provided include visits to both physicians between August and December 2005. These records detail symptoms and treatment as noted above.The patient is seeking reimbursement for antibiotic therapy beyond September 2005 as well as authorization and coverage for future IV therapy. The Health Plan has denied this request on the basis that the therapy at issue is not medically necessary.The submitted clinical evidence does not include any documentation of physical examination findings suggestive of Lyme disease (e.g., evidence of arthritis or CNS disease). Laboratory test results disclose a positive IgG for Mycoplasma pneumoniae (indicating a past Mycoplasma infection), a Babesia microti IgG of 1:20 (at the lowest level of positivity and not meaningful as a single value), and a Lyme IgG Western Blot with three positive bands (negative by CDC criteria, which requires five positive bands).  Even if there was convincing evidence of Lyme disease, there is no peer-reviewed data supporting more than 30 days of IV antibiotic treatment for Lyme disease in any form.Based upon the information set forth above, I have determined the therapy at issue was/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 76-year-old man who was diagnosed with prostate cancer. His PSA was 7.0 in April 2005 and biopsies in June 2005 revealed a high volume of tumor. The left base had a Gleason score of 4+5 with 13% involvement, right apex had a Gleason score of 4+4 with 44% involvement, right mid had a Gleason score of 4+5 with 100% involvement and right base had a Gleason score of 4+5 with 100% involvement.  Physical exam described a firm nodule in the right gland. Ultrasound revealed tumor extension through the gland and seminal vesicle involvement bilaterally. The patient was started on hormone therapy in July 2005. The patient requests treatment with external beam radiation therapy (EBRT) with gold seed implantation followed by high-dose-rate brachytherapy (HDR-B). The Health Plan has denied authorization and coverage based upon their determination that the requested therapies are not medically necessary.This patient has advanced disease and a very high-grade tumor. His PSA is 7.0, Gleason score 9 and he is stage T3b Nx Mo.  The Partins Tables suggest an incidence of pelvic lymph node involvement as high as 29%. Hormone therapy (started in July 2005) is the most effective treatment at this time and both sides agree with that approach, but unfortunately, the tumor does not always respond. To determine the best course of treatment for the patient, the PSA should be rechecked and a digital rectal examination (DRE) should be performed.  If the patient has had a good response to hormone therapy and DRE shows no palpable tumor, HDR-B is not medically necessary. If however, there is still significant tumor volume, HDR-B is medically necessary and should be authorized.  EBRT with gold seed implantation is not medically necessary regardless of the clinical response to hormone therapy.  With a good response to hormone therapy, EBRT is not required.  If there has not been a good response to hormone therapy and HDR-B is required, the role of EBRT is no longer significant and HDB-R is the conformal therapy of choice.  Based upon the information set forth above, I have determined that EBRT with gold seed implantation is not medically necessary for treatment of the patients medical condition. In addition, I have determined that HDR-B is not medically necessary for treatment of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time. If the results of a PSA recheck and DRE reveal significant tumor volume, HDR-B should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 46-year-old female less than one year postoperative from gastric bypass surgery.  Her weight had decreased by 168 pounds as of October 2005.  The patient is troubled by macerated skin under the pannus and multiple regions of excess skin.  She is requesting authorization for panniculectomy and body contouring procedures. The Health Plan has denied the request citing a lack of medical necessity.The record submitted for review included limited medical records, a note from a plastic surgeon, copies of photographs of the patient, and letters from the patient. From these documents there is evidence the patient is still in the process of weight loss with early hanging of excess skin. In October 2005, it was noted by the consulting specialist that the patient was on her diet regimen and was losing approximately one pound per week. There is however, no evidence of medical necessity for the proposed procedures at this time. The Health Plan is correct in suggesting that the patient await the complete results of the bypass procedure prior to consideration of surgical intervention. Therefore, I have determined the requested procedures 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 52-year-old woman with a long history of allergic asthma. She has been receiving monthly treatment with Xolair.  The patients provider reports the patient had a decreased need for albuterol and improved spirometry while using Xolair.  The patient experiences adverse side effects from Advair. Spirometry from September 2005 demonstrates an FEV-1 65% of predicted and an FEF 35% of predicted.  Continued use of Xolair has been recommended for treatment of the patients asthma. The Health Plan has denied coverage for the requested medication indicating it is not medically necessary for treatment of the patients medical condition.Review of the submitted clinical records indicates Xolair is medically indicated for the patient. She has allergic asthma with a low FEV, (57% in July 2005 was 57%, and 65% in September 2005, which is diagnostic of severe airway obstruction). Additionally, her previous response to Xolair therapy at 150 mg SQ every 4 weeks was documented in January 2005, April 2005 and September 2005. There is a note indicating good response on Xolair. Although this response is not necessarily reflected in her FEV, it is reflected in reduction in serious adverse events such as urgent care visits, severe exacerbations and hospitalizations. Furthermore, the patients IqE of 55 is within the recommended treatment range. Moreover, the submitted records indicate maximum therapy with oral steroid use. The patient has documented intolerance to inhaled corticosteroids.For these reasons, 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 48-year-old male with a weight of 290 pounds and a body mass index (BMI) of 38. His comorbid conditions include Type II diabetes mellitus, hyperlipidemia, hypertension, obstructive sleep apnea, and gastro-esophageal reflux disease (GERD). He has completed psychological and nutritional evaluations and was deemed an appropriate candidate for weight loss surgery. He has requested authorization and coverage for laparoscopic adjustable gastric banding (Lap Band) which the Health Plan has denied based upon their determination that it is not medically necessary for treatment of the patients morbid obesity.The Lap Band procedure has been promoted as a low risk, easy operation to perform. Patients can however, experience complications after surgery with this procedure. Most complications are not serious but some may require re-hospitalization and/or re-operation. A clinical study with 3-year follow-up conducted in the United States reported that 88% of the 299 patients had one or more mild to severe adverse events. Nausea and vomiting were the most common post-operative complications (51%), as well as GERD (34%), band slippage/pouch dilatation (24%) and stoma obstruction (14%).  In the study, 25% of the patients had their band systems removed, most often following an adverse event.   Additionally, tightening of the band is required to promote weight loss and that process has been shown to worsen GERD, a pre-existing comorbid condition in this patient.I would agree with the Health Plan that the patient should consider other surgical procedures for treatment of his obesity. 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: Overturned Decision of Health Plan

The patient is a 54-year-old female with multiple medical problems who was treated for arteriosclerotic cardiovascular disease with stent placement in August 2005. She is anti-coagulated with aspirin and Plavix.  The patient now has an infected tooth with a draining fistula requiring urgent surgical treatment. This procedure would typically be carried out in an oral surgery office.  The patients oral surgeon however believes that she remains at risk for MI and stent occlusion and has requested authorization to perform the procedure under general anesthesia in a hospital operating room. The Health Plan denied authorization based upon a determination that the requested services are not medically necessary.The standard of care dictates the avoidance of elective oral surgery and ambulatory in-office general anesthesia or drip sedation for at least 6 months after stent placement when possible.  This patient has an acute condition and surgical intervention cannot be delayed.  There does not appear to be any dispute on that issue.  It is the judgment of her treating oral surgeon that the risks related to IV sedation or general anesthesia with oral surgery carried out in the office setting, are unacceptable at this time.  I concur that this procedure should be carried out in a hospital setting with IV sedation or general anesthesia and appropriate cardiac and vital sign monitoring. Treatment facilities for stent occlusion or MI should be immediately available. Although the risk for cardiac complications maybe small, a treatment risk remains in this American Surgical Association (ASA) class II or class III patient and the risks associated with treatment in an oral surgery office are significant enough to contraindicate an office procedure at this time.Based upon the information set forth above, I have determined the requested services are 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 female said to have mixed inflammatory and osteoarthritic joint problems and diagnosed by her rheumatologist with rheumatoid arthritis (RA). She has been followed by the rheumatologist since 2001 and is maintained on combinations of sulfasalazine, various non-steroidal anti-inflammatory drugs (NSAIDs), Fosamax for osteoporosis, and pain medications for low back pain. She is apparently stable at present on this regimen. Her Health Plan has denied authorization for follow-up care with her rheumatologist at six-month intervals based upon their determination that these services are not medically necessary.Most rheumatologists will see new patients with RA at intervals of one to two times per month while the diagnosis is being clarified and medications are evaluated. Once stable, a patient will typically be seen at intervals of two to four months. Regular follow-up by a rheumatologist is necessary to assess the status of a patients RA, to determine if significant joint damage is occurring despite seemingly effective treatment, to assess whether current medications remain appropriate and in optimal dosages, to determine if medication side-effects are occurring, with or without the patients awareness, and to determine whether other or newer agents might be necessary for optimal treatment. It is also the responsibility of the rheumatologist to separate the patients RA from other musculoskeletal problems in order to avoid unnecessary, inappropriate, or dangerous interventions.The recommendation that this patient see her rheumatologist at intervals of one to two years falls outside the standard of care for rheumatologic practice.  The patient should be followed by a rheumatologist at four to six-month intervals for the reasons noted above.  Therefore, I have determined the requested services 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 51-year-old female with a history of headaches, diagnosed as muscular tension headaches. The headaches have apparently been disabling. The patients provider indicates the patient has failed treatment with Relpax, and is currently taking Zoloft, Depakote, clonazepam, Seroquel, lisinopril and Skelaxin. It has been recommended that the patient undergo a trial of botulinum toxin injections. The Health Plan indicates the requested therapy is not medically necessary for treatment of the patients headaches.Based upon the clinical information provided, the patients degree of disability is unknown. It is possible the patient is experiencing chronic migraine rather than muscular tension headaches. Although there is no significant evidence that botulinum toxin injections are effective for the treatment of tension type headaches, there is data to suggest that the injections are beneficial for patients with migraine headaches. In any event, it appears that preventative therapies have not been exhausted in this case. Additional attempts at conservative therapy are indicated prior to consideration of botulinum toxin injections. 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: Overturned Decision of Health Plan

The patient is a 58-year-old female with stage IIIC, high-grade papillary serous ovarian cancer diagnosed in January 2002.  Her CEA-125 was 1749 and she underwent debulking and staging surgery in February 2002.  The patient received several cycles of chemotherapy and her CEA-125 decreased to 10.9 and a CT scan indicated she was disease free.  At issue is whether the PET scan of September 2005 was medically necessary for evaluation of the patients medical condition.Upon review of the submitted clinical evidence, the PET scan at issue was medically appropriate and indicated for evaluation of the patients clinical status. The PET/CT scan was invaluable in answering the questions regarding the extent of the tumor burden. The information gleaned was essential in avoiding unnecessary surgery. Therefore, I have determined the PET scan at issue was medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.