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

The patient is a 47-year-old woman with multiple sclerosis who has a functional electric wheelchair for her mobility. She has requested authorization for a manual  wheelchair as well. The Health Plan denied her request based upon a determination that the equipment is not medically necessaryThe patient has a functional electric wheelchair, which does duplicate the function of a manual chair and, indeed, extends her function because it can be used with increasing weakness.  The patient indicates that her old manual wheelchair is wearing out, but there is no documentation from her or her provider that explains why a back up manual wheelchair is necessary.  Since the electric wheelchair meets the patients mobility needs, the medical necessity of a manual wheelchair is not established. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old male who presented with severe bilateral leg edema, felt to be a combination of lymphedema and venous insufficiency.  A venous duplex study showed no evidence of deep venous obstruction.  The patient had not used conservative measures such as leg elevation, compression stockings, or exercise.  These measures were prescribed, as well as a pneumatic compression device.  The patient did not return to the provider to assess the results of the conservative therapies or the compression device. The patient has requested reimbursement for the cost of the pneumatic compression device.  The Health Plan denied his request based on a determination that the device was not medically necessary for the treatment of his venous stasis and lymphedema.Pneumatic compression devices or lymphedema pumps, are considered to be the `last resort` for managing lymphedema. It is generally held that symptoms must be severe and debilitating and conservative therapies must have been tried and failed before such a device is prescribed. Conservative therapies include limb elevation, custom compression garments, and exercise.  This patient apparently tried none of these therapies prior to the rental of the pneumatic compression pump.  The Medicare Coverage Issues Manual provides reasonable guidelines for determining the medical necessity of a pneumatic compression device. It states: Pneumatic compression devices are covered only when prescribed by a physician and when they are used with appropriate physician oversight, i.e., physician evaluation of the patient's condition to determine medical necessity of the device, assuring suitable instruction in the operation of the machine, a treatment plan defining the pressure to be used and the frequency and duration of use, and ongoing monitoring of use and response to treatment. The determination by the physician of the medical necessity of a pneumatic compression device must include: 1.The patient's diagnosis and prognosis; 2.Symptoms and objective findings, including measurements which establish the severity of the condition; 3.The reason the device is required, including the treatments which have been tried and failed; and 4.The clinical response to an initial treatment with the device. The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters, and the ability of the patient (or caregiver) to apply the device for continued use in the home.The patient never returned for a clinical assessment of the results of the pump and no post-treatment measurements were made to document the success of the therapy.  Therefore, I have determined the device 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 45-year-old female who presented with symptomatic varicose veins.  There is no documentation of any complications such as bleeding, ulceration, or thrombophlebitis. The patients primary care provider prescribed compression stockings in April 2006 as well as analgesics. No follow-up visit is documented; it is unknown if the compression stockings were successful in treating the patients symptoms.  The patient has requested authorization for a consultation with a vascular surgeon. The Health Plan denied this request based upon a determination that the consultation is not medically necessary.Compression therapy is the appropriate first line treatment for venous insufficiency.   A referral to a vascular surgeon is warranted when complications of varicose vein disease are present or conservative management (compression stockings) fails to adequately control the patients symptoms.  Neither complications nor failure of conservative therapy have been documented in this case.  Therefore, I have determined the requested service is not medically necessary for evaluation 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 65-year-old male with a PSA of 11.14 in September 2005, which decreased to 8.5 in January 2006. A transrectal ultrasound-guided prostate biopsy performed in November 2005 indicated he was benign on the right side; however, in 10% of the specimen from the left side there was a Gleason score of 4+3 for a total of 7 adenocarcinoma of the prostate. A bone scan showed no evidence of metastatic disease. Digital rectal examination in February 2006 revealed an enlarged but smooth prostate with no nodules. The patient has been found to have a stage T1c prostate adenocarcinoma, with a Gleason score of 7 (4+3).The Health Plan has authorized surgery, a laparoscopic radical prostatectomy, without robotic assistance. The patient wishes to have the procedure performed with robotic assistance. The Health Plans denial should be upheld. To date, there is insufficient peer-reviewed medical literature demonstrating that robotic assisted laparoscopic prostatectomy results in clinically superior outcomes. As such, the requested procedure is not medically warranted. The procedure offered by the Health Plan is within the standard of care for prostate adenocarcinoma, and is medically reasonable and appropriate. 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 56-year-old female with a history of pulmonary hypertension, emphysema and cardiomyopathy with an ejection fraction of 35% and an increase in her wedge pressure. No background data related to the patients diagnosis of emphysema is included and her hypertension (pulmonary) is described only as mild to moderate with no number value assigned.  The patients provider did not indicate a value for left ventricular end diastolic pressure and increased wedge pressure was not included as one of her diagnoses. The patients provider requested authorization for Revatio. The Health Plan denied the request based upon a determination that the medication is not medically necessary for treatment of the patients pulmonary hypertension.Significant pulmonary hypertension is seen in only about 5% of patients with COPD emphysema and typically does not require therapy. Sleep disordered breathing could also be a factor in the patients pulmonary hypertension but the issue is not discussed in the progress notes that were made available. It would appear at the very least that the patients left ventricular failure is partially responsible for her pulmonary hypertension. Based upon the information provided, 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 five-year-old male with a diagnosis of autism accompanied by receptive and expressive language delays.  He received speech therapy and auditory processing therapy from April 2005 through November 2005. The patients parent has requested reimbursement for the cost of the auditory processing therapy.  The Health Plan denied the request based on a determination that the therapy was not medically necessary for treatment of the patients receptive and expressive language delays.I have reviewed the available literature including a Cochrane review of auditory integration training (AIT). There is no evidence of functional benefit with AIT and the available data does not support the application of the therapy. Additionally, any suggestion of an improvement in language skills related to the auditory processing therapy is questionable as the patient was receiving concomitant speech therapy, which could be the sole basis for his gains. 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

The patient is an 18-year-old female with approximately a four-year history of binging and purging with notable reduction in body weight from a high of 137 pounds to 96.4 pounds by the point of admission to residential treatment in August 2005.  The patient had also engaged in some minor self-abusive behaviors of cutting on herself on two occasions and was noted as quite obsessed about her boyfriend. Her admission lab work revealed evidence of mild malnutrition, dehydration, and hypokalemia. During her stay, she was treated with a number of psychotherapies as well as Prozac 20 mg, which she tolerated well. The patient engaged fully in the various therapies and appeared to have no problem complying with the dietary demands of the program.  All told, she was seen as having sustained a good deal of improvement by the end of her stay in October 2005, such that she weighed 108.2 pounds, with zero body image distortion.  At issue in this case is whether the residential treatment services from September 2005 through October 2005 were medically necessary for treatment of the patients medical condition.There is no question that the patient suffered from bulimia nervosa.  However, all of the progress notes in September 2005 indicate the patient had experienced significant improvement by that point. The issue of zero body image distortion is also noted in several of the progress notes during the period at issue. The patient was eventually stepped down to a continuation program affiliated with the residential program; there is no evidence that such a step-down was not medically appropriate as of September 2005.  Accordingly, I have determined the services at issue were 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 who was diagnosed with mild to moderate sleep apnea in August 1994 with a respiratory disturbance index (RDI) of 32.5 events per hour.  The patient indicates she has used CPAP with nasal pillows since that time.  A follow-up sleep study was completed in August 2005. The patient believes the results of the study were inaccurate. She has requested authorization for replacement supplies for her CPAP machine. Based on the results of the August 2005 study, the Health Plan has determined CPAP therapy is not medically necessary.The patient has a documented history of obstructive sleep apnea and associated symptomatology. She was started on CPAP therapy with good results. It is medically reasonable and appropriate to continue this treatment, which has proven effective for the patient in the past.  As such, the requested CPAP supplies are medically warranted and should be authorized. Accordingly, I have determined the requested supplies 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

This patient is a 55-year-old woman with rheumatoid arthritis involving both of her knees; apparently the right knee is worse than the left. She has a history of severe right knee pain and was treated with Supartz injections in June 2003, July 2004 and April 2005, and responded very well according to her orthopedist. At this point in time, her pain has returned and she has requested authorization for a repeat series of injections.  The Health Plan denied this request on the basis that Supartz injections are not medically necessary for treatment of her arthritis.The patient is relatively young and has severe arthritis in her right knee.  Although she will eventually require knee replacement, Supartz injections appear to give her nearly one year of relief from her symptoms. An additional series of Supartz injections is appropriate for this patient as the efficacy is well established and the therapy will allow the postponement of surgical intervention. Therefore, I have determined 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 50-year-old female with a body mass index of 53. She has requested authorization for laparoscopic adjustable gastric banding (Lap-band). She reports comorbid conditions including asthma, depression, gastroesophageal reflux disease, back pain and obstructive sleep apnea. The patient has completed a psychological evaluation and was found to be an acceptable candidate for bariatric surgery. At issue is whether the requested Lap-band procedure is medically necessary for this patient.Current scientific literature does not demonstrate that Lap-band surgery results in any clear benefit for any specific group of patients. Most of the scientific data available have small numbers, short-term follow-up, and unacceptable success rates. Thus, gastric banding is less efficacious than alternative weight loss procedures and is not medically warranted in this case. 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 33-year-old male who is undergoing evaluation for sleep apnea.  He has complaints of loud snoring, disrupted breathing while sleeping, feeling unrested upon awakening, memory difficulties and sexual dysfunction.  Comorbid conditions include hypertension, obesity and depression.  The patients request for inpatient polysomnography has been denied by the Health Plan as not medically necessary.The patient does meet the clinical criteria for evaluation of a possible sleep disorder by polysomnography. However, an overnight stay in a hospital is not necessary if the option of an adequate home sleep study is available for diagnosis.  The home sleep study should include the monitoring of at least four parameters, not simply pulse oximetry or airflow.  If the patient needs support to ensure that the study is performed correctly, an attendant should be provided to assist with the setup of the equipment and possible monitoring.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for evaluation 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 66-year-old male who is diabetic and has a non-healing foot wound.  The providers notes are difficult to read, but it is apparent that the wound is deep and beefy red and there is no indication of infection.  The pedal pulses are not palpable and it is not known if they can be assessed with Doppler. No ankle-brachial index or toe pressure measurements were apparent in the medical record provided for review.  The patient has requested authorization for treatment of his foot wound with Regranex 0.01% gel. The Health Plan denied his request based upon a determination that the therapy is not medically necessary.The manufacturer of Regranex lists the indications for its use as the treatment of lower extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond and have an adequate blood supply.  An adequate blood supply is important in order for the growth factors in Regranex to be effective, and studies showing the clinical benefits of treatment with Regranex required that the wound have an adequate blood supply. In this instance, the provider documents that the patients pedal pulses are not palpable.  This could be an indication that the patients blood supply is not adequate for wound healing. Objective physiologic tests such as the ankle-brachial index and toe pressure measurements that would provide confirmation of the adequacy of the blood supply are not included in the record. As such, it appears that the blood supply is inadequate and the use of Regranex would be considered off-label.  While off-label usage does not preclude medical necessity, a specific justification for such use should be provided.  In this setting neither the adequacy of the blood supply nor a special circumstance justifying the use of Regranex have been established.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: Overturned Decision of Health Plan

The patient is a 52-year-old male who has a complicated history of hepatitis C and complaints related to the hepatitis C including cryoglobulinemia with renal involvement, neuropathy, congestive heart failure, and skin involvement. The patient has ischemic colon injury, requiring surgery. The patient has failed treatment with interferon, plasmapheresis, and Cytoxan. It is felt by his hematologist and hepatologist that he requires rituximab as salvage therapy. A review of the patients records and applicable literature demonstrates the patient has attempted all appropriate treatments. Based upon the patients available evidence and the patients history the next in line agent to attempt would be rituximab. The evidence presented indicates the patient may have a smoldering B-cell lymphoma; if this is correct, rituximab would clearly be indicated. Regardless, as set forth above the patients history and available evidence demonstrate rituximab is appropriate and indicated. Therefore, I have determined 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 seeking bilateral breast reduction surgery. The patient has moderately hypertrophic breasts, but the anticipated volume is below the 5th percentile on the Schnur table. The plastic surgeons note describes conservative care, but no evidence documenting such care has been submitted. In addition, no evidence confirming a history of long-standing musculoskeletal pain has been provided.Due to the small volume to be resected, medical necessity for the proposed breast reduction cannot be established. This patients history of back, shoulder and neck pain are consistent for symptomatic macromastia; however, no objective evidence verifying this history has been submitted. Photocopies of photographs confirm moderately large, ptotic breasts. The proposed resection of 275 to 350 grams per breast is quite small and may not correct the patients symptoms. According to Schnur, et al., a breast reduction of 575 grams per side for this patient would be required to meet the 22nd percentile for weight of reduction. In Schnurs study, resection weights above the 22nd percentile indicated that the patients motivation is purely medical. The planned resection of 275 to 350 grams for this patient is below the 5th percentile guideline of 367 grams per breast. According to the Schnur data, this would indicate the procedure is not medically necessary. While the question of what volume of resection is adequate to correct patient symptoms remains controversial, the Schnur data would suggest that the planned reduction is small enough that the procedure should be considered cosmetic. Based upon accepted criteria, a breast reduction of 275 to 350 grams per breast would not be considered medically necessary for this patient. Furthermore, in the absence of any documentation confirming a history of long-standing musculoskeletal pain and the failure of conservative care, authorization of the requested procedure cannot be justified.Based upon the information set forth above, I have determined the requested procedure 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 71-year-old male who has requested authorization and coverage for Byetta. He has had type II diabetes for more than 10 years. He has neuropathy, renal impairment and retinopathy. The patients hemoglobin A1c dropped from 7.2% to 6.5% in June 2005. In September 2005 he was started on Byetta 5mcg twice daily. In January 2006 the dose was increased to 10mcg twice a day. He has lost 4 pounds since starting Byetta. According to the physicians notes in February 2006, the patients blood glucose values have not improved. The patient is currently using Byetta 10mcg twice daily, glipizide 3.5mg in the morning and 5mg with dinner and Lantus insulin 20 units at bedtime. The patients physician states that the patient has substantial insulin resistance.At issue is whether Byetta is medically necessary for treatment of the patients medical condition.In clinical trials, Byetta was indicated only in patients who had a hemoglobin A1c over 7%. This patient had a hemoglobin A1c of 6.5% at the time of initiation of Byetta. Thus, he was at goal according to the guidelines of the American Association of Clinical Endocrinologists and the American Diabetes Association. His blood sugars have not substantially improved since being placed on Byetta. Byetta improves postprandial blood glucose and does not improve insulin resistance. This patient appears to have insulin resistance. For these reasons, 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: Overturned Decision of Health Plan

The patient is a 53-year-old woman with osteoarthritis who has undergone a series of Synvisc injections on several occasions in order to alleviate her knee pain. A request has been made for repeat Synvisc injections. The Health Plan has denied this request on the basis that the requested injections are not medically necessary for treatment of the patients knee pain.The patient has achieved significant pain relief with Synvisc. There have been no documented side effects or other complications from the therapy. She is attempting to avoid knee replacement surgery at this time. Repeat Synvisc injections are medically reasonable and appropriate at this time to alleviate pain and postpone surgical intervention. Therefore, I have determined the requested injections are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.