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

The patient is a 25-year-old woman who was seen by her physician on 4/23/04 and 7/29/04. At both visits, the patient indicated she had thickened, yellowed toenails. This was confirmed in the physicians physical examination. The patient reports that her toes are painful, making it difficult for her to walk. A fungus culture dated 8/27/04 reported Bipolaris species and Penicillium species. The patients provider recommended treatment with Lamisil. The Health Plan has determined the requested medication is not medically necessary for treatment of the patients medical condition.The patient has painful onychomycosis. Due to the pain, she experiences difficulty walking, which is a functional impairment. The fungus culture grew out Penicillium and Bipolaris species, two organisms that are opportunistic fungal contaminants probably secondary to the deterioration of the nails. Contaminants grow more rapidly in culture than pathogens and therefore, mark the presence of pathogens. Thus, though they may not be apparent, pathogens are present is this culture. As such, treatment with Lamisil is medically indicated for treatment of the patients medical condition.Based upon the information set forth above, 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 50-year-old perimenopausal female found to have primary hyperparathyroidism in 2001. She has had two unsuccessful neck surgeries suggesting the likelihood of a substantial mediastinal adenocarcinoma. She has many symptoms, which are disabling. Her symptom complex has both usual (nausea and fatigue), and unusual (bone pain and anxiety) components. The patient has received the drug Sensipar, approved by the Food and Drug Administration for treatment of secondary hyperparathy, with normalization of her calcium and resolution of her symptoms. The Health Plan has determined that Sensipar is not medically necessary for treatment of the patients medical condition.Review of the submitted evidence indicates the patient has had two unsuccessful neck explorations. The neck is where 90 percent of primary hyperparathyroid causing adenomas are found. The mediasternum is the next most common site. Thus, further surgery would involve major chest surgery including the splitting of the sternum. Morbidity, short- and long-term, of surgery is substantial and mortality though infrequent is not inconsequential.The evidence for benefit of Sensipar in treatment of secondary hyperparathy is compelling and the limited data currently available for primary hyperparathy is equally impressive. The drug appears to be effective and safe for at least moderate lengths of use. Chronic primary hyperparathy is not a benign disease, especially in menopausal women with significant long-term risk of ulcer disease, hypertension, nephrolithasis, and osteoporosis with fractures.Therefore, in weighing the risk/benefit ratio of Sensipar versus surgery or no additional treatment, it appears treatment with Sensipar is the optimal choice. As such, 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

This patient is a 78-year-old female who is requesting a surveillance colonoscopy. She has a history of prior colonoscopies. Polyps were apparently found on those exams. She also reports a significant family history of colon cancer. The Health Plan has determined a colonoscopy is not medically necessary for evaluation of the patients medical condition.The patients family history is irrelevant as she already has undergone a screening exam at least once if not twice in the last ten years and was not found to have cancer. What are determinative in this case are the findings of prior examinations, (i.e., if adenomatous polyps were present on prior exams, and if so, the size and number of lesions present). These results will determine the appropriate follow-up interval. If adenomas were found on the patients last exam, a follow-up exam five years later is warranted as long as the exam was a high-quality study and the patients general health supports further surveillance. If no adenomatous polyps have ever been detected then no further screening for colorectal neoplasia may be needed (or at least not for ten years) as the patient had no neoplasia by age 74 and the likelihood of development of neoplasia that will affect her in her lifetime is remote. Therefore, I have determined that the requested colonoscopy 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 39-year-old male who was previously diagnosed with borderline personality disorder, polysubstance abuse, and post-traumatic stress disorder with several inpatient hospitalizations for depression and suicidality (one from 8/27/04 to 9/16/04 and the most recent from 10/11/04 to 10/15/04). Inpatient stays have often been preceded by use of amphetamine as well as alcohol. The stays themselves are marked by the patients dramatics and disgruntlement. The last hospitalization ended in the patient leaving against medical advice. At that point, he was offered different options including intensive outpatient treatment, residential placement, partial hospitalization, and dialectical behavioral therapy (DBT), all of which he refused, demanding instead to leave immediately. His psychiatrist for both the first and second hospitalization noted, his axis II personality disorder has dominated his clinical course, the same as during previous hospitalizations. Elsewhere, he was noted to be very manipulative, demanding, attention-seeking, and was emotionally labile. He was also exhibiting self-defeating and self-destructive behavior by pushing away help and treatment offered to him. Finally, he was said to be inappropriate and intrusive and did not follow the instructions of the group coordinator in some of the groups so he was dismissed from a couple of the groups. At the time of his discharge against medical advice, he was not suicidal and was discharged with a regimen of Lexapro 10mg and Seroquel 25mg.The Health Plan has denied the patients request for individual weekly psychotherapy suggesting that he pursue treatment in a chemical dependency recovery program prior to undergoing psychotherapy.Review of the patients records indicates that he has only been marginally dedicated to treatment of any kind. The patients contention is that he requires out-of-plan therapy. However, there is no evidence that the Health Plan cannot or will not provide him with capable psychiatric services. The Health Plan recommends the patient successfully complete a chemical dependency recovery program prior to psychotherapy. It is within the purview of the Health Plan to decide on the optimal ordering of how services ought to be offered, particularly given the patients character pathology. It is not unreasonable, for example, for the Health Plan to mandate that the patient stop abusing amphetamines and alcohol before more meaningfully engaging in psychotherapy. As such, individual weekly psychotherapy is not medically warranted at this time.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: Upheld Decision of Health Plan

The patient is a 51-year-old woman with a history of obesity, hypertension, elevated cholesterol and a back injury for which she underwent fusion surgery. She underwent an EBCT scan on 11/4/02 to assess for coronary calcification. At that time, there was no history or documentation of any potential anginal discomfort. The Health Plan has denied coverage for the EBCT scan on the basis that it was not medically necessary for evaluation of the patients medical condition.In this circumstance, the patient has a few cardiac risk factors such as obesity, hypertension, and elevated cholesterol, but no symptoms to suggest an active coronary process. Current guidelines already exist and are being continually updated by expert communities in the field pertaining to risk factor modification and treatment. To date, these guidelines do not incorporate routine use of EBCT in this patients population. In addition, there has been no incremental value demonstrated for EBCT beyond that already achievable by a combination of current clinical risk indices and stress testing (when necessary and indicated). Therefore, I have determined that the EBCT scan at issue was 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 59-year-old man who has been diagnosed with T1c prostate cancer with Gleason score of 3+3=6 and a PSA of 6.8. Biopsy results showed 5-10% involvement in 6 out of 12 specimens. Most of the tumor is on the right side where 5 out of 6 biopsied specimens contain 5-10% tumor.  Metastatic workup (including a bone scan, and CT scans of the abdomen and pelvis) was negative. Based on Partins tables, the chance that the tumor is confined to the prostate alone is 75%, the chance of capsular involvement is 24%, and the chance of seminal vesicle involvement is 2%. No involvement of the pelvic lymph nodes was described. In April 2004, the patient received Lupron. His PSA dropped to 3.4 in July 2004. At the recommendation of his radiation oncologist the patient prefers to receive proton beam therapy. The Health Plan has denied authorization and coverage for proton beam therapy on the basis it is not medically necessary for treatment of the patients medical condition.Review of the submitted records reveals most of the patients tumor is on the right side with only 5-10% involvement. This volume of tumor is small enough to be highly curable by conventional radiation therapy. Lupron therapy has further reduced this volume of tumor making it more likely to be of curable nature with any form of radiation therapy including external beam therapy. Based on these findings, there is no medical indication for proton beam therapy. The patient can be effectively treated with other forms of radiation 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: Overturned Decision of Health Plan

The patient is a 54-year-old male with localized T1c prostate cancer. The patient has decided to pursue radical prostatectomy for treatment of his prostate cancer. The patient wishes to have this procedure performed using the laparoscopic technique. The Health Plan denied authorization and coverage for a laparoscopic radical prostatectomy on the basis the requested procedure is not medically necessary for treatment of the patients prostate cancer.Laparoscopic radical prostatectomy has proven to be safe and effective for the treatment of prostate cancer. It has demonstrated similar oncologic results to open prostatectomy. The laparoscopic procedure has advantages over the open procedure in that it involves reduced blood loss, less pain, and more rapid recovery (short- and long-term) compared to open surgery. It appears the patient is an appropriate candidate for laparoscopic radical prostatectomy. In light of the advantages of the laparoscopic procedure compared to open surgery, the laparoscopic procedure is medically appropriate and indicated for this patient. 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 an eight-year-old female with an inoperable brain tumor who is status post ventriculoperitoneal shunt implantation. The patients parent has requested authorization and coverage for a referral to a pediatric neurosurgery capable facility for a monitoring MRI. The Health Plan has denied her request on the basis that the requested referral is not medically necessary.There is no medical indication for the patients monitoring MRI to be performed at a facility with an on-site pediatric neurosurgeon. Medically reasonable and appropriate services have been authorized by the Health Plan. There is no evidence to suggest the presence of a neurosurgeon at the MRI facility is medically warranted. Therefore, I have determined that the requested referral 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

This patient is a 12-year-old male with a diagnosis of autism with significant speech delays including severe moderate to severe language processing and auditory memory defect. The patient has difficulty in semantic organization and word finding. He has been receiving speech therapy for six years. The speech therapist has requested authorization and coverage for continued speech therapy services. In addition, a request has been made for coverage for the patients previous speech therapy. The Health Plan has determined that speech therapy has not been medically necessary for treatment of the patients medical condition since July 2003.Review of the relevant medical literature reveals there are no placebo-controlled, blinded clinical trials evaluating speech in autism. However, standard of care for patients such as this patient is speech therapy to treat their language skills. The submitted documentation provided by the patients speech therapist provides objective clinical data (i.e., CIEF-3, TOPS, LPT), which reflect that this patient has been making slow, steady progress over a two-year period ending in July 2004. As such, the speech therapy the patient received since July 2003 was medically indicated. Furthermore, given the chronic nature of autism, the patient can be expected to continue to show improvement with additional speech therapy. Therefore, the patient should continue to receive speech therapy two times per week, with re-evaluation every six months. Therapy should continue until objective data verifies a plateau of skills or the deficient skills fall within normal. 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 49-year-old male who has been experiencing marital problems. The patient has been receiving psychotherapy since January 2003. The patient has also been in marriage counseling. The submitted notes indicate the patient has been diagnosed with adjustment disorder. A request has been made for continued psychotherapy sessions. The Health Plan has determined the requested therapy is not medically necessary for treatment of the patients medical condition.The Health Plans denial should be upheld. Review of the submitted treatment notes reveals no medical justification for continued therapy. The patient has been diagnosed with an adjustment disorder, which is a condition typically considered appropriate for brief interventions. There is no indication of any serious symptoms in the submitted psychotherapy notes. The services recommended by the Health Plan appear to be medically reasonable and appropriate for treatment of the patients condition. 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 had a colonoscopy in 1991 at which time inflammatory polyps were removed. Her colonoscopy in 1994 was normal. In 1999, another colonoscopy was normal. The patients father was diagnosed with colon cancer after age 60 and two aunts have also been diagnosed with colon cancer. The patient has requested authorization and coverage for a colonoscopy. The Health Plan has denied the patients request indicating a colonoscopy is not medically necessary at this time.The Health Plans denial should be upheld. For persons with a single first-degree relative diagnosed with colorectal cancer at age 60 or above there is an approximate two times greater risk of colon cancer than that observed in the general population. Furthermore, the risk for colon cancer at age 40 is the same as the risk in the general population at age 50. Thus, in this risk group the recommendations are the same as those for persons at average-risk (though screening should begin at age 40 rather than age 50). As such, a colonoscopy is not medically indicated for this patient at this time. Therefore, I have determined that 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: Overturned Decision of Health Plan

The patient is a 50-year-old male with severe asthma. A letter dated 11/3/03 from the patients pulmonologist states the patient has severe asthma based on his symptoms and pulmonary function tests. The patients FEV1 was 57% in September 2002 and declined to 41% in October 2003. The patients pulmonologist states the patient was on inhaled steroids. His IgE level was elevated at 343 IU/ml. The patient reports he has a family history of sudden asthma death. The patients provider started the patient on Xolair and has recommended that the patient continue on the drug. The Health Plan has denied authorization and coverage for Xolair on the basis it is not medically necessary for treatment of the patients asthma.Xolair is indicated in patients with moderate to severe asthma, positive skin test reactivity to aeroallergens, and an IgE level greater than 30. Xolair is useful in patients who are on inhaled steroids and leukotriene modifier drugs and still have poorly controlled asthma. Use of systemic steroids such as prednisone should be avoided because of a myriad of adverse effects, especially in this patient who is obese and has already undergone coronary artery bypass grafts.According to the records provided, the patient had been on inhaled corticosteroid and a leukotriene modifier. The patients clinical condition improved when he was started on Xolair. Use of Xolair is indicated in this patient since his asthma was not controlled on his previous regimen. There has been demonstrated improvement in the patients condition since Xolair was initiated. Given these results and in light of the patients other medical problems, use of Xolair is medically appropriate and indicated. 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 58-year-old man with a long-standing history of gout with painful attacks in the elbow.  It has been recommended the patient undergo a bursectomy and excision of the gouty tophi. The Heath Plan has denied authorization and coverage for the requested surgery on the basis it is not medically necessary for treatment of the patients elbow pain.The patient has painful masses within the olecranon bursa that require surgical intervention. The requested surgery has been recommended in order to resolve a functional impairment. Without surgical intervention, it is not likely the patients pain will resolve. The requested surgery is medically appropriate and indicated in order to relieve the patients pain. Therefore, I have determined the requested surgery 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 41-year-old female with a prior history of varicose veins with removal, but no history of greater saphenous vein removal. The patient indicates she is now experiencing severe pain due to her varicose veins, which have been refractory to conservative treatment (i.e., stockings). The results of an ultrasound exam show bilateral greater saphenous vein reflux. The patients provider has recommended the patient undergo repeat vein stripping.Given these facts, radiofrequency ablation closure of greater saphenous veins with removal of painful varicose veins is clinically indicated and medically necessary. The patient has greater saphenous vein reflux, which is an anatomic deficiency. The standard of care for this symptomatic patient is vein stripping. 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 64-year-old male with a history of diabetes, hypertension, and Cushings disease. He uses a four-wheeled walker to assist with ambulation. He indicates he is having difficulty with his current walker because of its five-inch wheels. The patient believes eight-inch wheels are necessary. The Health Plan has denied the patients request for eight-inch wheels.A physical therapy note from 6/21/04 indicates the patient does not utilize a walker in the home and is able to ambulate independently in the home with an SPC. Furthermore, a physical therapy note from 8/11/04 indicates the patient is able to ambulate with a walker without difficulty. Based upon this information, there is no evidence the requested eight-inch wheels are medically necessary. Therefore, I have determined the requested equipment is not medically necessary for the patients mobility. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 49-year-old morbidly obese female who has an overhanging pannus with treatable intertrigo. The patient wishes to undergo a panniculectomy. She was seen and evaluated by a plastic surgeon who recommended weight loss prior to any procedure. The patient weighed 276 pounds prior to her TAB and bladder suspension in 2002. The submitted notes indicate the patient recently weighed 281 pounds. Additionally, the patient has hypothyroidism and is non-compliant with her thyroid replacement therapy, further adding to her weight problem. The patients intertrigo has responded to appropriate treatment in the past and was not noted to be significant when the patient was evaluated by the plastic surgeon in June 2004. The Health Plan has denied authorization and coverage for a panniculectomy on the basis it is not medically necessary for treatment of the patients medical condition.The submitted medical records and photographs demonstrate a morbidly obese female with a thick abdominal pannus and evidence of intra-abdominal visceral adipose pushing the upper abdomen outward. The possibility of wound breakdown and long-term hospitalization for open abdominal wound infection and possible deep venous thrombosis as well as pulmonary embolus are motivating factors to have the patient lose considerable weight before embarking on a risky procedure. The Health Plans recommendation that the patient lose weight prior to pursuing surgical intervention is an appropriate and reasonable approach for the care of this patient. 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.