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

The patient is 62-year-old male with severe osteoarthritis of the knee. A request has been made for a BioniCare unit to treat the patients arthritis. The Health Plan has denied the request on the basis the requested device is not medically necessary for treatment of the patients knee pain.The requested device is not a standard treatment protocol for patients with arthritic conditions. The efficacy of the BioniCare device for this clinical indication has not been established. There are no long-term prospective studies supporting the use of this device for patients such as this patient. There are other treatment modalities available to manage the patients pain. Therefore, I have determined the requested device 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 71-year-old male who apparently has lower urinary tract obstructive symptoms caused by benign hypertrophy (prostatism). A cystoscopy report has not been submitted and therefore, the patients apparent diagnosis has not been fully confirmed. The patients provider has recommended treatment with Flomax. The Health Plan has denied this request and recommended treatment with Hytrin or Cardura.There are two types of non-surgical treatment with medications known to be effective in the treatment of prostatism  alpha blocking medications, which relax the nerves that tighten the bladder neck and 5-alpha reductase inhibitors, which block the transformation of testosterone to dihydrotestosterone. Each class of drug has a different mechanism of action and each has its own pattern of side effects. The alpha blocking medications usually work faster than the 5-alpha reductase inhibitors. Although Flomax is a newer drug than Hytrin or Cardura, all of the drugs are effective for the treatment of prostatism. Furthermore, there is no evidence demonstrating that Hytrin or Cardura are contraindicated for treatment of the patients condition. Therefore, based upon the information provided, I have determined the Health Plans denial should be upheld. However, should the patient have any contraindication to Hytrin or Cardura or should the patient develop intolerance to these medications or should these medications prove ineffective, the Health Plan should authorize Flomax.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 29-year-old male with a history of stuttering. He is seeking reimbursement for a SpeechEasy device. The Health Plan has determined there is no evidence supporting the need for this device and has denied reimbursement.The information submitted does not demonstrate the severity of the patients stuttering. In addition, there is limited evidence demonstrating appropriate evaluation and treatment by a speech therapist. Furthermore, the scientific evidence does not demonstrate the long-term effectiveness of the device at issue. The small studies available are not case controlled and several studies were performed with participants reading so there is little information regarding how patients would do during normal conversation. Therefore, there is a lack of clinical and scientific evidence demonstrating the equipment at issue was medically necessary for this patient. As such, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an 11-year-old female are requesting authorization for speech therapy for her diagnosis of severe autism with global developmental delay and impairment in all functional areas of language. The patients primary care physician described the patient in June 2005 as `basically non-verbal. The patient has been enrolled in outpatient speech therapy since October 2002. During this period there were two interruptions of approximately 4-5 months each during which the patient was taken to China for alternative therapy (acupuncture). The patient has recently completed a 12-week course of speech therapy and her parents and therapists are requesting authorization for on-going speech therapy in 12-week increments. The Health Plan has denied this request indicating continued speech therapy is not medically necessary for treatment of the patients condition.Review of the submitted clinical information indicates the patient has had several years of twice weekly speech therapy since October 2002. She remains basically non-verbal in the eyes of her primary care doctor. To date, none of the nine goals of therapy that were established have been accomplished. Three of the goals are scored as `not met,` one goal is scored as `partially met` and three goals are listed as `ongoing.` Upon detailed review of the progress report it is evident the patient has not demonstrated significant, sustainable improvement in any of her speech or communication goals and therefore, additional therapy is not likely to have clinical value.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: Upheld Decision of Health Plan

The patient is a 37-year-old man with dental malocclusion, mandibular retrognathia, and CPAP resistant sleep apnea.  Evaluations by two maxillofacial surgeons resulted in recommendations for the extraction of the third molars, pre-operative orthodontic treatment and bi-maxillary advancement with maxillary and mandibular osteotomies.  The patient had the third molars removed and he now wishes to forego pre-operative orthodontic treatment against the advice of the surgeons.Pre-operative orthodontic treatment in anticipation of orthognathic surgery is the usual and recommended sequence of case management.  A stable dental occlusion is key to the success of the surgery and necessary to prevent a relapse of the bone fragments into an undesirable post-operative position. To proceed with surgical correction without pre-operative orthodontic treatment would pose the unnecessary risk of a poor surgical outcome. The patients surgeons are correct to insist on pre-operative orthodontic treatment if, in their judgment, the quality of care would be diminished without this treatment. Therefore, 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: Overturned Decision of Health Plan

The patient is a 43-year-old woman with a body mass index (BMI) of 45. In addition, the patient has multiple comorbid conditions. The patient has failed attempts at standard weight loss modalities. The submitted records indicate the patient has undergone three psychological evaluations to determine her suitability for weight loss surgery with varying results. The results of the first two psychological evaluations indicated the patient was not an appropriate candidate for weight loss surgery. However, a third psychological evaluation, which appears to be the most recent, determined the patient met psychological criteria for weight loss surgery. At issue is whether the requested surgery is medically necessary for treatment of the patients condition.The patient meets national medical necessity criteria for weight loss surgery based upon her BMI of 45 and documented comorbid conditions. In addition, the results of a psychological consult in August 2005 demonstrate the patient is currently relatively stable and has the emotional capacity to undergo weight loss surgery. As such, there is sufficient clinical documentation of need and compliance to warrant bariatric surgery in this case. 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: Upheld Decision of Health Plan

The patient is a 56-year-old woman who requests a bone mineral density study to determine the progress of her osteoporosis evaluated on two previous scans in February 2002 and March 2004. The second scan showed progressive loss of bone at the hip and spine in excess of what might be expected at her age. At that time she was apparently taking hormones and thyroid medications and had some recommendations according to the note from her physician. Eighteen months later, the etiology of her bone mineral density loss is unknown, and her present medications are unknown. Her physician has recommended another bone density study.The etiology of the patients bone loss is unknown. It could be due to an early menopause, now without estrogen replacement, or excessive thyroid hormone treatment, or some other cause for secondary osteoporosis. The patient should be referred to a physician who has knowledge in the diagnosis and monitoring of the treatment of osteoporosis.If, after a thorough evaluation this patient is diagnosed with post-menopausal osteoporosis and appropriate treatment is begun, there are several ways to monitor the success of the specific treatment. To monitor the progression of post-menopausal osteoporosis, a baseline bone density study and/or markers of bone turnover can be obtained and either a repeat bone density study at two years of treatment, or bone markers at six months would be appropriate. Based upon the information provided, there is no clinical indication for a bone density study at this time. Therefore, I have determined that the requested bone density study 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 62-year-old female who indicates she has a 10-year history of allergies and asthma. The patients allergist indicates the patient has persistent allergy mediated asthma. The submitted clinical records show an IGE level of 15.9IU/ML. There is no mention in the submitted records of the frequency of prednisone bursts. Pulmonary function studies have not been provided.  The patients allergist has recommended a 12-month trial of Xolair. The Health Plan has denied authorization for the requested medication on the basis it is not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. The clinical information provided does not demonstrate the patient meets medical necessity criteria for authorization of Xolair. As noted above, the frequency of prednisone bursts is unknown and symptoms of steroid dependence are not documented. Nor is there documentation the patient required emergent treatment. Furthermore, there is no documentation of a spirometric study or a positive allergy skin test. Moreover, it does not appear consideration has been given to other diagnoses, which may be contributing to the patients asthmatic symptoms (e.g., reflux). Based upon the information provided, it has not been demonstrated that use of Xolair is medically warranted. Accordingly, 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

The patient is a 51-year-old female who is seeking xanthelasma excision from her eyelids. The patient has been treating this condition for some time with recurrence and progression. The Health Plan has determined the patients condition does not cause functional impairment and therefore, there is no evidence demonstrating the requested procedure is medically necessary.The Health Plans denial is correct. This patients condition is considered cosmetic and treatment of this condition through surgery is not considered medically necessary. There is no evidence the patients condition is not causing a functional impairment. She has undergone surgical excision of her xanthelasma previously and, not unexpectedly, her condition recurred. Furthermore, surgical excision could lead to a worsening of her condition. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 63-year-old male with a history of vitreous floaters and blurred vision. To treat this condition the patient decided to proceed with a Yag procedure, which was performed on two separate occasions in June 2005.  The Health Plan did not authorize this procedure and has denied reimbursement. The Health Plan recommended a closed vitrectomy for the patient.Vitreous floaters are a common problem where treatment is rarely advised as all available treatments have significant risks. Both the Yag procedure and the closed vitrectomy have the potential risk of retinal detachment. Closed vitrectomy results in an increase in cataract formation while it is unknown how much of an increase in cataract formation results from a Yag procedure. Furthermore, laser therapy such as the Yag procedure often results in a large opacity converting to numerous small opacities. Moreover, treatment of any type is not considered standard of care for vitreous floaters.Based upon the risks and variable efficacy of the procedure at issue, I have determined the procedure at issue was not medically necessary for treatment of the patients condition. Therefore, the Heath Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 45-year-old male who has a body mass index (BMI) of 43.3. He is 5'8` and weighs 284 pounds. He is requesting authorization for vertical gastrectomy/gastroplasty for treatment of his morbid obesity. The Health Plan has denied this request indicating the requested procedure is considered investigational for treatment of his medical condition.The requested procedure has been described in scientific literature not only as a definitive procedure but also as a staging procedure. The physiologic basis of this procedure is no different than proximal gastric bypass, which is a restrictive procedure. The proposed procedure is medically reasonable and appropriate and likely to be effective for patients such as this patient. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 45-year-old male with morbid obesity and comorbidities. He has failed multiple medical treatments. He has no contradictions to surgery. He has requested authorization and coverage for vertical gastrectomy/gastroplasty, which has been denied by the Health Plan on the basis it is considered investigational.The patient has extensively reviewed his options. He does not wish to undergo a malabsorptive procedure. A gastric restrictive procedure has been recommended. The proposed procedure has an acceptable success rate with a very favorable risk profile. It is a well-established procedure with proven efficacy. Hence, it is a reasonable alternative with an adequate safety profile. Furthermore, should the restrictive procedure fail over time, a future malabsorptive procedure would not be precluded.For these reasons, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: This patient is a 45-year-old male with a BMI of 43 and related comorbidities. He wishes to undergo weight loss surgery and believes vertical gastroplasty/gastrectomy is the most appropriate procedure for treatment of his condition. The Health Plan has denied coverage for the proposed procedure on the basis it has not been shown to be efficacious for patients such as this patient.Review of the relevant medical literature reveals there is insufficient evidence of the efficacy of vertical gastroplasty/gastrectomy. The proposed procedure has been used as a component of a staged procedure in the super obese (BMI greater than 60). It is not generally used as sole therapy in the average morbidly obese patient. Further studies are needed before vertical gastroplasty/gastrectomy can be recommended for patients such as this patient. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 64-year-old female with a body mass index (BMI) of 49.1. She has significant clinical comorbidities. The patient has failed monitored weight loss programs. She is a candidate for bariatric surgery and wishes to undergo a Lap-Band procedure. There is no evidence in the submitted documentation the patient has undergone a psychological evaluation to determine if she is an appropriate candidate for weight loss surgery. The Health Plan has denied authorization for the proposed Lap-Band procedure.Review of the relevant medical literature demonstrates there is sufficient evidence to support the use of the Lap-Band procedure for weight loss. The Lap-Band was approved by the Food and Drug Administration in 2001. Morbidity seems to be lower with the Lap-Band procedure than with traditional vertical banding gastroplasty and Roux-en-Y gastric bypass. Additionally, there is generally a slower rate of weight loss with Lap-Band than with Roux-en-Y gastric bypass, which may be beneficial in this case given the patients age. For these reasons, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should obtain psychological clearance before Lap-Band surgery is authorized.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

This case concerns a seven-year-old female who was denied coverage for growth hormone (GH) therapy for short stature.  The patient had severe intra-uterine growth retardation (IUGR), weighing only three pounds eleven ounces at full term.  She failed to undergo catch-up growth by two years of age and demonstrated poor muscle tone with weakness and hypotonia.  The patient had hip dysplasia and treatment for clubfeet. She was also treated for wheezy bronchitis.  The patient is relatively obese, and has a mother who weighs 200 pounds and a paternal grandmother with diabetes.  Her pediatric endocrinologist predicted an adult height of less than 59 inches, which, based on mean parental heights, is more than two standard deviations below her target height.  The patient had a bone age of five years and six months in October of 2004, as compared to her chronological age of six years and four months.  In August of 2004 she had normal thyroid tests, a normal IGF-1 level at 82, and a normal IGFBP-3 level at 2.6.  The latter two results do not suggest a growth hormone deficiency.There appears to be some misunderstanding about the term IUGR in the record. This term has the same meaning as small for gestational age (SGA). SGA is an indication for GH therapy, provided the patient was born SGA, as defined by a birth weight or length equal to or greater than two standard deviations below the mean for gestational age, and fails to manifest catch-up growth from birth through age three, defined as a height equal to or greater than two standard deviations below the mean for age and sex. In this instance, the patient meets these criteria; as such, growth hormone therapy should be authorized. 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: Overturned Decision of Health Plan

The patient is a 46-year-old male with chronic hepatitis B beginning in April 2004 with a detectable viral count and elevated liver enzymes. As of July 2005, the patient has an undetectable viral count and normal liver enzymes. The patient has been treated with Hepsera for two years and currently his surface antigen is negative. The patient is seeking continued treatment with Hepsera. The Health Plan has denied this request.The evidence regarding whether to continue indefinitely or discontinue Hepsera when a patients viral load is undetectable remains unsettled. Discontinuing Hepsera at this point would place the patient at risk for a relapse. Furthermore, it is standard of care within the gastroenterological community to continue Hepsera in these situations so as to avoid relapses. Therefore, because the evidence remains unsettled and because discontinuing Hepsera would place the patient at risk for a relapse, I have determined the requested therapy is medically necessary for treatment of the patients 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 male with coronary artery disease. He has requested reimbursement for EECP therapy. Information provided indicates the patient had a myocardial infarction in 2001. In 2002, a thallium stress test revealed inferior basal wall ischemia, apical defect and hyperkinesis. The patients provider diagnosed the patient with asymptomatic angina and recommended treatment with EECP. The Health Plan has denied reimbursement for the EECP.The Health Plans denial should be upheld. The patient does not have documented angina or congestive heart failure. In 2002, the American College of Cardiology and American Medical Association issued a joint statement indicating EECP is considered experimental. In 1999, Medicare approved EECP as a reasonable and necessary treatment for certain patients suffering from stable angina pectoris refractory to medical and/or surgical therapy. Further, under Medicare guidelines, coverage for EECP is provided for patients who have been diagnosed with disabling angina who in the opinion of a cardiologist or cardiothoracic surgeon are not readily amenable to surgical intervention.Although EECP has a place in the management of angina pectoris and congestive heart failure refractory to conventional therapy, the information presented does not demonstrate this patient has either condition or that he failed first-line therapy prior to EECP. 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: Overturned Decision of Health Plan

The patient is a 15-year-old female who has two keloids, which have progressively enlarged and are occasionally painful. She is seeking removal of the keloids. She has been evaluated by a dermatologist who has agreed to surgical removal of the keloids and Kenalog injections. The Health Plan has denied authorization for these procedures on the basis that they are considered cosmetic in nature and not medically necessary.The patient has large, disfiguring keloids, which have become painful. Therefore, there is a functional component to the requested procedures. Furthermore, the requested procedures are appropriate for treatment of the patients condition. Because correction of the patients condition does have a functional component, I have determined the requested procedures are medically necessary for treatment of the patients condition. Therefore, the Health Plans denial should be overturned.