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

The patient is a 27-year-old male with a long history of behavioral health problems. He has a history of prior hospitalizations. Prior pharmacologic treatment included mood stabilizers, neuroleptics, and antidepressants. In December 2004, the patient discontinued his medications and began using cannibus and abusing alcohol. In February 2005, he was admitted to a prison psychiatric unit after violating a restraining order.  In April 2005, the patient was transferred from the prison psychiatric unit to an acute inpatient psychiatric treatment program. The Health Plan has denied coverage for the patients acute inpatient admission on the basis it was not medically necessary for treatment of the patients condition.It is apparent from the enclosed documentation that this patient is chronically and persistently mentally ill. He has a long history of delusions and hallucinations. His psychotic symptoms are rather severe. No doubt that his illness has been exacerbated at times by the use of multiple substances. However, he also demonstrated severe symptoms while hospitalized on a locked unit. This patient as evidenced by the documentation provided responds best in the most structured, highest level of care. As such, the patients admission to a residential level of care was medically indicated for treatment of his chronic mental illness. Based upon the information set forth above, I have determined that the services at issue were medically necessary for treatment of the patients condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 56-year-old male with morbid obesity who underwent a lap band procedure in January 2005. The patient lost an initial 30 pounds and has now stopped losing weight. The patient indicates the band is too tight and he is requesting takedown of the band followed by a Roux-en-Y procedure. He has had an outside psychiatric evaluation, but has not completed in-plan counseling. He has arthritic complaints affecting his back and hip. His band has not been adjusted since the procedure was originally performed. The Health Plan has denied authorization for the proposed procedures on the basis they are not medically necessary for treatment of the patients condition.At this point the patient is failing to lose weight with a gastric restrictive procedure. This requires an active effort to reduce intake. This raises clinical concerns as to compliance with a restrictive/malabsorptive procedure that will have more severe metabolic consequences. The urgency in the patients letters implies he is looking for a gastric fix.A full bariatric evaluation as recommended by the Health Plan is medically appropriate and reasonable at this time. The band could be evaluated and adjusted or removed with either concomitant or deferred Roux-en-Y gastric bypass as a part of an overall treatment plan for this patient. This needs to be approached in a programmatic and team-oriented fashion. Since further evaluation is needed, 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 24-year-old female who experienced significant weight loss following gastric bypass surgery. The patient underwent evaluation by two plastic surgeons. The patients physician notes the patient is still morbidly obese. The patient has a skin rash in the suprapubic region, a large abdominal pannus and folds, large arm folds, and a typical bat wing type deformity. In addition, the patient reports experiencing rashes on her back, abdomen, arms, breasts, and thighs. The enrollee has requested authorization and coverage for a panniculectomy, brachioplasty, and lower body lift.The patient is requesting authorization for panniculectomy, brachioplasty and lower body lift. She has been examined by two plastic surgeons who noted the presence of a rash in the suprapubic area. However, both physicians indicated the patient was still morbidly obese and therefore, a panniculectomy was not medically indicated. Based upon the information provided, the patient is not an appropriate candidate for panniculectomy at this time. If the patient continues to lose weight her request for a panniculectomy should be reconsidered. Furthermore, brachioplasty and lower body lift are body-contouring procedures and are generally cosmetic in nature. There is no medical necessity for these procedures based upon the evidence provided. For these reasons, I have determined that 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: Upheld Decision of Health Plan

The patient is a 62-year-old male with approximately a 40-year history of chronic intermittent fatigue. He reports he has hypopituitarism and a possible sleep disorder based on unknown diagnostic studies. The patient further reports his symptoms been partially resolved with Provigil, compounded micronized hydrocortisone, compounded testosterone/progesterone gel and compounded T4/T3. The patient has requested authorization and coverage for these medications from the Health Plan. The Health Plan has denied the patients request on the basis these medications are not medically necessary for treatment of the patients condition.The Health Plans denial should be upheld. There is no documentation of any hormonal disease or sleep disturbance. In addition, all of the blood tests provided are normal. A sleep study report has not been provided. Furthermore, there is no scientific data demonstrating the need or effectiveness of Provigil, compounded micronized hydrocortisone, compounded testosterone/progesterone gel, and compounded T4/T3 in this case. The compounded supplements are not standardized formulary medications available for use. Moreover, the indications for the use of generic metformin and branded HGH are also lacking in this case. For these reasons, I have determined the requested medications 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 50-year-old male with daytime somnolence confirmed by MSLT with mean time to sleep 6.5 minutes. His condition has been attributed to idiopathic hypersomnolence though there are references to obstructive sleep apnea with a failed CPAP trial. The patient has had an affirmative clinical trial with Provigil with decreased sleepiness and fatigue. Finally, the patient remains symptomatic without Provigil therapy.  The Health Plan has denied authorization and coverage for Provigil on the basis it is not medically necessary for treatment of the patients condition.Though there is neither polysomnography confirmation of obstructive sleep apnea nor confirmation of narcolepsy, there is significant peer-reviewed medical literature to show Provigil's effectiveness in the treatment of daytime somnolence. The submitted clinical documentation demonstrates the patient has excessive daytime sleepiness, which is adversely affecting the patients work performance. Clinically, there is an inference of risk of falling asleep while driving. Provigil has been an effective therapy for the patient. Given the patients therapeutic response, continued treatment with Provigil 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: Upheld Decision of Health Plan

The patient is six-year-old male with a history of speech delays consisting of substitution and distorted r sounds. The patients therapist has recommended speech therapy services, which the patient received from January 2005 to February 2005. The Health Plan has denied coverage for the speech therapy services on the basis they were not medically necessary.Review of the submitted information does not document objective findings or specific functional goals for the therapy at issue. In addition, the patients delays are developmental in nature. There is no medical cause for the patients delays. Given the poorly defined objectives of therapy and the absence of a documented medical condition, there was no medical indication for speech therapy. 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 a 16-year-old female with a significant history of obesity and family obesity. She is reported to weigh 300 pounds with a BMI of 44. She has been overweight since age seven. She has made multiple attempts at non-surgical weight loss without success and with weight gain. She has comorbidities including hypertension and asthma. The patients mother has requested authorization for gastric bypass surgery to treat the patients morbid obesity.Although there are surgeons and surgical centers specializing in bariatric surgery for adolescents, there is a limited amount of scientific evidence regarding bariatric surgery in adolescent patients. Significant concerns involving adolescent patients and bariatric surgery include growth retardation and behavior modification. If treated with bariatric surgery, adolescents should only undergo restrictive operations such as proximal gastric bypass.Given the potential for growth retardation and the fact that there is no evidence the patients growth plates are closed, weight loss surgery is not indicated for this patient. Furthermore, the patients continued failure of non-surgical weight loss attempts and actually gaining weight creates concerns regarding the patients ability to modify her behavior appropriately after gastric bypass surgery. Moreover, bariatric surgery for adolescents is not considered standard of care. When it is confirmed that the patients growth plates are closed and that the patient has a full understanding of lifestyle changes necessary for the success of bariatric surgery and the ability to implement those changes, surgery may be appropriate for this patient.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: Overturned Decision of Health Plan

The patient has HIV and has been undergoing treatment with antiretroviral drugs. Over time he has developed facial lipoatrophy as a result of HIV infection and as a side effect of his treatment. This condition is disfiguring and is causing the patient emotional difficulty as well as some functional disability (difficulty chewing without biting the buccal surface due to the deformity). Photographs of the patient demonstrate classic signs of severe facial lipoatrophy. The patients infectious diseases specialist and a plastic surgeon have recommended Sculptra for treatment of the patients condition. The Health Plan has denied this request.The patient has a disfiguring deformity known as facial lipoatrophy as a result of HIV infection and treatment with antiretroviral medications. Sculptra is considered safe and effective for treatment of the patients condition. In addition, Sculptra is medically necessary to correct the patients condition to the extent possible. Furthermore, Sculptra is the only approved treatment for this condition. The patients condition is related to a disease and the requested medication will give the patient a normal appearance to the extent possible.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a five-year-old male diagnosed with autism/pervasive developmental disorder with an associate mixed receptive and expressive language delay. The patient has been receiving speech therapy services since May 2003. Goals established included improvement in pragmatic language, increase in expressive vocabulary, combining word to phrases and following directions. The Health Plan has denied coverage for speech therapy from January 2005 onward on the basis that speech therapy is not medically necessary for this patient.In reviewing the goals as outlined in May 2003 and comparing them with the summary dated May 2005 there is sufficient evidence the patient has been making gains. These gains have been slow, but the goals and objectives are appropriate and he has achieved the goals. Given that the patients therapist provided appropriate goals and there have been documented gains in these goals, I have determined that continued speech therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. The patient should continue to receive speech therapy services with re-evaluation in six months.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 48-year-old woman with chronic knee pain. The patient indicates she has been tried on Clinoril. The patient continues to have pain and therefore, has requested authorization for an MRI study. The Health Plan has denied authorization for the requested MRI indicating there is insufficient evidence the patient has been tried on conservative measures. The Health Plans denial should be upheld. The submitted documentation indicates the patient was examined by an orthopedist in August 2005. Results of this examination revealed no objective evidence of internal derangement. The examining provider did not find an MRI study of the patients knees is indicated. Based upon the information provided, there is insufficient evidence an MRI is medically warranted at this time. Therefore, I have determined the requested MRI 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 63-year-old man who underwent radiation treatment for cancer of the left aryepiglottic fold and arytenoid squamous cell carcinoma. The radiation dose was 6600 Gy fraction. Treatment may have included portions of the tooth-bearing mandible. Post radiation the patient had extensive dental caries; he underwent full mouth extractions and alveoloplasty including excision of mandibular tori.  The patient received prophylactic hyperbaric oxygen therapy 20 dives pre-operatively and 10 dives post-operatively according to the Marx protocol. The patient recovered well from oral surgery. A request has been made for reimbursement for the hyperbaric oxygen therapy. The Health Plan has denied this request indicating the therapy at issue was not medically necessary.There is no evidence-based indication for prophylactic use of hyperbaric oxygen for management of routine dental alveolar surgery in the maxillo and mandible to prevent osteoradionecrosis. The Marx protocol was proposed in 1970 for patients receiving greater than 6800 Gy to the tooth bearing areas. It appears this patient received less than 6800 Gy. In any event, the efficacy of hyperbaric oxygen for osteoradionecrosis prophylaxis in routine oral surgery has not been established at this time. Thus, the use of hyperbaric oxygen in this clinical setting was not medically warranted.Based upon the information set forth above, 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 a 34-year-old female who is seeking authorization for repair of her abdominal wall changes secondary to three pregnancies. Her obstetrician referred her to a board certified plastic surgeon who noted the problem and recommended repositioning of the rectus fascia and abdominoplasty (usually considered one procedure as there is no true hernia). The Health Plan has denied authorization for the requested procedure on the basis that it is considered cosmetic in nature.A review of the presented records, including photocopies of photographs, demonstrates an intact pair of rectus abdominis muscles with some spread in midline (diastasis) and excess skin and soft tissue of the abdominal wall. The information presented does not demonstrate the patient has any functional deficits related to her present condition. Furthermore, there is no evidence the proposed surgery would correct a functional deficit. 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 14-year-old female with an initial diagnosis of primary hypothyroidism at the age of 12, though symptoms of hypothyroidism were apparently present by history since the age of 8. Her height in April 2003 was already significantly below 2.S.D. Biochemical findings supported a severe hypothyroid state with T4 level <2.0 and a TSH of 697. A request has been made for authorization and coverage of growth hormone therapy. The Health Plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the patients condition.The patients diagnosis of hypothyroidism is sufficient to explain her short stature at presentation. In this case, a diagnosis of idiopathic short stature is not appropriate or indicated. Although most of this height deficit may be recovered with adequate therapy the patients thyroid function has remained poorly controlled, partly from non-compliance. Further, the unfortunate yet age appropriate onset of the patients pubertal development additionally limits the patients ability or time to recover the hypothyroidism-induced height deficit.Although success outcomes remain controversial, treatment with Lupron to retard pubertal maturation is medically indicated in patients such as this patient. However, there are no consistent evidence-based studies confirming that the addition of growth hormone in this particular setting is beneficial in increasing height potential. Therefore, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old female who walks with an assistive device. She indicates she experiences flares in her condition, which prevent her from walking. There is no evidence the patient is currently experiencing a flare, nor is it known how frequently these occur or how long they last. The medical documentation provided regarding the patients gait indicates the patient walks slowly while ascending stairs and walks independently for short distances. The patient has requested authorization and coverage for a power-operated vehicle (POV). :The Health Plans denial should be upheld. The submitted information does not demonstrate the patient is non-ambulatory. The patient has a manual wheelchair that she is able to use. Thus, the provided documentation does not demonstrate the patient is precluded from operating a manual wheelchair. As such, the medical necessity of a POV has not been established. Therefore, I have determined the requested POV 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 17-year-old male who entered intensive outpatient treatment (IOP) in March 2004 for treatment of oppositional defiant/conduct disorder and polysubstance abuse. The patient continued to receive IOP services until August 2004. The Health Plan indicates IOP services were not medically necessary as of May 2004.The patient clearly has the predominant diagnosis of oppositional defiant/conduct disorder and polysubstance abuse. There is no evidence the intensive outpatient program included psychiatric oversight or treatment monitoring. Given the patients clinical condition at admission, clinical expectations, and his response to the IOP services he had already received, he did not meet medically necessity criteria for continued IOP services as of May 2004. The submitted documentation does not substantiate that the patient was unable to receive treatment in a traditional outpatient setting. Therefore, I have determined that the services at issue were not medically necessary for treatment of the patients condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 37-year-old male with degenerative disc disease at L5-S1. The patient is status post discectomy. His provider is recommending a single level disc replacement utilizing the Charite artificial disc. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental, as there is no long-term data demonstrating long-term safety and efficacy of the procedure. Moreover, the patient does not meet FDA criteria for lumbar disc replacement as he has had a previous discectomy at L5-S1 and has leg numbness and pain. Previous surgery such as this is considered a contraindication to artificial disc replacement. Based upon the information set forth above, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient is a 37-year-old male with degenerative disc disease at L5-S1. Artificial disc replacement has been recommended. The patients provider indicates the patient has previously undergone discectomy at L5-S1. The Health Plan has denied authorization for the requested procedure indicating the efficacy of artificial disc replacement has not been established.The proposed procedure is experimental without established long-term safety and efficacy. Available data does not demonstrate an advantage to disc replacement over fusion. The long-term safety profile is unknown. There is no clinical indication demonstrating the proposed procedure is the best treatment option for this patient. There are other treatments available. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 3: The patient is a 37-year-old male with degenerative disc disease. He is seeking authorization for artificial disc replacement utilizing the Charite III disc. The Health Plan has denied this request because it considers artificial disc replacement experimental.The current clinical evidence regarding the Charite III disc has allowed for Food and Drug Administration (FDA) approval that it is not inferior compared to fusion. Similarly, current studies appear to indicate it is not worse than fusion. Additional claims of efficacy are based upon a small number of short-term, non-randomized studies. A 300 patient FDA regulated investigational device exemption trial with long-term follow-up is underway. Without the results of this trial, the Charite III disc replacement remains experimental. Furthermore, it is not established as superior to fusion. Therefore, I have determined 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.