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

The patient is a 17-year-old female who has been diagnosed with bipolar disorder and has manifestations of a pervasive developmental disability with mild mental retardation. She did well with her symptoms of attention deficit hyperactivity disorder (ADHD) when she was on Ritalin, but the long acting stimulants have caused her to have some agitation. The patient was started on Abilify and Provigil for symptoms of ADHD, depression and other behavioral issues. She was sedated with the Abilify alone, but with the combination of Abilify and Provigil the patient was reported to have done well. The patients parent has requested authorization for continued treatment with Provigil. The Health Plan denied the request citing a lack of medical necessity. A review of the patients history indicates she has had a positive response to a stimulant medication in the past. Initially Ritalin was used and was found to be effective. Over a long period of time it became less effective and was eventually discontinued. The use of Provigil with Abilify has also proven to be clinically effective. Provigil is currently approved by the FDA for the treatment of sleep apnea and other indications not related to ADHD or sedation secondary to third generation antipsychotic medications. Specifically, the use of Provigil to reverse the sedative effects of antipsychotic medications is not an FDA approved application. It is likely that Ritalin would again be effective to reverse the sedation effects of Abilify, and there is no record of a recent trial of this medication. Therefore, 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 37-year-old male with chronic pain due to fibromyalgia. The patients provider indicates the patient has been tried on many medications but is highly allergic to the time-release ingredient in many medications and also has acetaminophen intolerance. The provider started the patient on a regimen of Subutex and compounded hydrocodone, which he indicates has been very effective. The Health Plan has denied authorization for these medications on the basis that they are not medically necessary.Subutex and compounded hydrocodone are not clinically appropriate for the long-term chronic management of fibromyalgia pain. Although these medications may be utilized for brief periods, their long-term use is not recommended or within the standard of care. Patients with fibromyalgia often benefit from a baseline exercise physical rehabilitation program, which does not appear to have been incorporated in this case. In any event, the long-term use of Subutex and compounded hydrocodone is not clinically indicated or medically warranted. Therefore, 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 46-year-old female with a prior history of major depression. She presented to the emergency room of a hospital due to substantial increase in depression and anxiety to the point of not having slept in three nights, and feeling hopeless and helpless.  When evaluated in the emergency room, her psychiatrist noted the patient as obviously quite agitated, with jumbled up thoughts in her mind and feeling seeming inadequate. The psychiatrist stated that her negativity was almost of delusional proportion. The patient stated that she was not willing to go on with life. She had been helped significantly five years earlier when she was hospitalized after several attempts with outpatient psychiatrists. Prior to her most recent hospitalization, she had a two-month history of feeling depressed with gastric irritation and diarrhea. She began limiting her activities at work and made frequent visits to the family physician, though the symptoms continued unabated.  Interview in the emergency room revealed blunted affect and she was very concerned about medications, not wanting to try any new medication without being observed. She was diagnosed with major depression, recurrent, severe.  After admission to the inpatient unit, the nurses noted the patient as very tearful and labile, becoming very irritable and demanding at times though quickly apologetic. The patient cited worrying about many things in her life, inclusive of not getting the right medical and psychiatric care from the health care team. Due to noted past sensitivity to a variety of antidepressants, the patient was started on very low dose Celexa during her three-day hospital stay, in addition to Seroquel 50 mg per night. Fairly quickly, her sleep and anxiety improved and she was discharged within three days of admission. At issue is whether the patients acute inpatient hospitalization in August 206 was medically necessary. Review of the submitted clinical records indicates the patient was quite depressed and anxious by the point of her presentation to the emergency room and given her negative rumination (noted as nearly to the degree of delusion), admission for inpatient treatment was indicated. Given the tenor of the patients anxiety and depressive rumination, it is extremely unlikely that outpatient treatment would have fared nearly as well as the immediacy of brief, inpatient stabilization. Three days worth of inpatient treatment also does not seem a disproportionately long period in which to stabilize a patient.  All told, I find that the services at issue were 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 four-year-old female born 8 pounds 2 ounces with no significant motor delays. She has a history of multiple ear infections with enlarged adenoids and tonsils.   She underwent an adenoidectomy and tonsillectomy at the age of three. Office notes from her otolaryngologist dated April 2006 document a normal hearing exam. Speech therapy was recommended for an articulation delay and decreased auditory comprehension. At issue is whether speech therapy is medically necessary.Review of the submitted clinical evidence does not demonstrate that speech therapy is medically necessary. Records from the patients otolaryngologist indicate the patients hearing exam in April 2006 was normal. There was no documentation of recurrent ear infections at that time. The information provided by the patients otolaryngologist does not demonstrate the patients speech delay is caused by a disease, congenital anomaly or injury. Although the otolaryngologist recommends speech therapy, no goals are outlined and there is no determination that a medical condition is the cause of the impairment. Based upon the information provided, the patients articulation disorder is a developmental disorder and speech therapy in this setting is educational in nature. Accordingly, 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 44-year-old woman first diagnosed with breast cancer in 2002. She was initially treated with surgery, radiation therapy and chemotherapy with doxorubicin and Cytoxan, followed by Taxotere. In June 2005 the patient was found to have rising markers, indicative of recurrent breast cancer. Treatment with Herceptin and Avastin was not effective, and she was begun on Abraxane in November 2005. This did produce a lowering of her tumor markers, though they have been rising since discontinuation of the Abraxane. At issue is whether Abraxane was medically necessary for treatment of the patients medical condition.Abraxane is a form of Taxol and has been approved for use in cases involving women with metastatic breast cancer after a failure of combination chemotherapy for metastatic disease and/or relapse after adjuvant chemotherapy including an anthracycline. This patient had progression of metastatic disease after combination chemotherapy. Furthermore, she had adjuvant therapy including an anthracycline (doxorubicin). Therefore, her treatment with Abraxane was medically necessary and within current approved guidelines for metastatic breast cancer.For the reasons set forth above, I have determined the therapy at issue was 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 65-year-old-female who is status post cholecystectomy in 2005. According to the record provided for review, she saw her provider several times in early 2006 with a complaint of persistent abdominal pain. The patients provider ordered an abdominal CT to further investigate the source of the patients pain. The patient had the CT performed in April 2006 and has requested reimbursement for the cost of the diagnostic procedure. The Health Plan denied the request, citing a lack of medical necessity.This patient is status post cholecystectomy in 2005 and later developed abdominal pain.  The record indicates the patient saw her provider three times with this complaint, and after examination of the patient, the provider ordered an abdominal CT scan for further evaluation. As the etiology of the patients pain was unknown, abdominal CT was a reasonable approach and likely to provide a better view of the abdomen and more complete information regarding any pathological processes. Therefore, I have determined the diagnostic procedure at issue was medically necessary for evaluation 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 45-year-old female who was diagnosed with stage III ovarian cancer in June 2004. She was treated with chemotherapy. The patients CA 125 rose from 7 in August 2005 to 65 in September 2006. On serial CT scans, there has been the development of a 1.4cm low-density lesion along the spleen. The patients gynecologist has requested a PET scan for further evaluation. The Health Plan has denied this request.Prior Centers for Medicare and Medicaid Services (CMS) reimbursement standards did not include ovarian cancer as an indication for PET scan. However, the National Oncologic PET Registry (NOPR) was developed in response to the CMS proposal to expand coverage for PET scans to include cancers and indications not previously eligible for Medicare reimbursement. NOPR lists ovarian cancer as an indication for PET scan for the purposes of diagnosis, staging, restaging, and monitoring.Furthermore, review of the scientific literature reveals that PET scans have been shown to be more sensitive than CT scans (87% versus 53%) for suspected recurrent ovarian cancer when there is a rising CA 125. The Gontier, et. al. study found the sensitivity and positive predictive value of PET/CT for lesions larger than 1cm were, respectively, 83% and 93% in a prospective study of 22 patients suspected of having recurrence because of an increasing CA 125 level but who had normal or equivocal findings on CT.  In another study of 56 women, PET/CT resulted in a major change of management plan in 58% of the patients (Simcock, et. al.). These studies demonstrate that PET scan is medically appropriate in this clinical setting and is likely to be superior to other diagnostic modalities.For the reasons set forth above, I have determined the requested PET scan is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 51-year-old female with a history of optic neuritis in 1978 and subsequent recurring neurological problems. The record indicates she has been seen by several different neurologists over the past six years, and there is disagreement as to a clear diagnosis of multiple sclerosis (MS). The patient has had negative spinal fluid, reportedly normal evoked potentials and MRIs in June 2006 which showed an essentially normal spinal cord and a few small scattered lesions in the deep white matter, not consistent with classic MS findings. The patient has been treated with Rebif for the past year, and until recently, her persistent weakness and unsteadiness have been responsive to treatment with steroids. The patients provider recommended treatment with IVIG and a request for authorization was submitted to the Health Plan. The Health Plan denied the request citing a lack of medical necessity.After a thorough review of the medical records, a diagnosis of clinically definite MS is not clear. Nonetheless, IVIG is not considered a first-line therapy for the treatment of MS. It has been recommended in Germany as a second-line therapy for patients who cannot tolerate interferons and/or glatiramer acetate. In the United States, the FDA has approved several well-studied therapies including Copaxone and Novantrone and it does not appear the patient has had a trial of these medications.  I do not agree that treatment with IVIG is clinically appropriate at this juncture. 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

The patient is a 53-year-old man who has a PSA of 8.4, a Gleason score of 3+3=6 and a non-palpable tumor. As of July 2005 the patients PSA was 4.7. It rose to 5.7 in January 2006, 6.3 in April 2006 and was 8.4 in August 2006 with 7% free. Biopsy revealed a Gleason score of 6(3+3) in 60% of the specimen from the left base. No tumor was found in the remaining biopsies. The patient is sexually active and believes proton beam therapy is the most appropriate treatment modality for his condition. The Health Plan has denied coverage for proton beam therapy on the basis that it is not medically necessary.This patient has an early carcinoma of the prostate that can be cured with any form of radiation therapy. His cancer is T1c No Mo based on the records provided. Partins Tables suggest a 75% chance that the tumor is confined to the prostate, 23% chance of capsule involvement, and 2% chance of seminal vesicle involvement. Given the patients volume of cancer, any treatment modality that will deliver at least 7000 cGy to the prostate is adequate to treat this patient. Conventional radiation therapy can deliver 7000 cGy with minimal side effects. Further, the published scientific evidence does not demonstrate that proton beam therapy is a superior treatment to other forms of radiation therapy. 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

The patient is a 35-year-old obese woman who had gained 30 pounds over a one-year period. She was able to lose most of it while on a trial of Byetta. She now seeks authorization for coverage for Byetta from her Health Plan for further weight loss. She has sleep apnea and dyslipidemia by history and is worried about the possibility of developing diabetes. The Health Plan indicates Byetta is not approved for weight loss or for treatment of a metabolic syndrome or prediabetes.Based on the evidence provided, this patient does not have diabetes. Her physician raised the possibility of metabolic syndrome because of her obesity, unspecified dyslipidemia and one glucose reading (presumably fasting) greater than 100 mg/dl, which would be consistent with impaired fasting glucose or prediabetes, if persistent.Although the patient is concerned about developing diabetes there are several scientific peer-reviewed alternatives to diabetes prevention in susceptible populations including diet and exercise, metformin or acerbose. Given the availability of other alternatives, the use of Byetta is not medically warranted. Therefore, 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

This patient is a 50-year-old woman with painful arthritis involving her right and left knees. She has undergone arthroscopic procedures on both knees; the left in 2000 and the right in 2005. The patient has been treated with Synvisc injections in the past and found them to be beneficial. Her provider has requested authorization for a repeat series of bilateral Synvisc injections. The Health Plan denied the request based upon a determination that the therapy is not medically necessary.The patient is a relatively young woman with severe osteoarthritis who wishes to delay knee replacement. Her orthopedist reports significant relief with previous Synvisc injections and recommends an additional series at this time. Synvisc therapy is an appropriate intervention to alleviate pain and postpone surgical intervention and a repeat series of injections is a reasonable treatment option for this patient. 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 40-year-old female who has abdominal wall laxity that is an expected outcome of pregnancy and is a natural occurrence. She has requested authorization from her Health Plan for an abdominoplasty. The Health Plan has denied her request on the basis that the requested procedure is not medically necessary for treatment of the patients condition.The proposed abdominoplasty is not medically necessary.  The patient states that she has back pain due to her diastasis and abdominal wall laxity. The records, however, do not contain any PCP documentation of a workup or conservative treatment (e.g., physical therapy) for her back pain. Her back pain may be due to a lack of core muscle strength that could be improved with physical therapy or medically supervised strengthening. The medical literature does not include any studies that show that excess abdominal skin causes or exacerbates back pain. In any event, the proposed procedure is not a conventional option for the treatment of back pain. Abdominal wall reconstruction using the techniques described by Toranto or Ramirez (cited above) should certainly be considered as a last resort type of procedure for patients that have undergone a thorough evaluation to rule out other causes for back pain and have failed a regimen of more standard conservative treatments for their symptoms. This does not appear to be the case for this particular patient.This patient has diastasis recti.  According to Sabistons Textbook of Surgery, the most common variant of normal anatomy seen in the abdominal wall is diastasis recti.  This consists of an upper midline protrusion of the abdominal wall between the right and the left rectus abdominis muscles. This abnormality represents a weakness of the linea alba and does not require treatment unless an epigastric hernia occurs in association with the diastasis.  The records do not document that the patient had a true ventral or epigastric hernia and therefore, diastasis recti repair is not medically necessary.The proposed procedure is a standard cosmetic abdominoplasty to improve abdominal contour and remove excess skin. The requested procedure is cosmetic in nature and is not medically warranted.For the reasons stated above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 44-year-old female with previously diagnosed Bipolar Disorder having entered partial hospitalization in June 2006 due to extreme anxiety, depressed mood, feelings of hopelessness, disrupted sleep, and poor concentration. Relevant stressors included a divorce from her husband, child custody issues and pending judicial hearings. She was initially seen three to four times per week and was intended to continue attending with a frequency of one to three times per week as of August 2006. Due to insurance issues it appears PHP was discontinued in September 2006. The Health Plan has denied coverage for additional PHP services on the basis that they are not medically necessary.Overall, the patient suffers from Bipolar Disorder and has had some very serious consequences of her unbridled illness. She also appears to have an excess sensitivity or perceived sensitivity to medications, which are mainstay treatments of her illness, namely Depakote and Lamictal. As such, it is appropriate for the patient to be tried on other medications in order to stabilize her, eg., Lithium. Based on the notes submitted, she appears to have still been rather depressed and anxious by the end of PHP in September 2006. In light of the continued social stressors the patient is experiencing, she meets authorization for additional PHP services. She should receive PHP services three times a week for an additional four weeks with re-evaluation by her psychiatrist at the end of the four-week period.Based upon the information set forth above, I have determined the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 52-year-old female with a body mass index of 43.5. She has several comorbid conditions including hypertension, high cholesterol, gastric reflux disease, joint pain, and depression. She has a history of Hurthle cell carcinoma. The patient has undergone psychological evaluation. The findings of the evaluation did not indicate the patient is an unsuitable candidate for weight loss surgery. She wishes to proceed with bariatric surgery and has requested authorization for the procedure from the Health Plan.With a BMI of 43 and comorbid conditions such as hypertension, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that weight loss surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the obese.Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.