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

 The patient is a 54-year-old female who was diagnosed with glioblastoma in February 2006, at which time she was found to have a left hemispheric high grade glioma, not amenable to surgery. She was treated with radiation and concurrent temozolomide. Follow-up imaging with MRI in September 2006 showed enhancement outside the field of radiation involving the cerebral peduncle and pons, which was felt to be consistent with tumor progression. With regard to the patients functional status, she is unable to speak, though comprehension remains intact. Her KPS is reported at 70%. At issue is whether Tarceva (erlotinib) is medically necessary for treatment of the patients recurrent glioma.Gliomas are the most common of CNS tumors with over 50% being of the most virulent type, glioblastoma multiforme (GBM). Apart from resection and radiotherapy, chemotherapy has afforded only a modest benefit. One of the important discoveries to date is that 50% of gliomas (mainly GBM) have dysregulation of the EGFR pathway, hence the clinical evaluation of the EGFR pathway inhibitors including erlotinib and gefitinib. Erlotinib continues to be evaluated in clinical trials. A phase I study of erlotinib, with and without temozolomide, has been reported. In the entire cohort, 6 out of 57 patients had a progression free survival of 6 months or longer, including 4 patients who had a positive response (Prados MD, et.s al). However, as of yet there are no randomized or phase II results published on the use of erlotinib in brain tumors. Furthermore, National Comprehensive Cancer Network (NCCN) treatment guidelines do not support the use of erlotinib in this clinical setting. Instead, second-line agents listed include procarbazine, irinotecan, cisplatin and carboplatin. Any of these agents are more appropriate outside of a clinical trial. Thus, the use of erlotinib in this clinical setting is not supported by the medical literature and as such, is not medically warranted in this case.Based upon the information set forth above, I have determined the requested medication is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This patient is a 36-year-old female with sudden hearing loss. Audiological studies confirmed severe sensorineural hearing loss (SNHL) on the right. The patient was seen by an otolaryngologist and a seven-day course of prednisone and acyclovir was prescribed. Within the same timeframe, the patient consulted with an acupuncturist and received four acupuncture treatments. The patients hearing loss subsequently resolved, but the tinnitus has persisted. The patients request for reimbursement and prospective authorization for acupuncture treatment was denied by the Health Plan citing a lack of medically necessity.The studies reviewed had very split results and generally the Chinese studies reached the conclusion that acupuncture worked for SNHL and tinnitus. Studies in the context of traditional western medicine  came to the conclusion that this treatment is not effective. None of the studies were very powerful and conclusions were based on small sample sizes. These studies were not well-controlled or randomized would not withstand the scrutiny of peer review. As such, there is no compelling scientific evidence at this time that acupuncture, alone, can effectively reverse the effects of sudden SNHL. It may have had value as an adjuvant therapy, but the reversal of the patients sudden hearing loss was most likely due to steroid therapy. Additionally, there is no evidence to support the efficacy of on-going acupuncture therapy as treatment for residual tinnitus. Therefore, I have determined the therapy at issue was/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 60-year-old female with a history of neck and shoulder pain, status post cervical fusion in 1995. She has been treated with multiple medical regimens such as non-steroidal anti-inflammatory drugs, cox II inhibitors, muscle relaxants, Lido-derm patches, steroid injections, physical therapy, acupuncture and chiropractic therapy without sustained pain relief. A pain management specialist evaluated the patient in March 2006 and noted neck pain radiating to bilateral upper extremities and a pain level of 5-7/10. Studies, including a CT discogram, revealed degeneration of the zygapophyseal joints at C2-3 on the right, C3-4 on the right and C4-5 on the right. The consultant concluded the enrollees neck and shoulder pain may have been related to a combination of posterior element pain above and below her fusion and neural axial pain secondary to foraminal stenosis above her fusions. The specialty provider performed transforaminal epidural blocks at C4-5 and C6-7, cervical facet blocks at C4-5 and C6-7 and a cervical epidural block from C5 to T1. By report, the patient received significant pain relief from the procedures and has submitted a request for reimbursement. The Health Plan denied the request based upon a determination that this combination of procedures was not medically necessary.The patient has severe chronic pain syndrome. She tried and failed multiple conservative and interventional treatments and continued to have significant neck and shoulder pain. A pain management specialist evaluated the patient and offered treatment which provided durable pain relief. Imaging studies and discography demonstrated cervical degenerative joint disease and facet joint pathology and the patient had clearly exhausted all conservative treatment modalities. Epidural therapy and facet joint injection therapy were appropriate treatment alternatives given the severity of the patients pain and the failure of multiple conservative interventions. Therefore, I have determined the procedures 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

This patient is a 49-year-old female diagnosed with hepatitis C, liver cirrhosis, venous ulcers, degenerative disc disease and chronic pain syndrome. Multiple trails of medications had failed to manage her pain and her pain management specialist prescribed Actiq. Authorization was denied by the Health Plan and the patient paid out of pocket for the prescription. By report, Actiq has resulted in better pain control and improved functionality. The patients request for reimbursement and prospective authorization of Actiq was denied by the Health Plan based upon a determination that the medication is not medically necessary.The Health Plans denial is correct. Actiq is currently approved by the FDA for the management of cancer-related breakthrough pain. The medication has not been approved for the management of chronic pain due to non-cancer related syndromes. The use of Actiq in this context is not medically indicated and is not consistent with the community standard of care. Therefore, I have determined the medication at issue was/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 55-year-old woman who has a long history of chronic pain treated with analgesics. She has been tried on a multitude of opiate analgesics, anti-anxiety medications, and antidepressants without much relief. The patient has experienced increased tolerance of opiates as well as psychological dependence on the drugs. She has multiple physical problems, namely, fibromyalgia, hypertension, arthritis, hypothyroidism, colitis, chronic abdomen pain, and a history of abnormal heartbeat, chronic anemia, and hepatitis A. She also takes multiple medications. She lives with her husband and children; they are managing her medications, which is helping the situation somewhat. At issue is whether the patients admission to an inpatient detoxification program is medically necessary.The submitted documentation demonstrates the patient meets medical necessity criteria for inpatient detoxification services. The patient has documented opiate dependence as manifested by her increase in tolerability, psychological dependence, and opiate-seeking behavior. Although her motivation to seek help is present she continues to seek mind-altering chemicals. In other words, she does not demonstrate emotional motivation to say no to the opiates. She has multiple complex medical conditions and her use of medications for these conditions is a major risk factor for relapse. The patients participation in an inpatient detoxification program is within the standard of care and ASAM placement guidelines and should be authorized.For the reasons 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: Upheld Decision of Health Plan

The patient is a seven-year-old female with microcephaly, mental retardation and cerebral palsy with spastic quadriplegia. A detailed medical history was not submitted. The record indicates the patient was evaluated for outpatient physical therapy (PT) and participated from February 2006 to March 2006. She has also been evaluated for home therapies. The parent has requested that PT and OT be provided through a Home Health agency. The Health Plan denied his request based upon a determination that home therapies are not medically necessary.Concerns regarding the adequacy of the PT the patient has received thus far are valid. It is obvious from both the outpatient PT evaluation and the Home Health PT evaluation that neither therapist is experienced in treating children with cerebral palsy. A pediatric therapist experienced in treating patients with cerebral palsy is essential for this patient. However, there is no obvious need for the these therapies to be provided in the home environment. The Home Health aspect of the therapies appears to be a matter of convenience. The record did not include much medical history and the recent neurological evaluation and report were very limited. The need for Home Health PT and OT cannot be fully assessed without a complete medical history. Nonetheless, there is no indication of a medical condition that places the child at severe cardiopulmonary risk or an immunodeficiency creating a risk of infection in the outpatient setting. As there is no evidence that outpatient therapies would create an additional health risk for this patient, outpatient OT and PT therapy provided by therapists with pediatric experience would meet her medical needs. The therapists should establish functional goals that are measurable and progress to goals should be monitored by a pediatric physiatrist or pediatric orthopedist experienced in the treatment of patients with cerebral palsy. OT and PT evaluations should be completed at six month intervals to ensure the patient is making functional progress. If an evaluation does not document functional gain, transition to a monitored home program would be appropriate. In all likelihood, the patient would qualify for services at a Medical Therapy Unit through California Childrens Services, as eligibility is not income-based.Based upon the information set forth above, I have determined the requested Home Health therapies 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 45-year-old woman with an ankle fracture. During the course of her treatment a bone stimulator was utilized. The patient had proper immobilization of her fracture. It was noted at eight to ten weeks that she had no callus and persistent tenderness. Ultimately, it was felt she had a delayed union and surgical intervention was recommended. The patient is seeking reimbursement for the use of the bone growth stimulator. The Health Plan has denied her request citing a lack of medical necessity for the device.The use of a bone growth stimulator in this case was medically reasonable and acceptable. If the bone growth stimulator was effective, the patients pain would have diminished and her condition would have improved without the need for invasive treatment (i.e., surgery). Unfortunately, in this case union was not achieved and surgery was required. However, since the bone growth stimulator provided the potential of preventing the patient from having surgery, its use was clinically appropriate. Therefore, I have determined the device 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 five-year-old male with congenital central hypoventilation syndrome (CCHS). He underwent surgery in October 2005 for placement of diaphragmatic pacemakers. Previously, he had a tracheostomy and required mechanical ventilation. The patient was successfully decannulated in July 2006, and has since been monitored at night with continuous pulse oximetry and home health nursing. Nursing notes have documented normal oxygen saturations at night with no need for supplemental oxygen. However, multiple nurses have described very restless sleep and the need for frequent repositioning to maintain the integrity of the pacers and to ensure adequate oxygenation and ventilation. The parents request for continued authorization of home health nursing services (84 hours per week) was denied by the Health Plan based upon a determination that these services are no longer medically necessaryCCHS is an extremely rare disorder characterized by generally adequate ventilation while the patient is awake but alveolar hypoventilation with typically normal respiratory rates and shallow breathing (diminished tidal volume) during sleep. Those who are more severely affected demonstrate hypoventilation during wakefulness as well as sleep. All CCHS patients lack the appropriate arousal response to hypoxemia and hypercarbia, putting them at long-term risk for cardiac abnormalities (e.g. right heart failure), pulmonary hypertension, and death. Generally, the management of CCHS involves ventilatory support: tracheostomy with mechanical ventilation or diaphragmatic pacing. Diaphragmatic pacing may allow more freedom for those who require ventilatory support only during sleep. Children with CCHS must be managed with extreme vigilance. There is no inherent physiological response to hypoxemia or hypercarbia. Even during waking hours, these children will not experience shortness of breath in response to pneumonia or increase their respiratory rate in response to physical exertion. Frequently, patients with CCHS will not develop fever in response to infection. Severe respiratory distress can occur with minimal external manifestations. In addition, children with CCHS do not pace themselves appropriately during strenuous exercise because they cannot sense hypoxemia or hypercarbia. The literature also reports that autonomic dysfunction and cardiac abnormalities are common in CCHS.The patient is at significant risk for complications from his disorder. He is being successfully managed now with vigilant nursing care while he sleeps. Not only does the home health nursing staff ensure adequate functioning of the pacers, but their constant vigilance allows for early identification and intervention with any event that could compromise the patients already tenuous cardiopulmonary status. Therefore, 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: Upheld Decision of Health Plan

The patient is a 64-year-old male diagnosed with multiple myeloma that developed compression fractures of the thoracic and lumbar spine. He underwent three separate kyphoplasty procedures in April 2006, April 2006 and May 2006 which he indicates provided relief of his symptoms. The operative reports from April 2006 indicate an assistant or co-surgeon was utilized for these procedures. The Health Plan denied the patients request for reimbursement of the assistant surgeons charges based upon their determination that the services were not medically necessary.An assistant surgeon is defined as a physician who actively assists the operating surgeon in the performance of a surgical procedure. In this situation, one physician is acting as the surgeon and the other is acting under the direct supervision of the operating physician. In determining the need for an assistant surgeon, consideration is given to the complexity of the procedure and the condition of the patient. Kyphoplasty is typically performed by a single operating surgeon without an assistant. The procedure in this instance was not of sufficient complexity to require the use of an assistant surgeon. Accordingly, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 28-year-old female with a history of right ankle pain and clicking that began in 2004. There is no known injury or trauma; however x-ray showed mild anterior joint narrowing with osteopenia. Treatment consisted of non-steroidal anti-inflammatory medication and physical therapy. Physical therapy failed to improve her symptoms and she was referred to podiatry and then orthopedic surgery. An MRI of the right ankle in October 2004 revealed the talus had a large osteochondral defect medially. The lesion was approximately 20 by 15 millimeters. The patient was offered two surgical options and chose the less invasive. Right ankle arthroscopy, debridement of the osteochondral lesion and microfracture of the osteochondral lesion was performed in December 2004. The operative record indicated that the size of the lesion appeared to be at least 2.5 centimeters x 1.5 centimeters; larger than anticipated by preoperative imaging studies and her orthopedist expressed concern that the microfracture would not provide adequate healing. Postoperatively the patient continued to have pain and clicking and an osteochondral autograft transfer system procedure was planned, but postponed due to the patients pregnancy. MRI in March 2006 noted the ankle defect was smaller in size and a March 2006 progress note reported minimal pain and occasional clicking. The patients request for authorization of the osteochondral allograft was denied by the Health Plan citing a lack of medical necessity.The patient had a large osteochondral defect that did not respond to debridement and microfracture. Without further surgical intervention the patient is at risk for degenerative joint disease of the ankle. Osteochondral allograft transplant is the appropriate next step in her course of treatment. Therefore, I have determined 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: Overturned Decision of Health Plan

The patient is a 36-year-old male who underwent extensive surgery to his left knee, including ACL reconstruction and partial meniscectomy. Postoperatively he utilized a cold therapy unit as prescribed by his orthopedic surgeon. He is now requesting reimbursement for the rental cost of the device. The Health Plan denied his request based upon their determination that the cold therapy unit was not medically necessary following the patients surgery. A cold therapy unit is commonly prescribed by surgeons for postoperative rehabilitation following reconstructive surgery. The cool water is encompassed in a pad that wraps around the knee and is incorporated in the post operative dressing. This device is extremely helpful in relieving postoperative pain and swelling. The pad and unit are easy to use and several studies have shown the cold therapy unit is superior to ice packs alone with respect to postoperative recovery. Therefore, I have determined the device at issue was 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 15-year-old male with gynecomastia. According to the record he is not having pain or other physiologic problems related to his breast enlargement. He is said to suffer from low self-esteem, but there is no record of psychological counseling or psychotherapy included for review. The patients parent has requested authorization for bilateral reduction mammoplasty. The request was denied by the Health Plan based upon a determination that the procedure is not medically necessary.The record indicates the patient is obese, and obesity is a well-recognized cause of pubertal gynecomastia. According to Georgiadis, et al idiopathic gynecomastia is closely correlated with generalized obesity and reduced LH and testosterone levels which may be the result of increased conversion of testosterone to estradiol in increased adipose tissue mass. Weight loss is likely to improve this condition. The literature further indicates that gynecomastia generally resolves by age 18 when adult hormonal balance is achieved. Lazala and Saenger recommend delaying surgical intervention until puberty is completed, or nearly completed. The American Society of Plastic Surgeons (ASPS) reports that gynecomastia occurs in 38% of males ages 10 to 16 years. The ASPS attributes physiologic gynecomastia to an altered estrogen/androgen balance or to an increased sensitivity of breast tissue to a normal estrogen level and indicates that 90% of all cases will resolve spontaneously within three years. Where there is a pathological etiology for the gynecomastia such as obesity, the ASPS guidelines recommend six months of medical treatment prior to surgery. In this instance, the records do not document any medically supervised attempts at weight loss. Although reduction mammoplasty may seem appropriate from an aesthetic standpoint, a more conservative treatment approach focusing on weight loss and a waiting period for the patient to progress through puberty may accomplish the same goal and make the surgery unnecessary.  Based upon the information set forth 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 64-year-old male who has had chronic lumbar pain following a lumbar fusion at L4-5 and L5-S1. Because of persistent pain, an analgesic discogram has been recommended. The patient has requested authorization and coverage for the proposed discogram, which the Health Plan has denied on the basis that this diagnostic procedure is not medically necessary.An analgesic discogram is likely to be helpful in this case as it will aid in the patients providers ability to establish a cause for the patients persistent pain. Discography has established clinical utility in cases such as this that appear to involve multi-level disc pathology. It can help render a diagnosis which is needed in order to formulate an adequate treatment plan. Analgesic discography is the appropriate next step for this patient and the procedure should be authorized. Therefore, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.