Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A forty-eight year-old male with stage T4 pancreatic cancer is requesting coverage of stereotactic radiosurgery.  Reviewers Findings:  The reviewing physician found that there is no scientific evidence demonstrating that stereotactic radiosurgery will result in any improvement in the patients condition.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 48-year-old woman who was first diagnosed with breast cancer in June 2004. At that time she was found to have a poorly differentiated invasive ductal adenocarcinoma, 2cm in size. Estrogen and progesterone receptors were negative. HER2-neu assay was also negative. Surgical options and chemotherapy were recommended to the patient but she declined, preferring instead to pursue holistic therapies.In October 2004, the patient was found to have diffuse bone metastases, as well as liver metastases. She elected to pursue non-conventional treatment in Germany. Currently, the patient has requested therapy with Herceptin, which has been denied by the Health Plan on the basis it is not medically necessary for treatment of the patients condition.Herceptin is an antibody with real usefulness in the treatment of metastatic breast cancer and has very low toxicity. However, its efficacy completely depends upon the presence of over expression of the HER2 gene by the cancer cells. Such positivity is only present in about 25% of breast cancers. Given that the patients cells do not demonstrate over expression of the gene, Herceptin will not be of any value in her treatment and therefore, is not clinically indicated. Accordingly, I have determined that 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

The patient is a 10-month-old male whose parents wished him to be circumcised in the neonatal period. However, he had medical problems including aspiration pneumonia and gastroesophageal reflux requiring hospitalization for medical treatment in the neonatal intensive care unit. He could not have a circumcision then and for some time afterwards due to his medical condition. He has by now recovered from those medical problems well enough to undergo circumcision, and the parents wish to have it performed. The patients primary care physician referred the patient to an urologist and the patients parents have consulted with the urologist for the purpose of having their child circumcised. However, the Health Plan, which would have covered as a medical routine circumcision in the neonatal period, has denied authorization.The American Academy of Pediatrics 1999 Task Force on Circumcision concluded that parents should determine what is in the best interest of the child after being counseled regarding the potential benefits and risks of this elective procedure. That is the current situation in this case - the parents wish to have their child circumcised. The Health Plan would have authorized the procedure as a covered benefit in the neonatal period, but as much as the parents wanted it performed then, the patient was not in medical condition to have it performed. The patient is currently in the appropriate condition to have the circumcision performed. The circumcision, which was delayed during the neonatal period due to medical reasons, should be authorized and performed. Therefore, I have determined that the requested procedure is necessary for treatment of the enrollees medical condition. The Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 43-year-old male who has been evaluated by a plastic surgeon on referral by his primary care physician for gynecomastia. The patient apparently stated that the breast tissue has been painful for several years. His primary care physician noted complaint of painful gynecomastia, but no treatment other than referral is noted. His plastic surgeon has requested authorization for bilateral breast lipectomy, which was denied by the Health Plan on the basis that the requested procedure is not medically necessary.Review of the submitted photographic evidence of the patient, as well as the notes of the patients primary care physician, cardiologist, and his plastic surgeon does not demonstrate the requested procedure is medically necessary. These records lack evidence of diagnostic findings and/or treatment regimens for the patients gynecomastia. Based upon the American Society of Plastic Surgeons Guidelines, the clinical findings do not support surgical intervention at this time. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 39-year-old female with a history of Cushings disease status post one-third partial hypophysectomy. She reports current symptoms of decreased energy, poor sleep and exercise intolerance. Physical findings of central obesity, and decreased lean body mass have been noted. A consulting endocrinologist indicated the patient is now growth hormone (GH) deficient based on a minimally decreased IGF-1 (100 with N1 greater than 106) and a barely positive argentine/GHRH (10 mg GH deficiency less than or equal to 9) stimulation test. It is noted that her weight increased from 125 pounds in 2000 to her current weight of 178 pounds. Additional reported signs and symptoms include fatigue, fibromyalgia like pain, panic attacks, irritability, and decreased memory. The patients provider indicates the patient has hypothyroidism for which she is on replacement medication.Medications include 10 different psychotropic drugs. It is unknown what medications were/are taken concurrently. Laboratory studies reveal elevated PRL, normal thyroid studies, and equivocal androgen and estrogen levels. An imaging study revealed normal pituitary gland. Pathology revealed no definitive findings of Cushings disease. The patients provider has recommended GH therapy for the patient. The Health Plan has denied the request indicating GH therapy is not medically necessary.Review of the submitted documentation reveals findings of a normal MRI, normal ACTH, and minimally elevated 24hr UFC on a single occasion (which can occur with obesity and/or depression). In light of these findings, the initial diagnosis of Cushings disease is questionable.Though the patient is status post one-third partial hypophysectomy, most people can function normally with two-thirds of their pituitary. The patients minimally decreased IGF-1 could be due to her excess weight. It is not likely the reported hypothyroidism is due to pituitary disease. The patients physical findings and galactorrhea can be ascribed to possible polycystic ovary syndrome with an elevated PRL. The pituitary pathology report does not support a diagnosis of Cushings disease. Given the evidence provided, it appears a full pituitary hormone evaluation should be performed including repeat PRL, plus LH, FSH and ITT for growth hormone stimulation. Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 60-year-old female who has symptomatic large recurrent varicose veins on the left side. She is status post left side greater saphenous vein stripping. The photographs, history, and physicians findings confirm this. The patient has requested authorization and coverage for varicose vein surgery. The Health Plan has denied the request on the basis the requested surgery is not medically necessary. Review of the submitted documentation does not demonstrate the patients condition warrants surgical intervention at this time. There is no evidence the patient has undergone a recent trial of conservative treatment. If the patient fails to receive benefit from a trial of compression stockings, then her request for varicose vein surgery should be reconsidered. Accordingly, I have determined that the requested surgery is not medically necessary for treatment of the patients medical condition at this time. The Health Plans denial should be upheld at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 28-year-old female with a history of Achilles tendonitis. She has attempted physical therapy without success. Her provider has recommended an RS-4i stimulator for the patient. The Health Plan considers this experimental and has denied authorization.There is no class I literature supporting the use of the RS-4i sequential stimulator in cases of Achilles tendonitis. This is considered an experimental treatment and is not the standard of care. Furthermore, there are available therapies with established efficacy for treatment of this patients condition. Therefore, because of the lack of evidence supporting the efficacy of the requested RS-4i sequential stimulator, I have determined the requested equipment 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.Physician 2: The patient is a 28-year-old female with pain and tightness at the Achilles/gastrocnemius junction consistent with Achilles tendonitis. Her condition has not responded to numerous treatment modalities, which have included taping, soft tissue mobilization, ultrasound with phonophoresis, electrical stimulation with iontophoresis, and a home exercise program. She has been unable to return to her full range of activities. Use of an RS-4i sequential stimulator has been requested by the patients treating physician with the Health Plan denying authorization.There are many physical modalities currently utilized in the management of tendon disorders. Ultrasound, phonophoresis, electrical stimulation, and iontophoresis are routinely prescribed in clinical practice for patients with tendonitis and tendonosis. Scientific evidence on the effectiveness of these standard physical modalities is sparse and controversial. In the case of inferential stimulation, there is an absence of scientific evidence demonstrating that it is more effective than standard available therapies. Therefore, I have determined the requested equipment 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.Physician 3: The patient is a 28-year-old female with Achilles tendonitis. She has attempted a number of treatments without sustained benefit. A request has been made for an RS-4i stimulator.The requested equipment is neither required nor necessary for treatment of the patients condition. Achilles tendonitis is treated with rest, medication, physical therapy, home exercise, and may include ultrasound and electrical stimulation with a TENS unit. There is no prospective study demonstrating any advantage of an RS-4i stimulator over any other electrical stimulation product.Based upon the information set forth above, I have determined the requested equipment 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 42-year-old female who requested reimbursement for surgical procedures she underwent on 11/18/03. The Health Plan has denied this request indicating the surgery was not medically necessary for treatment of her pelvic pain. The patient has a 20-year history of pelvic pain. She has had multiple laparoscopic procedures for excision of endometriosis without significant improvement. In addition, she has been treated with pain medication and antidepressants.Review of the submitted clinical information reveals the diagnostic laparoscopy was medically appropriate. The lysis of adhesions, left salpingoectomy, and excision of the endometriosis are within the standard of practice for patients such as this patient. The issue of a hernia repair would have been best left to a preoperative MRI and consultation with a general surgeon and was not medically necessary based upon the information provided. The pudendal nerve block was not medically necessary or appropriate since long-term benefit is not expected. The hysteroscopy and D & C were medically warranted because of a thickened endometrial on sonogram. The uterine suspension and myomectomy did not have any medical indication. Plication of the round ligaments is not an effective method to treat retroversion and myomectomy of an asymptomatic fibroid was not medically warranted.Accordingly, I have determined a portion of the procedures at issue were within the standard of practice and medically necessary for treatment of the patients condition. Specifically, the diagnostic laparoscopy, lysis of adhesions, left salpingoectomy, excision of endometriosis, hysteroscopy, and D & C are were medically necessary for treatment of the patients medical condition. The other procedures performed on 11/18/03 were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 40-year-old female who has a long history of obsessive-compulsive disorder (OCD). Though she has been attending twice-weekly cognitive behavioral therapy sessions she has not achieved an adequate response to therapy. The patients medications include Paxil. She wants to have another child and therefore is tapering her medications. The patients provider has recommended the patient attend intensive outpatient cognitive-behavioral therapy. The Health Plan has determined the requested therapy is not medically necessary.Review of the submitted clinical information indicates the patient has been on Paxil, an SSRI. Though SSRIs have been used throughout pregnancy, they are a category C drug (meaning risk is present). The patient should have the option of a medication-free pregnancy. It is likely the patient will obtain good results from intensive cognitive-behavioral therapy alone. Therefore, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 56-year-old female with degenerative disc disease. She had a herniated disc at L5-S1 and underwent subsequent microdiscectomy. Her provider is recommending artificial disc replacement. The Health Plan considers this procedure experimental.The Health Plan is correct that the proposed procedure is considered experimental. There is no evidence to support disc replacement surgery for this patient. The proposed procedure is still under investigation and is not considered standard of care. The long-term success rate and safety profile remain unknown. Because there is no evidence supporting the long-term safety and efficacy of the proposed procedure, 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 56-year-old woman who has degenerative disc disease at L5-S1 and facet sclerosis. She underwent microdiscectomy in December 2004 and had temporary relief. She is now symptomatic and has requested an artificial disc replacement. The Health Plan has denied her request on the basis the requested procedure is considered investigational.The current clinical evidence regarding the artificial 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, artificial 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.Physician 3: The patient is a 56-year-old female with degenerative disc disease at L5-S1. The patient is status post a microdiscectomy. She is requesting authorization for artificial disc replacement. The Health Plan has denied authorization for the requested procedure.The proposed procedure is experimental without established long-term efficacy. The best published results reveal outcomes equivalent to fusion. However, the majority of studies show a failure rate of 35%. Furthermore, the long-term safety profile is unknown. In addition, 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 44-year-old female with apparent panic disorder. She has been treated with Klonopin in both pill and wafer form. The patients current dosage of Klonopin is unknown. The patient has requested authorization and coverage for Klonopin wafers for rapid treatment of panic symptoms. The Health Plan has denied the request on the basis the requested medication is not medically necessary.The Health Plans denial should be upheld. Based upon the information provided, it appears the patient may be undertreated with the pill form of Klonopin at present. Usually, Klonopin is absorbed in 1 to 4 hours with a 30 to 40 hour elimination half-life, making it a long-acting benzodiazepine. Furthermore, other medications (e.g., SSRIs, tricyclic antidepressants, mood stabilizers) could be used in addition to therapy for relaxation techniques. Moreover, there is no evidence the patient has difficulty swallowing pills. Thus, there is no medical indication for the use of Klonopin wafers in this case. 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

The patient is a 36-year-old male with a body mass index (BMI) of 59.3. The patient has multiple comorbidities including sleep apnea. The patient reports multiple failed attempts at diets, all of which have resulted in weight regain. The patients provider has recommended the patient undergo gastric bypass with duodenal switch. The Health Plan indicates the long-term safety and efficacy of the procedure has not been established.The patient is an appropriate candidate for surgical intervention to treat his morbid obesity. There is more than substantial data in the literature to support the use of duodenal switch to accomplish this goal. Consequently, duodenal switch is an accepted and medically necessary procedure for this patients medical condition. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 15-year-old female with severe mandibular prognathism (hypoplasia) as documented by photographs, x-rays, and cephalometric analysis. Anterior/posterior dental discrepancy is around 9 mm, more than 2 standard deviations from normal dental occlusion. The submitted medical records show three severely dysfunctional dental malocclusions, untreatable with orthodontic therapy, which will worsen over time. The patients provider has recommended a bilateral sagittal spilt mandibular osteotomy. The Health Plan indicates the requested procedure is not medically necessary.This treatment plan consisting of bilateral mandibular osteotomies is medically appropriate and the patient meets medical necessity standards for surgical intervention. The occlusion is clearly abnormal; the occlusion does produce signs of masticatory dysfunction as seen in the medical records; the structure/abnormality is congenital as seen by the grossly distorted development; and the deformity is two standard deviations or more on cephalometric analysis. Non-surgical treatment will not correct the problem. Therefore, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A review of the medical records indicates the patient is a 56-year-old male with a history of obesity, hypertension, and hyperlipidemia. In addition, the patient self reports a history of sleep apnea and leg pain. The patients provider has recommended a weight management program for significant and sustained weight reduction. The Health Plan has denied this request.The Health Plans denial should be upheld. There is no documentation demonstrating the requested weight management program is medically necessary. The patient has unsuccessfully attempted a weight management program within the last five years. According to the information provided, the patient voluntarily withdrew from the program prior to meeting his weight reduction goals. It is medically reasonable and appropriate for the patient to undergo a nutritional evaluation with a dietician and attempt a physician supervised diet program with his present primary care provider. There is significant evidence demonstrating programs such as Weight Watchers can be successful. Furthermore, there is potential that low calorie meal planning in conjunction with aerobic exercise under the supervision of the patients primary care provider could be successful. As such, there is no evidence that the requested weight management program is medically necessary. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 53-year-old male with moderate to severe atrophy of the maxillary anterior ridge and well pneumotized maxillary sinuses. He is currently wearing a maxillary full denture. Records do not indicate any history of malnutrition. Dental records from October 2004 indicate an obese patient wearing a full upper denture with fair retention and a partial lower denture. The patients treatment plan is for bone grafting to allow placement of dental implants for improved retention of his denture.The requested procedure is dental in nature and will provide improved retention of a maxillary denture. However, the patient does not have a medical condition that has resulted from the wearing of a full maxillary denture for 37 years. As stated above submitted records provide no evidence of malnutrition with fair retention of the upper denture. Therefore, based upon the records provided, there is no evidence the requested procedure is medically necessary. As such, the Health Plans denial should be upheld.