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

The patient is a 53-year-old male who has a history of gastrointestinal bleed due to NSAID medication. He has rheumatoid arthritis and bilateral carpel tunnel syndrome and has been tried on Celebrex with good results. He wishes to continue on Celebrex and has requested authorization and coverage for the medication from the Health Plan. The Health Plan has denied his request indicating the patient has not tried and failed an NSAID and a proton pump inhibitor combination. At issue is whether Celebrex is medically necessary for the patient.Review of the submitted clinical information indicates Celebrex has been beneficial for the patient. There is no reason to have the patient try and fail another NSAID and risk sustaining another GI bleed. Celebrex has been shown to be effective in his case and its continued use by the patient is medically appropriate and clinically indicated given his history of GI bleed. Therefore, I have determined 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 a 58-year-old man with a three-year history of post-traumatic right head pain. He responded partially to occipital nerve blocks for two weeks, but developed tenderness at the site of injection. He had two weeks of pain relief after a right C2-3 nerve block and partial response to indomethacin. Lyrica was initially helpful at a dose of 50mg. The dose was subsequently increased, but the patients response is not documented. He is now seeking authorization and coverage for botulinum toxin injections. The Health Plan has denied his request on the basis that the requested injections are not medically necessaryThe patient has post-traumatic pain syndrome involving the right side of the head. He did respond to a C2-3 block, occipital nerve block and Lyrica, to some degree. The records indicate the patients pain is usually mild and not disabling. There is no evidence the patient has been tried on a variety of standard therapies including tricyclic antidepressants or antiepileptic drugs that have been useful for pain (e.g., topiramate, gabitril, etc.). In addition, another trial of nerve root block may be appropriate in this setting. Furthermore, although botulinum toxin has reasonable data in the treatment of chronic migraine, there are only scattered case reports of its use in occipital neuralgia. All told, there are multiple standard therapies, which have not been utilized in this case and should be attempted prior to consideration of botulinum toxin.For the reasons set forth above, I have determined the requested injections 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

This patient is a 32-year-old female who is currently pregnant and has not been diagnosed with cancer. However, the patients mother was recently diagnosed with ovarian cancer and the mothers sister died of breast cancer and her age at diagnosis is unknown. The patients mothers mother died of cervical/uterine cancer and her mothers brother may have colon cancer, but this has not been confirmed.  Due to her family history, the patient is requesting authorization for BRCA testing to detect a genetic susceptibility to cancer. The Health Plan denied her request for authorization citing a lack of medical necessity.BRCA testing detects certain gene mutations that significantly increase the risk of ovarian and/or breast cancer. These mutations are usually detected in families wherein there are a number of young women with breast cancer and/or ovarian cancer; overall these are rare findings. Criteria have been established so that the testing is only done in women who might reasonably test positive. In women who have not had cancer, the Health Plans authorization criteria require a family history of three or more relatives with breast or ovarian cancer, at least one of which is a first degree relative (e.g. mother or sister). These criteria provide a reasonable method for determining if BRCA testing is medically indicated, and the patient clearly does not meet the criteria. Therefore, I have determined the requested services are 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 45-year-old female with neuropathic pain in her feet and a clinical diagnosis of tarsal tunnel syndrome has been made. The record did not include evidence of electro-diagnostic testing to confirm or disprove a diagnosis of polyneuropathy versus focal entrapment neuropathies. The patient is said to have failed treatment with Neurontin at an unspecified dosage and it is not noted whether she failed due to side-effects or lack of benefit at the maximal dosage. The patient appears to be tolerating Lyrica and indicates a benefit in reduction of pain symptoms. The patients provider indicates there is less than complete relief of the patients symptoms with Lyrica, and other than Neurontin, there is no indication other medications have been utilized for treatment of the patients peripheral neuropathic pain. The patients request for reimbursement and prospective authorization of Lyrica was denied by the Health Plan based upon a determination that the medication is not medically necessary.The patient has a diagnosis of neuropathic pain disorder which may represent bilateral focal mononeuropathies (tarsal tunnel) or an idiopathic polyneuropathy. There are no medications specifically approved for either condition and a review of the literature did not reveal relevant studies involving Lyrica. However, medications useful for the treatment of diabetic polyneuropathy are often useful in the treatment of polyneuropathies from other causes as well as idiopathic polyneuropathy. Diabetic neuropathic pain is potentially responsive to tricyclic agents, Neurontin, or opiates. A treatment approach for a case such as this one can reasonably be extrapolated from data and experience with diabetic neuropathy. If Neurontin were to be halted with an absence of side-effects, it could be re-tried, and titrated as high as 1800mg per day or to the point of benefit or failure due to side-effects. A trial of tricyclic medications or opiates at bedtime may also be helpful. These first-line medications should be shown to be ineffective before on-going management of the patients neuropathic pain with Lyrica is appropriate.Based upon the information set forth above, 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: Upheld Decision of Health Plan

The patient is a 20 year old male who underwent surgical removal of four impacted third molars in January 2006 at the age of 19. The procedure was performed under general anesthesia. The Health Plan has denied reimbursement for the general anesthesia services indicating the services were not medically necessary.The question to be answered is whether it was medically necessary to have general anesthesia for the surgical removal of four impacted third molars. Medical necessity for general anesthesia is determined either by the complexity of the surgical procedure being performed or by the presence of an underlying medical condition for which general anesthesia is required. Review of the submitted records indicates the patient was a healthy, American Society of Anesthesiology Class I, 19-year-old male with no significant medical or emotional conditions that necessitated general anesthesia. In addition, the submitted records indicate that it required 14 minutes for the surgeon to surgically remove all four impacted wisdom teeth. This strongly suggests that there was no unusual complexity to the surgical procedure that would necessitate general anesthesia. Consequently, medical necessity for general anesthesia has not been established.For the reasons stated above, 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: Upheld Decision of Health Plan

The patient is a 62-year-old woman who has a history of gastroparesis. She has low back pain and diabetes and is on multiple medications. The patient takes naloxone to treat her narcotic induced constipation. She has requested authorization and coverage for continued use of naloxone. The Health Plan has denied her request on the basis that the requested medication is not medically necessary.The Health Plans denial is correct. While naloxone has been effective in reversing the effects of narcotics in cases involving opioid overdose, the use of this medication to treat constipation induced by narcotics is quite unusual. This is neither the standard of care nor the community standard. There are other ways to treat the patients condition that are more clinically appropriate. 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 55-year-old woman who had painful keloids of her abdomen including the epigastric/inframmary area of the lower abdomen, which were surgically removed at the time of gallbladder surgery in September 2005. Shortly thereafter, she received radiation therapy in an effort to prevent recurrence of the keloids; unfortunately, some of the painful keloids did recur. The patient was subsequently treated by a dermatologist with intralesional Kenalog with some improvement. Both the patient and her dermatologist want the intralesional Kenalog treatments to continue because the keloids are painful and itchy. The Health Plan has denied coverage for continued follow-up with the patients dermatologist for Kenalog injections on the basis that treatment of the patients keloids is not medically necessary.The treatment of painful, itchy keloids is medically necessary. Pain and itching results in functional impairment. Intralesional corticosteroid treatment is a universally accepted form of treatment for painful, itchy keloids. Dermatologists are the physicians best qualified to administer and assess this treatment because of their training and experience. 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 50-year-old female who is requesting coverage for the medication Actiq for severe axial neck pain due to minimal degenerative cervical spine arthritis and a small left local disc protrusion at C5-6. The Health Plan has denied coverage for Actiq on the basis that it is not medically necessary for the patients chronic pain.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 neck pain secondary to cervical spine disease. 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: Upheld Decision of Health Plan

The patient is a 59-year-old woman who had a diagnosis of low bone mass sometime prior to December 2003. She has been on Fosamax and Evista for an unknown period of time. Two DEXA scans performed in December 2004 and December 2005 revealed stable osteopenia of an undisclosed aspect of her lumbar spine. In a letter dated June 2006 the patients provider states that she is having an unspecified toxic reaction to something in her environment. He apparently obtained the second scan in preparation for stopping Evista to see if it was the cause of her toxic reaction.It is unknown whether the Evista was indeed stopped after the scan. At issue is whether the repeat DEXA scan in December 2005 was medically necessary.The patient was being treated with Fosamax and Evista for osteopenia of unspecified lumbar vertebrae. For unstated reasons, her internist believed Evista might have been causing an unspecified toxic reaction. A second DEXA scan was ordered just one year after her previous scan to reassess her bone density prior to discontinuing the Evista.It is the standard of care to order a scan every two years to assess response to therapy. The patients provider was concerned about a toxic reaction to Evista and therefore was planning to discontinue the drug. It is not likely the results of the DEXA scan would have altered this decision in light of the concerns over toxicity. The submitted records do not demonstrate any appropriate clinical indication for a repeat DEXA scan one year after the patients previous scan. Accordingly, I have determined the DEXA scan at issue was not medically necessary for evaluation 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 three-year-old female with a diagnosis of velocardiofacial syndrome with a history of global developmental delay with specific delays in gross motor skills. The patient has been receiving physical therapy for the gross motor delays since October 2004. In October 2005 the therapist documented gross motor delays at a 14-month level. In November 2005 the patient transitioned to another physical therapist and received seven therapy sessions from December 2005 to March 2006. At issue is whether continued physical therapy for the gross motor delays associated with velocardiofacial syndrome is medically necessary.   Review of the medical literature reveals no applicable scientific studies to support or refute the efficacy of physical therapy in patients with developmental delay.  However, physical therapy is commonly used to treat patients with developmental delay to address the goals as outlined in the clinical evaluation by the patients private therapist dated October 2005.  The goals as outlined are functional goals (walking up and down steps, single limb stance for dressing, and decreasing falls while running), which can be achieved in a reasonable amount of time. Since the family has stairs within the home this is not simply a school matter. The therapy, if successful, will significantly reduce the risk of falls.Chromosomal defects are a developmental condition.  However, there is no evidence that the patients condition precludes the efficacy of physical therapy. In this case the request for therapy is for specific treatment of motor strength and coordination to improve functional goals and is amenable to physical therapy. Physical therapy is warranted for the specific goals described. The therapy should be monitored every three months by a pediatric rehabilitation physician or developmental pediatrician experienced in prescribing therapies to ensure progress is being made.  If progress is not being made then a home program for the family should be established.For the reasons set forth above, 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: Overturned Decision of Health Plan

The patient is a 61-year-old male who is requesting authorization to have carpal tunnel release performed by a neurosurgeon rather than an orthopedic surgeon as proposed by his Health Plan. At issue is whether a referral to a neurosurgeon is medically necessary.The patient and his neurologist are requesting that the surgery be performed by a neurosurgeon. The Health Plan has proposed that an orthopedic surgeon perform the procedure. Neurosurgeons receive a substantial amount of training in carpal tunnel release as a standard part of their residency. The submitted evidence does not establish that orthopedists have training and experience in this surgical procedure that is equivalent to a neurosurgeon. Therefore, I have determined that the requested referral 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 59-year-old woman who has atonic bladder secondary to nerve damage from lumbar surgery. This requires intermittent self-catheterization four to six times per day. The technique is clean and the catheters can be washed and safely reused again. The patient is not chronically infected, nor does she have compromised immunity. She has requested authorization for 20 catheters per month to accommodate her needs when she is not at home. The Health Plan has authorized four catheters per month.The Health Plans approval of four catheters per month is too restrictive. Even with clean technique and re-washing, four catheters per month do not allow for the usual variations of daily living for a person who is not housebound. Approval of three catheters per week (15 per month) would be medically reasonable and appropriate in this particular setting. Therefore, I have determined that 15 catheters per month are medically necessary for treatment of the patients medical condition. Accordingly, Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient is a 46-year-old woman who underwent right total knee replacement in April 2005 due to osteoarthritis. Postoperatively, she developed arthrofibrosis with range of motion limited to 88 degrees; joint manipulation was performed under general anesthetic in June 2006. The continuous passive motion (CPM) machine along with physical therapy was prescribed by her orthopedic surgeon following the manipulation to maintain her range of motion. The patient is now requesting reimbursement for the rental cost of the device. The Health Plan denied her request based upon their determination that the CPM machine was not medically necessary following the patients right knee manipulation. A CPM device is the standard of care for postoperative rehabilitation following knee replacement. Patient compliance is high and many surgeons find that patients regain their range of motion faster and have better pain control with the device. In this case, the CPM machine was also prescribed to preserve the patients range of motion following manipulation of the knee. Mobilization of the joint was imperative for a patient such as this one to avoid loss of motion and the need for additional manipulation in the future. 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 62-year-old female enrollee who has daily headaches which have responded to Myobloc and Botox injections. She has an extended history of migraine with worsening of the headaches after two aneurysm surgeries. The patient has been treated with Topamax, Depakote, Neurontin, Inderal, verapamil, amitriptyline, Indocin, and Stadol. She is currently taking Topamax for treatment of both her seizures and her headaches. The patient began treatment with Myobloc/Botox injections about four years ago and the therapy has consistently reduced the severity of her headaches for three to four months and decreased her headache related disability. The patient has requested reimbursement for Botox injections provided from January 2006 through the present and future authorization and coverage for this therapy.  The Health Plan denied her request citing a lack of medical necessity.The patient has persistent migraine and chronic daily headaches. She has failed to respond to at least five preventative medications, and there are several migraine medications that are contraindicated due to her previous aneurysms and seizure disorder.  Myobloc/Botox injections have been used effectively for over four years and the patients pain level is reduced for several months following treatment. Myobloc/Botox injections are clearly beneficial for this patient and continued treatment is consistent with the standard of care within the neurological community. As such, 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 55-year old male with a history of left hand pain and numbness who underwent uncomplicated carpal tunnel surgery (CPT Code 64721) in January 2006. The surgery involved decompression of the left median nerve and limited flexor tenosynovectomy. The services of an assistant surgeon were utilized for the procedure and the patient is requesting reimbursement for the cost incurred.  The Health Plan denied his request based upon their determination that a surgical assistant was not medically necessary.According to the American College of Surgeons, an assistant surgeon is sometimes necessary for CPT Code 64721. The operative note in this case does not document any added complexity that would have necessitated an assistant surgeon for this patients procedure. The majority of hand surgeons do not utilize an assistant for open carpal tunnel release surgery, as this type of surgery can generally be performed with self-retaining retractors and assistance from a surgical nurse. For these reasons, 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 51-year-old female with metastatic GI stromal tumor (GIST). She underwent chemotherapy and surgery in 2005. The patient had CT scans in January 2006 and April 2006 and PET/CT scans in August 2005 and April 2006. A follow-up CT scan performed in July 2006 showed no change in the right pleural effusion, and slight decrease in the right lower lung atelectasis/infiltrate. Within the liver there had been a decrease in a right lobe lesion, new left lobe and caudate lobe lesions, and enlargement of lesions in the right and left lobes.The patients clinician has requested a follow-up PET scan to further evaluate the patients disease. The Health Plan has denied coverage for the proposed PET scan on the basis that it is not medically necessary.Prior CMS reimbursement standards included a limited number of cancers on its list of indications for PET scan. However, the National Oncologic PET Registry was developed in response to the Centers for Medicare and Medicaid Services (CMS) proposal to expand coverage for PET scans to include cancers and indications not previously eligible for Medicare reimbursement. Connective tissue and other soft tissue tumors are now listed, with PET scan being indicated for diagnosing, initial staging, treatment, monitoring and restaging/suspected recurrence of disease.It has been shown that PET (PET/CT) is helpful in the staging and restaging of GIST and has an impact on clinical decision making in these patients. In addition, the patient has had prior PET exams to evaluate her disease thus adding to the significance of changes on a follow-up exam. Accordingly, I have determined the requested PET scan is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.