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

A fifty-seven year-old female with mixed headache disorder is requesting authorization for treatment with Botox.  Reviewers Findings:  The reviewing physician found that the medical literature includes studies suggesting that Botox is safe and efficacious for treatment of patients such as this patient.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-one year old female who has had difficulties with her right leg is requesting authorization and coverage for surgical intervention.Reviewers Findings:  The reviewing physician found that there are no clinical indications for surgical intervention.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-three year-old female with arthritis involving both knees is requesting for authorization of Synvisc injections.  Reviewers Findings:  The reviewing physician found that this therapy can reasonably be expected to alleviate the pain and postpone the need for surgical intervention.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 54-year-old female enrollee has requested authorization and coverage for Botox injections for treatment of migraine headaches.Reviewers' Findings: Two of the three reviewing physicians found that patient has chronic daily headache in addition to migraine. Further trials of different preventive medications are not likely to offer further symptomatic relief. Botox has been demonstrated to be effective in treating chronic daily headache and migraine in double-blind placebo-controlled trials. Its use in this clinical setting is medically reasonable and appropriate and should be authorized.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of three-year-old male with expressive and receptive language delays are requesting reimbursement and prospective authorization of speech therapy.  Reviewers Findings:  The reviewing physician found that there is no evidence in the literature that the benefit derived from private therapy is greater than that provided in the school setting.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A sixty-two year-old female with excess abdominal skin following a substantial weight loss is requesting authorization for an abdominoplasty.  Reviewers Findings:  The reviewing physician found that the records provided do not establish medical necessity for the proposed abdominoplasty.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 14-year-old male with persistent pubertal gynecomastia is requesting reimbursement of a bilateral mastectomy.  Reviewers Findings:   The reviewing physician found that while the breast enlargement was not causing a physical functional impairment, the documentation submitted indicates that the breast enlargement was significantly affecting psychological functioning.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-one year-old female with a possible autoimmune peripheral neuropathy is requesting reimbursement and prospective authorization of intravenous immune globulin (IVIG).  Reviewers Findings:  The reviewing physician found that there is a lack of credible evidence supporting the efficacy IVIG therapy in this context. Given the potentially serious risks the application of IVIG therapy cannot be recommended for a patient such as this one.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-four year-old female with leg pain associated with varicose veins is requesting authorization of sclerotherapy.  Reviewers Findings:  The reviewing physician found that the patients symptoms meet the above criteria, but there is no documentation of conservative therapy.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty year-old male who has been diagnosed with chronic pain syndrome and post-laminectomy syndrome is requesting authorization for spinal cord stimulator implantation.Reviewers Findings:  The reviewing physician found that spinal cord stimulator implantation is not medically indicated at this time. This procedure has not been proven to improve functionality for patients with chronic pain.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee has requested authorization and coverage for a 64-slice CT angiography of the chest for evaluation of coronary artery disease.Reviewers' Findings:The three physician reviewers found that CT angiography is not an accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a medically acceptable replacement for other conventional screening tests within the standard of care such as treadmill stress testing. CT angiography would not be able to accurately confirm or exclude important coronary obstruction. The use of CT angiography in the diagnosis and prognosis of coronary artery disease currently remains an unproven application of this technology.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-eight year-old obese female with comorbid conditions is requesting authorization of a laparoscopic gastric banding procedure.  Reviewers Findings:  The reviewing physician found that the clinical record indicates the patient clearly meets the Health Plans criteria for authorization of bariatric surgery.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 A sixty-four year-old female with a complaint of osteoarthritis in her thumbs and wrists is requesting authorization for acupuncture therapy.Reviewers Findings:  The reviewing physician found that the patient had exhausted the more standard treatment modalities for the arthritis and the provider has referred the patient for acupuncture therapy. Arthritis is one of the conditions commonly treated by acupuncture.  The reviewing physician found the as the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-nine year old male with a progressive high frequency sensorineural hearing loss is requesting reimbursement for a Neuromonics Tinnitus Training program.Reviewers Findings:  The reviewing physician found that the safety and efficacy of the Neuromonics Tinnitus Training program has not been sufficiently established. Studies conducted to date have only involved a small number of subjects and these studies have been open.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A twenty-two year-old female diagnosed with polysubstance dependence is requesting authorization of Phase I Outpatient Program for Chemical Dependency.  Reviewers Findings:  The reviewing physician found that the treatment plan recommended by the Health Plan for weekly individual therapy may prove to be more beneficial than additional substance abuse treatment.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A fifty-three year-old female with a history of degenerative joint disease and chronic pain is requesting reimbursement and prospective authorization for Subutex.  Reviewers Findings:The reviewing physician found that treatment of chronic pain with Subutex is not an unreasonable alternative when (1) more standard medical management has failed to provide relief and (2) the patients care is managed by the appropriate specialist. The available records do not indicate that either of these prerequisites has been satisfied.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a fifteen year-old male with a history of substance abuse is requesting reimbursement for the patients previous residential stay as well as authorization for additional residential treatment services.Reviewers Findings:The reviewing physician found that the submitted clinical records do not demonstrate the patients residential treatment services were medically necessary. Nor is there any indication for the patients return to a residential level of care.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A twenty-four year-old female with a history of alcohol and cocaine abuse is requesting reimbursement for acute inpatient psychiatric services.  Reviewers Findings:The reviewing physician found that the submitted clinical information does not substantiate the need for acute inpatient psychiatric treatment.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A fifty-four year-old female who underwent an anterior cruciate ligament (ACL) reconstruction is requesting authorization for a continuous passive motion (CPM) machine.  Reviewers Findings:The reviewing physician found that a CPM device is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction, making the CPM medically appropriate.   The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a six-year-old female with a diagnosis of attention deficit hyperactivity disorder are requesting occupational therapy.  Reviewers Findings:  The reviewing physician found that the relevant medical literature reveals no scientific evidence that sensory integration therapy is beneficial in attention deficit disorder.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee has requested authorization and coverage for EBCT for evaluation of his heart disease.Reviewers' Findings:  The three physician reviewers found that EBCT is not a medically approved or accepted screening or confirmatory test for the diagnosis of coronary artery disease, and is not a standard of care modality such as treadmill stress testing. EBCT is also not a medically acceptable substitute for coronary angiography. The use of EBCT in the diagnosis and prognosis of coronary disease currently remains an unproven application of this technology.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-nine year-old female who was treated for right breast cancer, ductal carcinoma in situ is requesting authorization for an MRI.  Reviewers Findings:  The reviewing physician found that indications for MRI of the breast are including evaluation of pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high-risk patients and problem solving.  The reviewing physician found that the health plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a fourteen year-old male with short stature and has been on growth hormone therapy is requesting authorization for continued growth hormone therapy.   Reviewers Findings:   The reviewing physician found the patient should be continued on growth hormone therapy for three months from the date of the decision. At the end of the three-month period, if the patients endocrinologist documents a positive and significant growth response to therapy, GH therapy should be continued.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 16-year-old male with a history of apparent substance abuse and depression, though the submitted clinical records are generally vague and do not include a detailed history. The records refer to use of alcohol in addition to other substances. The submitted notes, though brief, refer to the patient as cooperative, 12-step compliant, well motivated and pleasant without evidence of withdrawal or any other major psychotic or medical symptoms. At issue is whether the patients continued participation in the residential chemical dependency treatment program is medically necessary.Given the data presented, there is no objective evidence demonstrating the medical necessity of continued residential chemical dependency treatment beyond November 2006. As of the last authorized date of service the patient was motivated, compliant, cooperative and seemingly symptom free. The patient was stable at that point and appropriate for treatment in an outpatient group setting. Therefore, I have determined the requested services are not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 16-year-old female who was admitted to a residential treatment facility in September 2006. Her care was authorized through October 2006. Treatment records indicate the patient is not being treated with medications because of her refusal to accept them. The parent states the patient continues to be a danger to herself and others in that she remains aggressive toward others. Prior to admission, the record indicates the patient engaged in high-risk behaviors.The progress notes from the residential treatment facility demonstrate that the patients primary therapy is conducted by a licensed marriage and family therapist (LMFT). Other groups were conducted by bachelor level therapists and trainees. There are some notes written by a psychologist (PsyD) and a licensed vocation nurse (LVN). There is no documentation of a psychiatric evaluation or of weekly progress notes from a psychiatrist. The treatment records strongly suggest a major depressive disorder, but according to the record provided no psychiatric referral or intervention was initiated.The primary focus of the patients treatment appears to be a 12-step program with individual sessions, group sessions and activity therapy. The progress notes prior to October 2006 document that the patient was not a threat to herself or to others, but she did continue to demonstrate signs and symptoms of a depressive disorder. According to the treatment records, there has been only minimal progress in addressing the mental health issues identified in the admission assessment. The facility did recommend that the patient return to the home of her mother but when the mother declined to take the patient home in October 2006, the health plan authorized an additional 10 days for appropriate discharge planning. As of October 2006, when continued authorization of residential care was denied, the primary issue appeared to be a parent-child relationship problem.  The parents request for retrospective reimbursement to October 2006 and on-going authorization for residential treatment services was denied by the Health Plan citing a lack of medical necessity.The patient was authorized for one month of care in the residential treatment facility. Her treatment plan did not include input from a psychiatrist and the facility did not offer pharmacological intervention. The patient apparently improved to the level where discharge was contemplated, but she was not able to return to the home of her mother and appropriate placement needed to be arranged. The health plan authorized 10 additional days of residential care so that the facility could identify an alternative placement for the patient. As of October 2006 the patient was clearly ready for discharge and no longer met criteria for residential treatment services. Based upon the information set forth above, I have determined the services at issue were/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 48-year-old woman with shoulder pain who was eventually treated with shoulder surgery. Post-operatively, the patient was prescribed a cooling device. The patients request for reimbursement for the cooling device has been denied by the Health Plan on the basis that it was not medically necessary.Cooling devices are extremely useful post-operatively to diminish pain and swelling. Use of a cooling device is an established modality and is generally accepted as beneficial in this clinical setting. It is superior to ice packs and patients achieve significant relief with its use. In the case of this patient, she clearly experienced a benefit from use of the device following her surgery. 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 37-year-old female with dysfunctional dental malocclusion. Her condition has been evaluated and the diagnosis confirmed by her oral surgeon and an orthodontist. The patient has a history of bruxism and headaches related to mandibular retrognathia and class II, over compensated dental malocclusion. The patients provider submitted a request for authorization of sagital split osteotomy (CPT Code 21196) and advancement genioplasty (CPT Code 21121). The Health Plan denied the request based upon a determination that the procedures are not medically necessary.The patient has a common condition which produces physical discomfort. The proposed treatment includes bilateral mandibular osteotomies to advance and reshape the mandible in order to provide a fully functional dental occlusion. Pre-surgical orthodontic treatment is usually required as it is in this instance. The goal of the surgery is the elimination of chronic pain by providing a balanced dental occlusion.  After reviewing the cephalometric analysis it does not appear there would be much, if any, cosmetic effect from the surgery (bilateral osteotomies). There would be a significant negative cosmetic effect if treatment of the malocclusion was attempted by dental extractions and orthodontia alone. It appears from the record the patient has good lip competence, so advancement genioplasty and submandibular liposuction are not part of the functional correction and are considered cosmetic procedures.In summary, correction of the mandibular retrognathia with bilateral mandibular ramus osteotomies (CPT Code 21196) will provide a fully functional dental occlusion and is medically indicated for treatment of the patients chronic pain. This procedure will likely result is significant functional improvement. However, advancement genioplasty and submental lipectomy would be primarily for cosmetic improvement, and would not be medically indicated. Therefore, I have determined that one of the requested procedures is medically necessary for treatment of the patients medical condition. The Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 62-year-old male with a history of respiratory failure and pneumonitis. He is status post VP shut placement and also has a history of chronic hepatic infection. A physical therapy evaluation performed in July 2006 documented a progressive neurological illness, generalized weakness, muscle wasting and impaired breathing. The patient received some physical therapy without documented benefit. His wife is seeking authorization for additional rehabilitation services, which the Health Plan has denied citing a lack of medical necessity for the services.Review of the submitted clinical information indicates the patient is 100% dependent and non-responsive to deep pain stimuli. Based on the records provided, the patient has not made progress with therapy. Furthermore, he is unable to participate in therapy from a cognitive standpoint. He requires positioning and range of motion, which can be performed by trained caregivers. Skilled physical therapy services are not clinically indicated for this patient. Therefore, I have determined the requested services 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 34-year-old woman who has a prior history of migraine type headaches. She is requesting authorization for Botox therapy. The submitted records indicate the patient has been on nortriptyline, Topamax, Atenolol and Depakote. She has used Imitrex for breakthrough headache activity. The records provided do not demonstrate any evidence that the patient has analgesic dependent headache. Her headache diary indicates headache activity of at least 30% in any given month. She has tried Botox with a reduction in frequency and severity of headache activity. At issue is whether Botox is medically necessary for treatment of the patients medical condition.Review of the submitted records indicates the patient has been treated with a number of different prophylactic agents without adequate relief. She meets the clinical criteria for migraine type headache and tension type headache. There is sufficient medical literature demonstrating the efficacy of Botox in double-blind, placebo-controlled studies. The use of Botox in this clinical setting is medically appropriate and indicated. 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: Overturned Decision of Health Plan

The patient is a 64-year-old woman with long-standing plantar fasciitis. The patient has tried and failed conservative treatment including medication, therapy, and two cortisone injections. A request has been made for authorization for extracorporeal shock wave therapy (ESWT), which the Health Plan has denied.ESWT has been established as a treatment for plantar fasciitis in patients who do not respond to conservative measures. It is a non-surgical means of alleviating pain and has an acceptable success rate. This patient has clearly failed conservative treatment. She is an appropriate candidate for ESWT and as such, the procedure should be authorized. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.