Persius/imr-appeals huggingface dataset:
The patient is a 53-year-old woman who reports a six-year history of gastrointestinal problems. She states that she became ill in December 2000 after eating watercress and drinking water from a stream. She reports multiple problems including irritable bowel syndrome, constipation, gas and abdominal bloating. The patient also experiences extreme fatigue, concentration problems, and short-term memory loss. She wishes to undergo further workup with an Intestinal Permeability and Comprehensive Digestive Stool Analysis. The Health Plan indicates the proposed testing is not medically necessary for evaluation of the patients condition.The Health Plans denial is correct. The patient has vague and generalized symptoms. It appears she has undergone a thorough workup with evaluations by multiple specialists. The use of the proposed intestinal permeability test in this patient is not within the community standard of care. The requested testing is not likely to add clinically useful information for the care and management of this patient. Therefore, I have determined the requested testing is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
The patient is a 36-year-old female who underwent Lap-band surgery in June 2004, and reports that after months of attempts to control her subsequent nausea and vomiting she elected to have the band removed. She then underwent a gastric bypass operation in July 2005. She reports only a 10-pound weight loss following that procedure. The patient at this time is reported to be 56 weighing 241 pounds with a body mass index (BMI) of 39. Her comorbid conditions include gastroesophageal reflux disease (GERD), asthma, exertional dyspnea, depression and anxiety. The patients provider has proposed gastric bypass revision to reduce the size of the patients stomach pouch and outlet. Review of the clinical evidence indicates the patients two previous weight loss surgical procedures were unsuccessful. The patients first procedure, the Lap-band, has a significant published rate of solid intolerance, nausea and vomiting associated with the procedure. After the gastric band was removed the patient underwent gastric bypass, also without success. The scientific data shows duodenal switch has the best long-term success of all weight loss surgical procedures. There is one peer-reviewed, published article that reports the outcome of patients with multiple weight loss surgical procedures. This article not only demonstrates the superior long-term outcome of the duodenal switch as a revisional operation, but also shows that patients with multiple previous restrictive operations (Lap-band, gastric bypass, etc.) will fail any other revision unless they have an operation that limits absorption as well.  The patient reports GERD as a comorbid condition. If her gastrojejunostomy anastomosis is reduced from 2.5 cm to 1.5 cm as proposed by her surgeon, it is likely the patients reflux disease will significantly worsen. Thus, although the patient meets criteria for a revisional weight loss procedure, the proposed procedure is not likely to result in adequate weight loss and will probably worsen her reflux disease. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
The patient is a 48-year-old female with a BMI of 43. She has a number of comorbid conditions including asthma, diabetes mellitus type 2, and depression. She has requested authorization for gastric bypass surgery. There is no evidence that the patient has undergone a psychological evaluation to determine whether she is considered an appropriate candidate for weight loss surgery.With a BMI of 43 and comorbid conditions such as diabetes the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. It is highly likely that gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. There is no clinical evidence demonstrating that further weight loss is necessary for a successful surgery and there is no scientific evidence supporting this requirement. However, although medically the patient meets criteria for consideration of weight loss surgery, the patient has not yet obtained psychological clearance for weight loss surgery. Based upon the information set forth above, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition depending upon the results of a psychological evaluation. Therefore, the Health Plans denial should be overturned. If the psychological evaluation indicates the patient is an appropriate candidate for weight loss surgery, the requested procedure should be authorized. If the psychological evaluation indicates the patient is not an appropriate candidate for weight loss surgery, the requested procedure should not be authorized.
The patient is a 33-year-old male who is undergoing evaluation for sleep apnea.  He has complaints of loud snoring, disrupted breathing while sleeping, feeling unrested upon awakening, memory difficulties and sexual dysfunction.  Comorbid conditions include hypertension, obesity and depression.  The patients request for inpatient polysomnography has been denied by the Health Plan as not medically necessary.The patient does meet the clinical criteria for evaluation of a possible sleep disorder by polysomnography. However, an overnight stay in a hospital is not necessary if the option of an adequate home sleep study is available for diagnosis.  The home sleep study should include the monitoring of at least four parameters, not simply pulse oximetry or airflow.  If the patient needs support to ensure that the study is performed correctly, an attendant should be provided to assist with the setup of the equipment and possible monitoring.Based upon the information set forth above, I have determined the requested procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
The patient is a 19-year-old male with idiopathic short stature and constitutionally delayed puberty. He was born the smaller of two twins weighing 2 pounds with his sibling weighing 5 pounds 4 ounces. The mid-parental height approximates 68 inches. On October 2005 the patients bone age was 15.5 years, while his height was near 53. His adult height prediction on these bases should approximate 54. He has had an endocrine workup, which revealed normal GH responses to stimuli, normal adult male hormone levels and a normal IGF-1 level of 184 in October 2004. Based upon the information provided, it appears the patient has been on growth hormone therapy since January 2006. At issue is whether growth hormone therapy is medically necessary for treatment of the patients medical condition.Review of the submitted clinical evidence demonstrates the patient meets medical necessity criteria for growth hormone therapy. In accordance with the AACE Medical Guidelines for growth hormone therapy, the therapy is medically necessary for patients such as this patient who was a small for gestational age infant who has not caught up, and is falling further from normal percentiles, and/or has idiopathic short stature and is not projected to achieve an adult height in the normal range and is under the care of a pediatric endocrinologist. The problem is however that the patients remaining growing time is very short and it is not known to what extent such therapy will be beneficial. Therefore, growth intervals should be obtained on a regular basis (every three months) to document that the patient is continuing to grow. In addition, a knee x-ray would be helpful to show the state of the epiphyses in the knee. Based upon the information 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.
The patient is a 47-year-old male with chronic back pain and is status post multiple lumbar surgeries. In addition, the patient underwent gastric bypass surgery in 2004. He is requesting authorization for 630 80mg OxyContin tablets per month for pain control. The Health Plan has authorized 540 80mg tablets of OxyContin per month. At issue is whether the requested prescription is medically necessary for treatment of the patients chronic pain.The Health Plans denial should be upheld. The amount of OxyContin the patient is requesting is well beyond the standard of care in pain management medicine, even in extreme cases. The requested prescription is excessive and not medically appropriate. The patient should pursue alternative forms of pain management in addition to narcotic management in order to allow for a decrease in his current level of OxyContin. Accordingly, I have determined the requested prescription is not medically necessary for treatment of the patients medical condition. As such, the Health Plans denial should be upheld.
The patient is a 31-year old female who has failed traditional medical care in eliminating or managing her head pain.  The patient reports she has obtained positive results from chiropractic care. The submitted records do not include detailed outcome assessments made by her provider.  The patient has requested that chiropractic care be authorized on an unlimited basis.  The Health Plan has denied authorization for continued chiropractic care on the basis it is not medically necessary.   A diagnosis of cervicogenic headache is one that is often treated successfully with chiropractic care.  Head pain can be a quality of life issue for the patient and it can be difficult for a clinician to achieve and maintain the desired results. Often, co-management is a better approach.  In this case, the patient states she finds chiropractic helpful in providing relief and in improving her quality of life.  By her assessment, the headaches have lessened and become controlled unlike before and she requires less medication.  This patients condition however, is chronic and after the second chiropractic reassessment, she was on a supportive treating schedule. There is no documentation of objective outcome measures being consistently monitored to determine the patients progress. In the absence of such documentation, medical necessity for continued chiropractic care has not been established.The Health Plans alternative recommendation for orthopedic consultation, pain management evaluation and assessment of work and lifestyle for contributing factors is reasonable and those services should be made available to the patient.  Should that approach fail, the patients request for additional chiropractic care should be reconsidered.Based upon the information set forth above, I have determined the requested chiropractic care is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
The patient is a 50-year-old woman who presented with an explosive course of bronchoalveolar adenocarcinoma and respiratory failure. She had a dramatic response to treatment with Iressa. When she later reached a plateau on Iressa, she was switched to Tarceva.  The Health Plan indicates it will not authorize Tarceva because it is not considered medically necessary unless it follows failed treatment with a platinum-based chemotherapy.When this patient initially presented, she was too sick for chemotherapy.  She was treated with Iressa, an EGFR-targeted treatment, and had a remarkable response. Although Tarcevas current indication is for second line treatment, it is another EGFR-targeted treatment that is routinely being used for subsets of patients with a high likelihood of benefit.  This patients response to Iressa indicates the expected benefit of Tarceva is far greater than that of a platinum-based chemotherapy.  The Health Plans guidelines would require a failed trial of platinum-based chemotherapy before the patient could continue with Tarceva, the treatment most likely to produce a positive result. Uninterrupted treatment with Tarceva is a more prudent course of treatment for this patient.  Therefore, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
The patient is a 40-year-old female with a history of migraines, worse with menstruation, for at least six years. In January 2005, the patients physician recommended an MRI of the brain due to an increase in the frequency of headaches. The MRI was unremarkable. The submitted status reports indicate that while the patient may have had a favorable response to various medications, it was only for a short duration. The patient started receiving acupuncture in February 2005. In addition, she changed her eating habits and began exercising regularly. The patient reports this regimen has helped reduce the frequency of her migraines and that she has lost weight and is generally feeling better with acupuncture treatment. The patient further indicates she has been able to reduce her medication dosage.  At issue is whether acupuncture is medically necessary for treatment of the patients medical condition.Because of the patients poor response to prescribed medications and her more favorable response to acupuncture treatment, continued acupuncture is more appropriate for treatment of the patients medical condition than pharmacotherapy. Since the patients symptoms appear to worsen during her menstrual period, one or two acupuncture treatments at that time are indicated for relief of migraines associated with her period. In addition, the patient should continue her exercise program and improved eating habits. Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
The patient is a 45-year-old man who underwent ACL reconstruction. Postoperatively the patient utilized a continuous passive motion (CPM) machine. The Health Plan has denied reimbursement for utilization of the CPM machine on the basis it was not medically necessary for treatment of the patients condition.Many surgeons believe CPM therapy is useful in gaining and maintaining motion following surgery. It is a matter of physician preference. Numerous studies have shown benefit with CPM. The device has been utilized for more than 20 years for a number of different reasons.In the case of this patient, the device was felt to be of benefit following the patients ACL reconstruction. Furthermore, there are no significant risks posed by use of a CPM machine. A CPM machine was medically reasonable and indicated for the patients successful postoperative rehabilitation. Therefore, I have determined that the equipment at issue was medically necessary for treatment of the patients medical condition. Accordingly, the Health Plans denial should be overturned.
The patient is a 58-year-old female who felt a small nodule in the inferior medial left breast. Mammogram in August 2004 was negative. In August 2004, the patient was evaluated by her clinician who performed an ultrasound and a core biopsy of a 1 cm mass at 7oclock. The pathology was fibroadipose tissue. In September 2004, the patient then underwent an excisional biopsy. The pathology results were benign nonproliferative fibrocystic changes. There was no evidence of malignancy.In a follow-up appointment with her clinician in November 2004, three fatty nodules were palpated at 9 oclock in the left breast. An MRI was ordered for further evaluation, which was performed in mid-November 2004. The patient has no history of breast cancer and has been on estrogen for many years. The Health Plan has denied reimbursement for the MRI at issue on the basis it was not medically necessary for evaluation of the patients medical condition.There are several indications for MRI of the breast, which include 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. An indication for non-malignant disease is evaluation of breast implants.Since this patient had a relatively recent mammogram, ultrasound, ultrasound-guided biopsy, and excisional biopsy of the left breast, a new malignancy in the breast would be very unlikely. A repeat left breast mammogram and ultrasound and follow-up clinical exam would have been appropriate before considering MRI and possibly another biopsy. Given the specifics of this case, an MRI was not medically warranted for this patient.Based upon the information set forth above, I have determined that the MRI at issue was not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
The patient is a 58-year-old female with a history of back, neck, and shoulder pain. She was seen by a chiropractor who suggested the patients symptoms would probably benefit from breast reduction surgery. The patient was previously seen by a physical therapist and a neurosurgeon for other back pain in the past. It appears from the submitted documentation that the board certified plastic surgeon who requested authorization for breast reduction surgery agreed the patient would benefit from the requested procedure. The Health Plan has denied authorization and coverage for the requested procedure on the basis it is not medically necessary.The submitted photocopies of photographs are of poor quality. Therefore, it is not possible to confirm that the patients breast size results in medical complications. Furthermore, the submitted consultation notes are insufficient to support medical necessity for breast reduction surgery. As such, it has not been established the requested procedure is medically warranted 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.
The patient is a 43-year-old female who has a history of depression and alcohol abuse. She began inpatient hospitalization in 2005. At the time of her admission, the patient was suicidal as evidenced by an emergency room visit secondary to taking excessive Xanax and alcohol. In the psychiatric history and evaluation, the patients chief complaint was constant thoughts of not wanting to be around. A request has been made for coverage for continued inpatient psychiatric treatment services. The Health Plan indicates the submitted documentation does not demonstrate the requested services are medically necessary.Although the patient had symptoms consistent with active suicidality upon admission, these symptoms were most likely precipitated or exacerbated by active alcohol intoxication. There is scant evidence in the medical record to suggest ongoing suicidality. It would have been medically reasonable and appropriate to transfer the patient to partial hospitalization or outpatient chemical dependency program, at which point the patient was stable. There is no evidence of acute alcohol withdrawal symptoms at the time of admission. Detoxification was optimal and certainly could have been completed. Therefore, I have determined that inpatient psychiatric treatment services were medically necessary. The Health Plans denial should be partially overturned.
The patient is a five-year-old male with a history of migraines, headaches, asthma, and allergies. Acupuncture has been recommended for treatment of these conditions. The Health Plan has denied this request on the basis acupuncture is not medically necessary for treatment of the patients condition.According to the California Department of Consumer Affairs, Acupuncture Board, the National Institutes of Health, and the World Health Organization, acupuncture is an acceptable and appropriate treatment for this patients condition. Acupuncture is commonly utilized to treat allergies/asthma, migraine headache, rhinitis, and sinusitis. There are controlled trials demonstrating acupuncture is an effective treatment for allergic rhinitis. Standard treatment for this patient would be acupuncture twice weekly for three to four weeks followed by evaluation to determine if further treatment is indicated.Based upon the information set forth above, I have determined the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
The patient is a 41-year-old male with erectile dysfunction. He had a complete physical examination and no specific etiology was identified. Treatment with Viagra was not successful but subsequent treatment with Levitra was successful. The Health Plan has denied authorization for Levitra because there is no known organic cause for the enrollees dysfunction. The cause of erectile dysfunction is irrelevant to the treatment. Regardless of the cause of erectile dysfunction, medications such as Viagra and Levitra are considered first-line therapy. This patient has experienced benefit from Levitra after having failed Viagra. Based upon these results, treatment of the patients erectile dysfunction with Levitra is medically necessary. Therefore, the Health Plans denial should be overturned.
The patient is a 53-year-old female with a history of a cyst on her right eye. The cyst has apparently recently grown in size. The patients provider has recommended excision of the cyst. The Health Plan has denied this request.The clinical evidence does not demonstrate the medical necessity of the requested medication. The submitted photographs do not provide clear or objective evidence of the patients condition. The drawing in the ophthalmologists record shows a moderate pinguecula with only a tiny extension onto the cornea. These are common, benign and virtually never require surgery. If they enlarge and extend onto the cornea, they are classified as pterygium. A decision to proceed with surgery would then be based on the extent to which the pterygium extended into the visual axis. There is no evidence of this in this case. Furthermore, inflamed pinguecula usually respond to topical therapy. There is no evidence this patient has attempted a trial of topical therapy. Moreover, a biopsy would be indicated prior to consideration of surgery after failure of topical therapy. Based upon the information set forth above, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.