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

A 55-year-old male enrollee requested authorization and coverage of thalidomide for the treatment of renal cancer that has metastasized to the lung.  The health plan denied the enrollees request indicating that thalidomide is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two physician reviewers concluded that the requested thalidomide is likely to be more beneficial for treatment of the enrollees cancer than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of a referral to an out-ofnetwork provider for the treatment of rectal cancer.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 10-year-old female enrollee requested authorization and coverage of continued speech therapy for the treatment of central hearing loss.  The health plan denied the enrollees request indicating that continued speech therapy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested speech therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee requested authorization and coverage of the medication Evista for the treatment of bone thinning as a result of menopause.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested authorization and coverage of metal-on-metal hip resurfacing for the treatment of osteoarthritis.  The health plan denied the enrollees request indicating that the requested procedure is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the metal-on-metal hip resurfacing is not likely to be more beneficial for treatment of the enrollees osteoarthritis than any available standard therapy.  Because all three-physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 16-year-old male enrollee requested authorization and coverage of an Otto Bock C-Leg (C-Leg) prosthesis for treatment of below the knee amputation as a result of Ewing Sarcoma.  The health plan denied the enrollees request indicating that the requested prosthesis is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee requested authorization and coverage of verapamil for the treatment of peyronies disease.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested authorization and coverage of Peglyated Interferon (PEGIntron) and Ribavirin (Rebetol) for the treatment of Hepatitis C.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male requested authorization and coverage of peginterferon alfa-2b (PegIntron) for the treatment of chronic Hepatitis C.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male requested authorization and coverage of a septoplasty for the treatment of deviated nasal septum.  The health plan denied the enrollees request indicating that the requested procedure is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested septoplasty is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old male requested authorization and coverage of intradiscal electrothermal therapy (IDET) for the treatment of back pain.  The health plan denied the enrollees request indicating that IDET is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that IDET is not likely to be more beneficial for treatment of the enrollees back pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a six-year-old male enrollee requested coverage of speech therapy for the treatment of speech delay.  The health plan denied the enrollees request indicating that speech therapy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested speech therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV) for the treatment of deteriorating osteoarthritis in knee.  The health plan denied the enrollees request indicating that a POV is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee requested authorization and coverage of a referral to a dermatologist for the removal of a sebaceous cyst.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested referral is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of a vertebroplasty for the treatment of osteoporosis and vertebral compression facture.  The health plan denied the enrollees request indicating that the requested vertebroplasty is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested vertebroplasty is not likely to be more beneficial for treatment of the enrollees vertebral compression facture than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee requested authorization and coverage of vocal cord surgery to eliminate hoarseness and feminize voice.  The health plan denied the enrollees request indicating that the surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of a six-year-old female enrollee requested authorization and coverage of thalidomide for treatment of a recurrent germ cell tumor.  The health plan denied the enrollees request indicating that thalidomide is not medically necessary.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three- physician reviewers concluded that thalidomide is likely to be more beneficial for treatment of the enrollees recurrent germ cell tumor than any available standard therapy.  Because all three- physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested authorization and coverage of endoluminal gastroplication for the treatment of gastro-esophageal reflux disease (GERD).  The health plan denied the enrollees request indicating that the requested procedure is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee requested authorization and coverage of a referral to an out-of-network plastic and reconstructive surgeon for umbilical hernia repair.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

An 18-year-old female enrollee requested authorization and coverage of continued acute mental health inpatient treatment for anorexia nervosa.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested continued acute mental health inpatient treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old female enrollee requested authorization and coverage of inpatient infusion therapy for treatment of Laundau Kleifner Syndrome.  The health plan denied the enrollees request indicating that inpatient infusion therapy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that receiving infusions in an inpatient setting is not medically necessary, and that the health plans offer to continue providing the services through home health or in a physicians office are acceptable treatment settings for the patients needs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 15-year-old male enrollee requested authorization and coverage of inpatient infusion therapy for treatment of Laundau Kleifner Syndrome. The health plan denied the enrollees request indicating that inpatient infusion therapy is not medically necessary. One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that receiving infusions in an inpatient setting is not medically necessary, and that the health plans offer to continue providing the services through home health or in a physicians office are acceptable treatment settings for the patients needs.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee requested authorization and coverage of an MRI of the cervical spine for treatment of shoulder and arm pain.  The health plan denied the enrollees request indicating that the requested MRI is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage of continued skilled nursing facility (SNF) care for treatment after a massive cerebral vascular accident.  The health plan denied the enrollees request indicating that a SNF level of care is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested SNF level of care is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee requested authorization and coverage of continued private speech therapy for the treatment of downs syndrom.  The health plan denied the enrollees request indicating that continued private speech therapy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested private speech therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested procedure is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male requested authorization and coverage of a full-body CT scan for the treatment of chronic abdominal and back pain.  The health plan denied the enrollees request indicating that the requested CT scan is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested CT scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee requested authorization and coverage of the medication Sporanox for the treatment of toenail fungus.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of an 18-year-old female enrollee requested authorization and coverage of an electric wheelchair for the treatment of cerebral palsy and spastic diplegia.  The health plan denied the enrollees request indicating that an electric wheelchair is not medically necessary.  The Plan authorized a self propelled lightweight wheelchair.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage of the medication Phentermine for treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a five-year-old male enrollee requested authorization and coverage of speech therapy for treatment of the enrollees speech delay.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested speech therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a three-year-old female enrollee requested authorization and coverage of occupational therapy for treatment of sensory modulation disorder.  The health plan denied the enrollees request indicating that occupational therapy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested occupational therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old male requested authorization and coverage of thalidomide for treatment of ocular melanoma with metastasis to the liver.  The health plan denied the enrollees request indicating that treatment with thalidomide is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three-physician reviewers concluded that thalidomide is not likely to be more beneficial for treatment of the enrollees ocular melanoma with metastasis to the liver than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee requested authorization and coverage of a referral to a non-contracted provider for a consultation and weight management program for treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a four-year-old female enrollee requested authorization and coverage of continued private speech therapy for the treatment of developmental delay.  The health plan denied the enrollees request indicating that the requested speech therapy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested speech therapy is medically necessary if a new Functional Communication Measure (FCM) evaluation details that the enrollee has made progress since the last FCM evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of a virtual colonoscopy based on family history and patient age.  The health plan denied the enrollees request indicating that a virtual colonoscopy is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested virtual colonoscopy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee requested authorization and coverage of the medication provigil for the treatment of neuropothy and myopothy.  The health plan denied the enrollees request indicating that provigil is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee requested authorization and coverage of an electric wheelchair for the treatment of Amyotrophic Lateral Sclerosis.  The health plan denied the enrollees request indicating that an electric wheelchair is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee requested authorization and coverage of gastric bypass surgery for treatment of morbid obesity with multiple comorbidities.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 73-year-old male enrollee requested authorization and coverage of follow-up care with an out-of-network retinal specialist for the treatment of retinal occlusion.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary.