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

The parent of a six-year-old female enrollee has requested authorization and coverage for monthly physical therapy. The health plan has denied this request on the basis that the requested services are not medically necessary for treatment of the enrollees progressive scoliosis.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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female requested authorization and coverage for breast reduction surgery. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees ptotic breasts.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 19-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity with comorbid conditions including stress incontinence, chronic back pain, and amenorrhea.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 at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 14-year-old female enrollee requested authorization and coverage for admission to a locked residential treatment facility for treatment of the enrollees medical condition. The health plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees symptoms consistent with borderline personality disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage for IDET. The health plan has denied this request indicating that IDET is considered investigational for treatment of the enrollees chronic low back pain.All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of your medical condition 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 your medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee requested authorization and coverage for a panniculectomy. The health plan has denied this request indicating that the requested procedure is considered cosmetic and not medically necessary for treatment of the enrollees low back pain, chronic infections, rashes and sores within the lower abdominal skin fold.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 considered cosmetic and is not medically necessary.  The reviewer cited a lack of significant documentation of medical problems associated with the panniculus.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This case involves a 55-year-old female who has requested authorization and coverage for breast prostheses replacement. The health plan has denied this request indicating that the requested procedure is cosmetic in nature and not medically necessary for treatment of the enrollees medical condition.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 considered cosmetic and is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested authorization and coverage for intradiscal electrothermal therapy (IDET).  The health plan has denied this request indicating that IDET is considered experimental for treatment of the enrollees chronic back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  The health plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage for continued Botox injections.  The health plan has denied this request indicating that Botox injections are considered investigational for treatment of the enrollees migraine headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Because two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee requested authorization and coverage for an abdominoplasty.  The health plan has denied this request indicating that the requested procedure is considered cosmetic for treatment of the enrollees dependent abdominal flap.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 considered cosmetic and is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old female enrollee requested authorization and coverage for an increase in dosage of the prescription medication Vioxx.  The health plan has denied this request indicating that the requested increase in dosage is not medically necessary for treatment of the enrollees osteoarthritis.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested increase in prescription dosage is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee requested authorization and coverage for the medication Vioxx or Celebrex for the treatment of severe gout.  The health plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that neither of the requested medications is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee requested authorization and coverage of a NeoTect scan for the treatment of bronchoalveolar carcinoma.  The health plan denied the request, indicating that the requested scan is considered investigational for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that the requested NeoTect scan is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.  Because two of the three physician reviewers concluded that the requested NeoTect scan is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the health plans denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This case involves a 41-year-old female enrollee who requested authorization and coverage of compression stockings for the treatment of varicose veins.  The health plan denied the request, indicating that the requested stockings are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested compression stockings are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

This case involves a female enrollee who requested authorization and coverage of 200mg of Celebrex twice per day.  The health plan denied the request, indicating that the requested prescription is not medically necessary for treatment of the enrollees bilateral hip osteoarthritis.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 12-year-old male enrollee who requested authorization and coverage of breast reduction surgery for treatment of gynecomastia.  The health plan denied the request, indicating that the requested surgery is not medically necessary for treatment of the enrollees medical condition.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: Overturned Decision of Health Plan

A 46-year-old female enrollee who has requested authorization and coverage for a standing referral to an otolaryngologist.  The health plan has denied this request indicating that a standing referral is not medically necessary for treatment of the enrollees ear infections.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested standing referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage for metal-on-metal hip resurfacing for treatment of rheumatoid arthritis and hip pain.  The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees medical condition.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

The parents of a 15-year-old male enrollee requested authorization and coverage for continued residential treatment of the enrollees anxiety and depression.  The health plan denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees medical condition.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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee requested authorization and coverage for gastric bypass surgery with duodenal switch.  The health plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  The health plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 15-year-old female enrollee requested authorization coverage for continued trigger point injections.  The health plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested injections are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee requested authorization and coverage for eyelid surgery for the treatment of vision impairment.  The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees medical condition. One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested procedures are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee requested authorization and coverage for an MRI. The health plan has denied this request indicating that the requested MRI is not medically necessary for treatment of the enrollees low back pain. 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: Overturned Decision of Health Plan

A 39-year-old male enrollee requested authorization and coverage for Silikon 1000 injections. The health plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees lipodystrophy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested injections are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage for the medication Fosamax. The health plan has denied this request indicating that Fosamax is not medically necessary for treatment of the enrollees osteopenia.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: Overturned Decision of Health Plan

A 51-year-old male enrollee requested authorization and coverage for the medication Viagra. The health plan has denied this request indicating that Viagra is not medically necessary for treatment of the enrollees erectile dysfunction.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

A 39-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees morbid obesity.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 at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

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

The parents of a 12-year-old male enrollee requested authorization and coverage for the medication Adderall XR.  The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Attention Deficit Disorder (ADD).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 53-year-old female enrollee requested authorization and coverage for compounded medication.  The health plan has denied this request indicating that the requested compounded medication is not medically necessary for treatment of the enrollee's cronic pain.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 36-year-old female requested authorization and coverage of a colonoscopy for colon cancer screening. The health plan denied this request, indicating that a 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 colonoscopy is not medically necessary and that the health plans recommendation of a sigmoidoscopy is appropriate.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female requested authorization and coverage for a referral to an out-of-plan provider for surgery. The health plan denied the request, indicating that the requested referral to an out-of-plan surgeon is not medically necessary, because there are in-plan providers who are experienced in thorascopic resection of lung tumors and mediastinal nodes who can treat the enrollee.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the plan has demonstrated that it has in-plan thoracic surgeons who can provide the medically necessary services required by the patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee requested authorization and coverage of radiofrequency endoluminal venous closure. The health plan denied the request, indicating that the requested procedure is not medically necessary for treatment of the enrollees painful varicose veins.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 female enrollee requested authorization and coverage for treatment with peglyated interferon (PEG-Intron) and rebetron. The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees chronic active hepatitis C. 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 at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee requested authorization and coverage for intradiscal electrothermal therapy (IDET). The health plan has denied this request indicating that IDET is considered investigational for treatment of the enrollees lower back pain.All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. The health plans denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee requested authorization and coverage for a referral to an orthopedist.  The health plan has denied this request indicating that the requested referral is not medically necessary for treatment of the enrollees arm and hand pain.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 parent of a six-year-old female requested authorization and coverage for speech therapy for treatment of the enrollees Duane Syndrome/Apraxia of Speech.  The health plan has denied this request.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested authorization and coverage for surgery.  The health plan has denied this request indicating that requested surgery is considered cosmetic in nature and not medically necessary for treatment of the enrollees irregular/uneven incision.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 cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee requested authorization and coverage for a CT scan of her sinuses for the treatment of a nasal obstruction which causes significant snoring and difficulty breathing.  The health plan has denied this request indicating that a CT scan of the sinuses is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the Health Plans denial on the basis that the requested CT scan is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a five-year-old male enrollee requested authorization and coverage for speech therapy for treatment of the enrollee's otis media.  The health plan has denied this request. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee requested authorization and coverage for an allogenic stem cell transplant.  The health plan has denied this request indicating that the requested therapy is considered experimental for treatment of the enrollees cancer.  Three physician reviewers performed an experimental/investigational Independent Medical Review. All three-physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  The health plan's denial was overturned.