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

A 51-year-old male enrollee requested authorization and coverage of pegylated interferon (PEG-Intron) for the treatment of hepatitis C.  The health plan has denied this request indicating that the requested therapy 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 therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested authorization and coverage for a blepharoplasty to remove excess tissue of the upper eyelid causing functional visual impairment.  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 referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee requested authorization and coverage for a referral to a dermatologist for the treatment of acne.  The health plan has denied this request indicating that the requested referral 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 referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee requested authorization and coverage for a referral to a dermatologist for the treatment of lesions that come and go.  The health plan has denied this request indicating that the requested referral 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 referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee requested authorization and coverage for a bone growth stimulator for the treatment of Osteoporosis.  The health plan has denied this request indicating that the requested equipment 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 equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee requested authorization and coverage for testosterone cream. The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees biopsy proven lichen sclerosis.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 34-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 not medically necessary for treatment of the enrollees multiple comorbid conditions including arthritis and hypertension.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 17-year-old female enrollee have requested authorization and coverage for residential treatment for treatment of the enrollees medical condition. The health plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees polysubstance abuse, self-mutilation, and depression.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 29-year-old female enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy. The health plan has denied this request indicating that IVIG is considered investigational for treatment of the enrollees recurrent pregnancy loss.All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the health plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee requested authorization and coverage for intradiscal electrothermal therapy (IDET). The health plan denied this request indicating that IDET is considered experimental for treatment of the enrollees chronic neck and back pain.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. 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 health plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage for acupuncture. The health plan has denied this request indicating that acupuncture is not medically necessary for treatment of the enrollees chronic sinusitis.One acupuncture reviewer performed a medical necessity Independent Medical Review. The acupuncture reviewer overturned the health plans denial on the basis that the requested treatment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee who has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy. The health plan denied this request indicating that IVIG is considered investigational for treatment of the enrollees history of recurrent pregnancy loss.All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.  Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the health plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a four-year-old male enrollee have requested authorization and coverage for an ABI Vest for treatment of the enrollees medical condition. The health plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees cystic fibrosis. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage for metal-on-metal hip resurfacing. The health plan denied this request indicating that the requested procedure is considered experimental for treatment of the enrollees osteoarthritis.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. 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 health plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-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 multiple obesity comorbid conditions including gastroesophageal reflux disease (GERD), reactive airway disease, stress incontinence, and degenerative joint disease.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 depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage for Enbrel 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage for uterine artery embolization (UAE). The health plan has denied this request indicating that UAE is not medically necessary for treatment of the enrollees menorrhagia, pelvic pain, and dysmenorrhea.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 54-year-old male enrollee requested authorization and coverage for a referral to non-contracted provider. The Health Plan has denied this request indicating that the requested referral is not medically necessary for treatment of the enrollees ankle fusion follow-up care.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

A 48-year-old male enrollee requested authorization and coverage for a bunionectomy for the treatment of chronic foot pain due to sesamoiditis.  The health plan has denied this request indicating that a bunionectomy is not medically necessary for treatment of the enrollees medical condition.One podiatry 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 48-year-old female enrollee requested authorization and coverage for an increase in the  current prescription medication Amerge for the treatment of severe migraine headaches.  The health plan indicates that the requested increase in the patients prescription 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 prescription amount increase is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee requested authorization and coverage for a wheelchair for the treatment of osteochondritis desecans of both knees. The health plan has denied this request indicating that the requested equipment 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee requested authorization and coverage for intradiscal electrothermal therapy (IDET) for treatment of chronic intractable pain.  The health plan has denied this request indicating that IDET is considered experimental for treatment of the enrollees medical condition.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 your medical condition 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 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 30-year-old female enrollee requested authorization and coverage for the medication Lamisil for the treatment of a fungal infection of the toenails on both feet.  The health plan has denied this request indicating that Lamisil is not medically necessary for treatment of the enrollees medical condition.One podiatry reviewer performed a medical necessity Independent Medical Review.  The podiatry 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

A 51-year-old female enrollee requested authorization and coverage for gastric bypass surgery for the treatment of morbid obesity complicated by gastroesophageal reflux disease (GERD).  The health plan has denied this 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 procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 15-year-old male enrollee have requested authorization and coverage for continued treatment in a residential treatment center for treatment of their sons severe major depression with psychotic features.  The health plan has denied this request indicating that continued residential 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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee requested authorization and coverage for a pulmonary function test for the treatment of asthma.  The health plan has denied this request indicating that the requested test 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 pulmonary function test is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee requested authorization and coverage for a referral to an otolaryngologist for treatment of severe allergies.  The health plan has denied this request indicating that the requested referral 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 referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee requested authorization and coverage for gastric bypass surgery for the treatment of morbid obesity.  The health plan has denied this 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 procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a nine-year-old female enrollee who suffers from cerebral palsy and spastic quadriplegia requested authorization and coverage for an ultra-lightweight wheelchair .  The health plan has denied this request indicating that the requested wheelchair 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 equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 16-year-old female enrollee have requested authorization and coverage for continued residential treatment for treatment of the enrollees major depression, severe, recurrent; bipolar disorder; eating disorder; borderline personality disorder; polysubstance abuse; and deterioration in level of functioning.  The health plan has denied this request indicating that continued residential 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 overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an 11-year-old male enrollee have requested authorization and coverage for the medication Concerta. The health plan has denied this request indicating that Concerta is not medically necessary for treatment of the enrollees ADHD.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 58-year-old male enrollee requested authorization and coverage for proton beam radiation therapy. The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees low-grade stage prostate cancer.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: Overturned Decision of Health Plan

A 32-year-old male enrollee requested authorization and coverage for Diflucan or Lamisil.  The health plan has denied this request indicating that neither of the requested medications is medically necessary for treatment of the enrollees Onychomycosis.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that either of the requested medications is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested authorization and coverage for the medication Procarin. The health plan has denied this request indicating that Procarin is considered investigational for treatment of the enrollees multiple sclerosis.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested medication is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage for a prescription for the medications Biaxin and Mepron.  The health plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees Lyme disease.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that a seven to ten day course of the requested medications is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage for the medication Vioxx. The health plan has denied this request indicating that Vioxx 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee requested authorization and coverage for enrollment in a phase I clinical trial. The health plan has denied this request indicating that the proposed trial is not medically necessary for treatment of the enrollees metastatic colon cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested clinical trial is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage for proton beam radiation therapy. The health plan has denied this request indicating the requested therapy is not medically necessary for treatment of the enrollees left frontal glioma. 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 42-year-old female enrollee requested authorization and coverage for the medication Actiq. The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee requested authorization and coverage for vitamin B12 injections. The health plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees pernicious anemia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested B12 injections are not medically necessary.