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

A 36-year-old female enrollee requested authorization and coverage of orthotripsy for the treatment of plantar fasciitis.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-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 treatment 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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee requested authorization and coverage of a referral to a gastroenterologist for the treatment of indigestion, abdominal pain and gas, rapid weight loss and nausea.  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 referral is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-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 treatment 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 for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of the medication sodium phenylbutyrate for the treatment of breast cancer.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication sodium phenylbutyrate is not likely to be more beneficial for treatment of the enrollees breast cancer 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 5-year-old male enrollee requested authorization and coverage of sensory integration therapy for the treatment of autism.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee requested authorization and coverage of an anterior cervical discectomy with fusion and plating at C4-5, C5-6, and C6-7 for the treatment of bilateral arm numbness.  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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee requested authorization and coverage of an Empi 6000 TENS unit (Empi 6000) for the treatment of back pain.  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 equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-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 treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that gastric bypass surgery is not likely to be more beneficial for treatment of the enrollees morbid obesity 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: Overturned Decision of Health Plan

A female enrollee requested authorization and coverage of the medication lamisil for the treatment of onychomycosis.  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 overturned the health plans denial on the basis that the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee requested authorization and coverage of a capsule endoscopy for the treatment of abdominal pain.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a capsule endoscopy is not likely to be more beneficial for treatment of the enrollees abdominal 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee requested authorization and coverage of the medication thalidomide for the treatment of ocular melanoma.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication thalidomide is likely to be more beneficial for treatment of the enrollees ocular melanoma 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: Overturned Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of a colonoscopy screening for cancer.  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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee requested authorization and coverage of Silikon 1000 injections for the treatment of facial lipodystrophy.  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 overturned the health plans denial on the basis that the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage of a gastric bypass surgery with duodenal switch for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a gastric bypass surgery with duodenal switch is not likely to be more beneficial for treatment of the enrollees morbid obesity 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: Overturned Decision of Health Plan

A 30-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of obesity.  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 overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee requested authorization and coverage of Peg-Intron 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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of an 11-year-old male enrollee requested authorization and coverage of a pediatric neurologist for the treatment of attention deficit hyperactivity disorder.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee requested authorization and coverage of weekly therapy sessions with a non-plan provider for the treatment of social phobia.  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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old enrollee requested authorization and coverage of a referral to an out-of-network sleep disorders clinic for the treatment of sleep difficulties.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 10-year-old male enrollee requested authorization and coverage of continued residential treatment for the treatment of behavioral disorders.  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 overturned the health plans denial on the basis that the requested services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee requested authorization and coverage of a referral to an endocrinologist for the treatment of hypothyroidism.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee requested authorization and coverage of breast reduction surgery for the treatment of neck, back and chest pain.  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 surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old male enrollee requested authorization and coverage of out-of-network wrist surgery, including a bone graft, for the treatment of a wrist injury.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 76-year-old male enrollee requested authorization and coverage of the medication bosentan for the treatment of pulmonary hypertension. The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication bosentan  is likely to be more beneficial for treatment of the enrollees pulmonary hypertension 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee requested authorization and coverage of  chemodenervation by botox injections for the treatment of migraine headaches.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that chemodenervation by botox injections are not likely to be more beneficial for treatment of the enrollees migraine headaches 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 55-year-old female enrollee requested authorization and coverage of the medication estrace for hormonal therapy.  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 medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested authorization and coverage of the medication epogen for the treatment of myelodysplastic syndrome.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication epogen is not likely to be more beneficial for treatment of the enrollees myelodysplastic syndrome 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 38-year-old female enrollee requested authorization and coverage of dilatation and curettage for the treatment of endometrial hyperplasia.  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 services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee requested authorization and coverage of the medication Vioxx for the treatment of osteoarthritis.  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 medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of a single proton emission computerized tomography (SPECT) brain scan to determine how to treat attention deficit disorder with medication.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a single proton emission computerized tomography (SPECT) brain scan to determine how to treat attention deficit disorder with medication is not likely to be more beneficial 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee requested authorization and coverage of an out-of-network laparoscopic duodenal switch bariatric surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that an out-of-network laparoscopic duodenal switch bariatric surgery is not likely to be more beneficial for treatment of the enrollees morbid obesity 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: Overturned Decision of Health Plan

A 33-year-old female enrollee requested authorization and coverage of a referral to a dermatologist for the treatment of moles.  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 overturned the health plans denial on the basis that the requested services are medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee requested authorization and coverage of an increase in the  medication Zomig for the treatment of headaches.  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 increase in medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old male enrollee requested authorization and coverage of a referral for a bilateral inguinal hernia repair at Shouldice Hospital in Canada.  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 services are not medically necessary for treatment of the patients medical condition.