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

A 30-year-old male enrollee requested authorization and coverage of a capsule endoscopy. The Health Plan denied the request indicating that the requested procedure is considered experimental for evaluation of the enrollees apparent Crohns disease.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for the 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

A 66-year-old female enrollee requested authorization and coverage of an open MRI. The Health Plan denied the request indicating that the requested MRI is not medically necessary for the evaluation of the enrollees neck 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of continued Botox injections. The Health Plan  denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees headaches.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 the treatment of the enrollee's medical condition than any available standard therapy. Because 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 Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-three year-old male with bilateral retinitis pigmentosa is requesting coverage of a referral to an eye institute.Reviewers Findings:  The reviewing physician found that the requested referral is not medically necessary for the patients condition.   The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested authorization and coverage of the Vest Airway Clearance System. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees bibasilar bronchiectasis. 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 46-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's 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 the 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 58-year-old male enrollee requested authorization and coverage of the medication Tegaserod. The Health Plan  denied the request indicating that the requested medication is considered investigational for the treatment of the enrollees dyspepsia.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested medication is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested medication is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested medication is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee requested authorization and coverage of the continuation of chemotherapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees chronic lymphocytic leukemia (CLL).Three physician reviewers performed a medical necessity 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. Because all three  physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 67-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees diabetes.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for THE treatment of the enrollee's 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 41-year-old female enrollee requested authorization and coverage of left breast mastopexy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees bilateral breast 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 procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee requested authorization and coverage of the medication Lamisil. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees onychomycosis.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 at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee requested authorization and coverage of a laminectomy and fusion. The Health Plan denied the request indicating that the requested procedures are not medically necessary for the treatment of the enrollees herniated disc.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedures are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee requested authorization and coverage of the medication Vioxx, 50mg. The Health Plan  denied the request indicating that the requested prescription is not medically necessary for the treatment of the enrollees degenerative joint disease and post-traumatic arthritis.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: Overturned Decision of Health Plan

The mother of a 14-year-old female enrollee requested authorization and coverage of speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees autism.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 49-year-old female enrollee requested authorization and coverage of a pneumatic vest. The Health Plan denied the request indicating that the requested equipment is not medically necessary for the 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 equipment 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 gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for the treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for the treatment of the enrollee's 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 36-year-old male enrollee requested authorization and coverage of a chest CT scan. The Health Plan denied the request indicating that the requested chest CT scan is not medically necessary for the evaluation of the enrollees risk of heart 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 CT scan is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of an 11-year-old male enrollee requested authorization and coverage of a magnetoencephalography for evaluation of the enrollees medical condition. The Health Plan denied the request indicating that the requested magnetoencephalography (MEG) is considered experimental for evaluation of the enrollees partial complex seizures.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested MEG is likely to be more beneficial for the evaluation of the enrollees medical condition than any available standard therapy. One physician reviewer concluded that the requested MEG is not likely to be more beneficial for the evaluation of the enrollees medical condition than any available standard therapy. Because two of the three physician reviewers determined that the requested MEG is likely to be more beneficial for the evaluation of the enrollees medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage of the medication Sarafem.  The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees premenstrual dysphoric 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 medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage of a gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee requested authorization and coverage of a total abdominal hysterectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees metrorrhagia 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested authorization and coverage of myopulse electrotherapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees abdominal pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's 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 the 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 mother of an eight-year-old male enrollee requested authorization and coverage of ongoing speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees language disorder.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The representative of a 22-year-old male enrollee requested authorization and coverage of intravenous Cipro and Tobramycin for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees pulmonary infections.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollees medical condition than any available standard therapy. Because all three physician reviewers determined that the requested therapy is not likely to be more beneficial for the 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 40-year-old female enrollee requested authorization and coverage of serial micro follicular transplantation. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees B-neoplasm of the scalp.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

A 55-year-old male enrollee requested reimbursement for the medication Sporanox. The Health Plan denied the request indicating that the medication at issue was not medically necessary for the treatment of the enrollees fungal infection.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the medication at issue was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee requested authorization and coverage of an inflatable penile implant. The Health Plan denied the request indicating that the requested implant 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

A 26-year-old female enrollee requested authorization and coverage of a lefort osteotomy and bilateral mandibular sagittal split osteotomies. The Health Plan denied the request indicating that the requested procedures are not medically necessary for the treatment of the enrollees temporomandibular joint dysfunction.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon reviewer overturned the Health Plans denial on the basis that the requested procedures are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of the medication Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees systemic lupus erythematosus (SLE) associated fatigue.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 53-year-old female enrollee requested authorization and coverage of the medication Evista.  The Health Plan denied the request indicating that the requested medication is not medically necessary for the prevention of osteoporosis.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 59-year-old male enrollee requested authorization and coverage of the medication Vicodin. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees chronic thoracic myofascial 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 51-year-old female enrollee requested authorization and coverage of the medication Fosamax. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees osteoporosis.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 male enrollee requested authorization and coverage of proton beam therapy.  The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees 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: Upheld Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the 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.