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

A 52-year-old male enrollee requested authorization and coverage of the medication Lotronex. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees irritable bowel syndrome.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 depending upon the patients fully informed consent and the patients providers registration under the GSK Prescribing Program.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 34-year-old female enrollee requested authorization and coverage of hepatic activation therapy.  The Health Plan  denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees diabetes mellitus. 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 treatment of the enrollee's 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 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 58-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 treatment of the enrollees daytime sleepiness.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 depending upon documented evidence that a trial of nasal CPAP has failed and that a diagnosis of narcolepsy has been ruled out.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee requested authorization and coverage of a PET scan. The Health Plan denied the request indicating that the requested PET scan is not medically necessary for evaluation 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 PET scan is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage of a power-operated vehicle (POV). The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees paraplegia. 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 38-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees cervical dystonia.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-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 considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewer 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. Because two of the three physician reviewers concluded that the requested procedure 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 59-year-old female enrollee requested authorization and coverage of a DEXA scan. The Health Plan denied the request indicating that the requested DEXA scan is not medically necessary for evaluation of the enrollees bone density.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested DEXA scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee requested authorization and coverage of a Helios oxygen system. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees cardiac problems.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 49-year-old female enrollee requested authorization and coverage of a DEXA scan. The Health Plan denied the request indicating that the requested DEXA scan is not medically necessary for evaluation of the enrollee for possible osteoporosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested DEXA scan is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-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 treatment of the enrollees 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 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 of intravenous Ketamine-infusion therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees foot and leg 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 therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee requested authorization and coverage of endoluminal radiofrequency ablation. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees varicose veins. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer 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.  Because two of the three physician reviewers concluded that the requested procedure 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: Overturned Decision of Health Plan

A 56-year-old female enrollee requested authorization and coverage of 18 Amerge 2.5mg tablets per month. The Health Plan denied the request indicating that the requested prescription is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested prescription is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee requested authorization and coverage of participation in an inpatient pain management program. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees chronic 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 services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee requested authorization and coverage of Lamisil. The Health Plan denied the request indicating that the requested medication is not medically necessary for 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: Overturned Decision of Health Plan

A 40-year-old female enrollee requested reimbursement for inpatient chemical dependency treatment received from 3/16/03 through 4/15/03. The Health Plan denied the request indicating that the services at issue were not medically necessary for treatment of the enrollees chemical dependency.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the services at issue were medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee requested authorization and coverage of the medication Neupogen. The Health Plan denied the request indicating that the requested medication is not medically necessary while the enrollee is undergoing chemotherapy.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

The parents of a 17-year-old female enrollee requested authorization and coverage of residential treatment services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health problems.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: Overturned Decision of Health Plan

A 42-year-old female enrollee requested authorization and coverage of right breast reduction mammoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees breast asymmetry.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 42-year-old female enrollee requested authorization and coverage of an intradiscal electrothermal therapy (IDET) procedure. The Health Plan denied the request indicating that the requested procedure is 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old male enrollee requested authorization and coverage of the medication Vioxx. The Health Plan denied the request indicating that the requested medication 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee requested authorization and coverage of a laminectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollee's back 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy depending upon the results of a psychological evaluation. One of the 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. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy depending upon the results of a psychological evaluation the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The father of a four-year-old male enrollee requested reimbursement for food allergy testing performed on 6/30/03. The Health Plan denied the request indicating that the services at issue were not medically necessary for treatment of the enrollees food allergies.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the services at issue were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a twenty-two month-old female with acute myeloid leukemia are requesting authorization for bone marrow transplantation with T-cell depletion and without total body irradiation.Reviewers Findings:  The reviewing physician found that the requested therapy is medically necessary for the patients condition.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee requested authorization and coverage of amphotericin. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic sinusitis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A forty-eight year-old female with dural cranial fistula is requesting authorization of a craniotomy.Reviewers Findings:  The reviewing physician found that the requested services are medically necessary for the patients condition.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee requested authorization and coverage of the medication Prevacid. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees gastroesophageal reflux 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 medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a 17-year-old female enrollee requested authorization and coverage of a referral to a plastic surgeon for evaluation for possible breast reduction surgery. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees breast hyperplasia.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: Upheld Decision of Health Plan

The father of an 11-month-old female enrollee requested authorization and coverage of a portable nebulizer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees respiratory problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old male enrollee requested authorization and coverage of a referral to a toxicologist. The Health Plan  denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees mold exposure.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 43-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 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

A 52-year-old female enrollee requested authorization and coverage of continued chiropractic therapy. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees neck pain.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic 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 50-year-old female enrollee requested authorization and coverage of Tri-Luma cream. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees skin 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee requested authorization and coverage of cervical discectomy with fusion. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees back and neck 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 67-year-old male enrollee requested authorization and coverage of laparoscopic radical prostatectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of bilateral breast reduction. The Health Plan  denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees back 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 43-year-old female enrollee requested authorization and coverage of a total abdominal hysterectomy with bilateral salpingo-oophorectomy and bladder suspension. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees menorrhagia.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

The father of an eight-year-old male enrollee requested authorization and coverage of continued speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees speech and language 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 therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-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 treatment of the enrollees daytime drowsiness. 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: Overturned Decision of Health Plan

A 33-year-old female enrollee requested authorization and coverage of a urology consultation. The Health Plan denied the request indicating that the requested consultation is not medically necessary for treatment of the enrollees urinary tract infection.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested consultation is medically necessary.