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

A 59-year-old female enrollee requested authorization and coverage of participation in a Phase I clinical trial of VEGF-AS. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees renal cell carcinoma. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the 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 two of the three  physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old female enrollee requested authorization and coverage of 18 Imitrex 100mg 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee requested authorization and coverage of biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees rectal incontinence. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the 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 two of the three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage of the medication Actiq. The Health Plan denied the enrollees request indicating that the requested medication is not medically necessary for treatment of the enrollees back 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 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 of breast reconstruction. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollee status post previous breast reconstruction.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: Overturned Decision of Health Plan

A 49-year-old male enrollee requested authorization and coverage of a Glucowatch. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees diabetes mellitus. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested equipment is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested equipment 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 equipment 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

The father of an 18-year-old male enrollee requested authorization and coverage of the medication Humatrope. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees impaired neurocognitive function.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of a colonoscopy. The Health Plan denied the request indicating that the requested procedure 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 procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old female enrollee requested authorization and coverage of lumbar epidural injections. The Health Plan denied the request indicating that the requested injections are not medically necessary for treatment of the enrollees back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested injections are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

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

A 42-year-old male enrollee requested authorization and coverage of a corneal transplant. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees limbal stem cell deficiency.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: Overturned Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of the medication Iressa. The Health Plan denied the request indicating that the requested medication is considered investigational for treatment of the enrollees pancreatic cancer. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested medication 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 medication 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee requested authorization and coverage of biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees sexual dysfunction and urinary and bowel incontinence. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three of the 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 of the  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

The father of a 14-year-old male enrollee requested authorization and coverage of the medication Humatrope. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested procedure is considered investigational 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 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 28-year-old female enrollee requested authorization and coverage of a referral to a high-risk obstetrician specialist. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees pregnancy.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 34-year-old female enrollee requested authorization and coverage of endovenous laser therapy. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees varicose veins.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 57-year-old female enrollee requested authorization and coverage of a wheelchair. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees fibromyalgia. 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 28-year-old female enrollee requested authorization and coverage of acute inpatient rehabilitation services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollee status post motor vehicle accident.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: Overturned Decision of Health Plan

A 54-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 pending confirmation of the enrollees body mass index.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee requested authorization and coverage of a continuous positive airway pressure (CPAP) device. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees obstructive sleep apnea.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 48-year-old female enrollee requested authorization and coverage of a panniculectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees excess skin.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: Overturned Decision of Health Plan

A 29-year-old male enrollee requested authorization and coverage of a Meniett-20 device. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees Menieres syndrome. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three of the 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 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: Overturned Decision of Health Plan

A 36-year-old female enrollee requested authorization and coverage of oral surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees temporomandibular joint disorder.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 procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee requested authorization and coverage of Heidelberg retinal tomography (HRT). The Health Plan denied the request indicating that the requested procedure is not medically necessary for evaluation of the enrollees vision.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 60-year-old male enrollee requested authorization and coverage of spinal reconstruction surgery. 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: Overturned Decision of Health Plan

A 72-year-old male 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 lungs.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: Overturned Decision of Health Plan

The representative of a 21-year-old female enrollee requested authorization and coverage of residential eating disorder treatment. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees eating disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of a revision panniculectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees abdominal tissue.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 49-year-old male enrollee requested authorization and coverage of Viagra. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees erectile dysfunction. 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 39-year-old male enrollee requested authorization and coverage of at least 30 days of residential chemical dependency treatment services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees alcoholism.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 35-year-old female enrollee requested authorization and coverage of heparin and prednisone. The Health Plan denied the request indicating that the requested medications are not medically necessary for treatment of the enrollee status post two spontaneous abortions.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medications are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old female enrollee requested authorization and coverage of 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 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 44-year-old male enrollee requested authorization and coverage of injectable Hylan G-F 20. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees knee 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 26-year-old female enrollee requested authorization and coverage of nuchal translucency screening. The Health Plan  denied the request indicating that the requested genetic screening is considered investigational for evaluation of the enrollees medical condition. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three of the physician reviewers concluded that the requested genetic screening is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three of the three  physician reviewers concluded that the requested genetic screening is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees degenerative disc disease. Three physician reviewers performed an experimental/investigational Independent Medical Review. All three CHDR 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 CHDR 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 39-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 investigational for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure 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 treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.