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

A 54-year-old female enrollee requested authorization and coverage of a referral to an urologist. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees bladder control 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 referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a 13-year-old male enrollee requested authorization and coverage of a referral to a podiatrist for treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees ingrown toenail.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old male enrollee requested authorization and coverage of a nebulizer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees asthma.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 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee requested authorization and coverage of the medication Vaniqa. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees facial hair.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 thirty year-old female diagnosed with an ependymoma in the lumbar spine is requesting a referral for treatment.  Reviewers Findings:  The three reviewing physicians found that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  The Health Plan denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested authorization and coverage of a deluxe commode transfer chair for assistance with her Parkinsons disease. The Health Plan has denied this request.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 at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage of a fully electric hospital bed for assistance with her Parkinsons disease. The Health Plan denied the request.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 at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a five-year-old male enrollee requested authorization and coverage of continued intensive physical therapy services. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees cerebral palsy.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 45-year-old female enrollee requested authorization and coverage for aquatic therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 19-year-old female enrollee requested reimbursement for residential treatment services the enrollee received from 6/21/01 to 6/29/01. The Health Plan denied the request indicating that residential treatment services were not medically necessary for treatment of the enrollees medical condition from 6/21/01 to 6/29/01.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 28-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested surgery 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 depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee requested authorization and coverage of additional pulmonary rehabilitation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees pulmonary disease.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

A 59-year-old female enrollee requested authorization and coverage of treatment with thalidomide. The Health Plan  denied the request indicating that thalidomide is considered experimental for treatment of the enrollees metastatic melanoma.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 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: Upheld Decision of Health Plan

The mother of a 26-year-old female enrollee requested authorization and coverage of licensed vocational nursing (LVN) services at home for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees Rett syndrome.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female 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. All 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 all 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, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old male requested authorization and coverage of a turbinoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees nasal airway obstruction.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: Overturned Decision of Health Plan

A 33-year-old female enrollee requested authorization and coverage of continued skilled nursing facility services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee requested authorization and coverage of physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees lymphedema.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: Overturned Decision of Health Plan

A 33-year-old female enrollee requested authorization and coverage of breast reduction surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees excessive breast tissue.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 31-year-old female enrollee requested authorization and coverage of enrollment in a clinical trial involving autologous stem cell transplantation. The Health Plan denied the request indicating that the proposed trial is considered experimental for treatment of the enrollees systemic lupus erythematosus (SLE).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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee requested authorization and coverage of genetic counseling and genetic testing. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees history of spontaneous abortion.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested genetic counseling is medically necessary, but that the requested genetic testing is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a three-year-old male requested authorization and coverage of additional speech therapy for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested speech therapy is not medically necessary for treatment of the enrollees speech-language disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that additional speech therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female requested authorization and coverage of a bunionectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees bunion.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a seven-month-old female enrollee requested authorization of a battery-operated nebulizer. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer 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 47-year-old female enrollee requested authorization and coverage of nerve decompression surgery. The Health Plan  denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees diabetic peripheral neuropathy.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 66-year-old male enrollee requested authorization and coverage of enhanced external counterpulsation (EECP). The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees coronary artery disease.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

The representatives of a 15-year-old male requested authorization and coverage of an oral splint for treatment of the enrollees snoring. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees snoring.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 37-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 procedure 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 procedure 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: Upheld Decision of Health Plan

A 60-year-old male requested authorization and coverage of a referral to a dermatologist. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees skin lesions.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 at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of uterine artery embolization. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees uterine fibroids.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

The representatives of a 59-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 considered experimental for treatment of the enrollees possible dementia.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested PET scan 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 PET scan 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 62-year-old male enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of 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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 54-year-old female enrollee requested authorization and coverage of the medication genotropin. The Health Plan denied the request indicating that the requested medication 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee requested authorization and coverage of a bilateral thoracic sympathectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees hyperhidrosis.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 64-year-old-male enrollee requested authorization and coverage of continued chiropractic care. The Health Plan denied the request indicating that continued chiropractic care 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 treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of a liver biopsy. The Health Plan denied the request indicating that the requested service is not medically necessary for treatment of the enrollees psoriasis.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 male enrollee requested authorization and coverage of a pain pump. The Health Plan denied the request indicating that the requested treatment 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 treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representatives of a 63-year-old male enrollee requested authorization and coverage of continued acute inpatient services for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 19-year-old female enrollee requested authorization and coverage of residential treatment for treatment of the enrollee's medical condition.  The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollee's medical condition.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the Health Plan's denial on the basis that the requested services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee requested authorization and coverage of reduced intensity allogenic stem cell transplantation. The Health Plan denied therequest indicating that the requested therapy is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested 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.