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

The father of a 16-year-old female enrollee requested authorization and coverage of a custom knee brace. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollee status post anterior cruciate ligament repair.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a 15-year-old male 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 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 medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old male enrollee requested authorization and coverage of sinus surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees sinus 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male 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 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

A 52-year-old female enrollee s requested authorization and coverage of a referral for surgical debulking with hyperthermic chemoperfusion. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees appendiceal cancer.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee requested authorization and coverage of Zoladex injections. The Health Plan denied the request indicating that the requested medication is considered investigational for treatment of the enrollees aggressive angiomyxoma.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 CHDR physician reviewer 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

The parents of an eight-month-old female enrollee requested authorization and coverage of the medication Synagis. 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: Upheld Decision of Health Plan

The parents of an eight-month-old male enrollee requested authorization and coverage of the medication Synagis. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of a 16-year-old male enrollee requested authorization and coverage of bilateral hip arthroplasties. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees avascular necrosis of the hips.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 enrollees 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 enrollees 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 27-year-old male enrollee requested authorization and coverage of laparoscopic vertical gastrectomy as a first stage for the duodenal switch procedure. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees super, super 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 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, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-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 the enrollees mobility.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 61-year-old female enrollee requested authorization and coverage of knee replacement surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees left knee 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 a hysterectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees abdominal 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 49-year-old male enrollee requested authorization and coverage of orthotripsy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees elbow tendonitis.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

A 26-year-old female enrollee requested authorization and coverage of an MRI of the lumbar spine. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollees back and right leg 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 MRI is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 54-year-old female 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 type I. Three physician reviewers performed an experimental/investigational Independent Medical Review. All 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 all 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, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee requested authorization and coverage of hyperbaric oxygen therapy. The Health Plan  denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees toxic encephalopathy. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee requested authorization and coverage of a Dynatronics STS device. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees foot and leg 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: Upheld Decision of Health Plan

A 43-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. 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 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 61-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 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 not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard procedure. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees migraine/headaches.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: Upheld Decision of Health Plan

A 37-year-old female enrollee requested authorization and coverage of an extended course of intravenous Rocephin. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees Lyme 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

A 28-year-old male enrollee requested authorization and coverage of an ear, nose, and throat (ENT) consultation. The Health Plan denied the request indicating that the requested consultation is not medically necessary for evaluation of the enrollees 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 consultation is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A forty-eight year-old female with a Chiari malformation is requesting coverage of a referral to a specific institute for Chiari malformation.    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: Overturned Decision of Health Plan

A 28-year-old female enrollee requested authorization and coverage of orthognathic surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for 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 procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 58-year-old male enrollee requested authorization and coverage of the medications Wellbutrin, Neurontin, Seroquel, and trazodone at previously prescribed levels. The Health Plan denied the request indicating that the requested prescriptions 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 prescriptions are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old male enrollee requested authorization and coverage of chiropractic treatment. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees neck and back pain.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic 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 50-year-old male 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 super 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 depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee requested authorization and coverage of Pravachol. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia.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 20-year-old male enrollee requested authorization and coverage of a magnetoencephalography (MEG) study. The Health Plan denied the request indicating that the requested MEG study is not medically necessary for evaluation of the enrollees seizure 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 MEG study is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of participation in a Phase I study of VEGF-Antisense Oligonucleotide.  The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees retroperitoneal sarcoma. 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 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 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 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 29-year-old male enrollee requested authorization and coverage of prolotherapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees shoulder 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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 32-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 depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a 14-year-old female enrollee requested authorization and coverage of an electric bone growth stimulator. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees finger status post fracture.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female 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 the treatment of the enrollees joint inflammation.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: Overturned Decision of Health Plan

A 25-year-old female enrollee requested authorization and coverage of intravenous Remicade therapy. The Health Plan  denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees positive HLA-B27 spondyloarthropathy with ankylosing spondylitis.  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 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 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 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

The mother of a four-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 delay.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.