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

A 41-year-old male enrollee requested authorization and coverage of cervical discectomy and fusion for the treatment of nerve compression due to cervical spondylosis.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee requested authorization and coverage of  a surgical procedure for the treatment of a bone spur and pinched nerve. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of an electronic wheelchair for the treatment of peripheral vascular disease.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested authorization and coverage of mandibular surgery for the treatment of mandibular hyperplasia.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee requested authorization and coverage of gastric bypass using the duodenal switch technique for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a gastric bypass using the duodenal switch technique  is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage to participate in a clinical trial for a total disc replacement for the treatment of excruciating pain due to disc degeneration between L4 and L5 of the spine.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that to participate in a clinical trial for a total disc replacement is not likely to be more beneficial for treatment of the enrollees excruciating pain due to disc degeneration between L4 and L5 of the spine than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old male enrollee requested authorization and coverage of a referral to a pain management physician for the treatment of lower back pain.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 47-year-old male enrollee requested authorization and coverage of the medication serostim for the treatment of HIV wasting and lipodystrophy.  The Health Plan denied the enrollees request indicating that the requested medication is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee requested authorization and coverage of the medication fosamax (70 mg) for the treatment of osteopenia in the lumbar spine.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee requested authorization and coverage of a repeat "MRA" of the head for the treatment of arterial stenosis.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old male enrollee requested authorization and coverage of transitional living center services for the treatment of traumatic brain injury.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee requested authorization and coverage of a panniculectomy and hernia repair for the treatment of a large abdominal pannus.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee requested authorization and coverage for a vitrectomy.  The health plan has denied this request indicating that the requested procedure is considered experimental for treatment of the enrollees pseudoxanthoma.Three physician reviewers performed an experimental/investigational Independent Medical Review. Because all three-physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of your medical condition than any available standard therapy at this time, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of out-of-network chiropractic care for the treatment of  fibromyalgia.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-year-old female requested authorization and coverage for gastric bypass surgery.  The health plan has denied this 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 depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee requested authorization and coverage of  partial hospitalization program for the treatment of bulimia.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee requested authorization and coverage for a trial of a C-PAP machine.  The health plan has denied this request indicating that a trial of C-PAP is not medically necessary for treatment of the enrollees Sleep apnea and fatigue. One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee requested authorization and coverage for the surgical removal of a soft tissue mass in the ball of the right foot. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees soft tissue mass.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 at this time.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested authorization and coverage for treatment with interferon gamma-1b.  The health plan has denied this request indicating that the requested treatment is considered experimental for treatment of the enrollees severe pulmonary fibrosis.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Because two of the three physician reviewers concluded that the requested therapy 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: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested authorization and coverage for BRCA testing.  The health plan has denied this request indicating that the requested genetic testing is not medically necessary for treatment of the enrollees breast 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 BRCA testing is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old female enrollee requested authorization and coverage for Botox injections.  The health plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees recurrent acute 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 Botox injections are medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested authorization and coverage for an endorectal MRI every 12 months.  The health plan has denied this request indicating that the requested testing 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 services are not likely to be more beneficial for treatment of your medical condition than any available standard therapy.  Because all three-physician reviewers concluded that the requested services are 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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 29-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The health plan has denied this 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 57-year-old male enrollee requested authorization and coverage for a referral to an out-of-network surgical oncologist. The health plan has denied this request indicating that the requested referral is not medically necessary for treatment of the enrollees 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 referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested authorization and coverage for an increase in dosage of the medication Celebrex. The health plan has denied this request indicating that the request is not medically necessary for treatment of the enrollees low 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 increase in the enrollees prescription dosage is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested authorization and coverage for high-dose chemotherapy and autologous stem cell transplant. The health plan has denied this request indicating that the requested therapy is considered experimental for treatment of the enrollees breast cancer.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 enrollees medical condition than any available standard therapy; therefore, the review organization upheld the health plan's denial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30year-old female enrollee requested authorization and coverage for orthognathic surgery.  The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees maxillary hyperplasia.One oral surgeon reviewer performed a medical necessity Independent Medical Review.  The 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

The parent of a three-year-old male enrollee requested authorization and coverage for speech therapy. The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees apraxia of speech.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested speech therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee requested authorization and coverage for physical therapy. The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees adhesive capsulitis of the left shoulder.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 55-year-old female enrollee requested authorization and coverage for a referral to a pulmonologist for the treatment of restless leg syndrome.  The health plan has denied this request indicating that a referral to a pulmonologist is 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 referral is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The treating provider of a 33-year-old female enrollee requested authorization and coverage for an allogenic stem cell transplant for treatment of the enrollees medical condition. The health plan has denied this request indicating that the requested therapy is considered experimental for treatment of the enrollees acute myelogenous leukemia.All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of your 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 your 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 58-year-old female enrollee requested authorization and coverage for biofeedback therapy.  The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees pain in the feet.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parent of a 17-year-old female enrollee who has suffered from severe back pain for 5-6 years requested authorization and coverage for intradiscal electrothermal therapy (IDET).  The health plan has denied this request indicating that IDET 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 procedure is not 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 procedure is not likely to be more beneficial for treatment of the enrollees 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 37-year-old female enrollee requested authorization and coverage for continued Botox injections for the treatment of migraines.  The health plan has denied this request 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 not likely to be more beneficial for treatment of your 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 your 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 52-year-old female enrollee requested authorization and coverage for the medication Lamisil. The health plan has denied this 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 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 38-year-old female enrollee requested authorization and coverage for hypnotherapy. The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees migraine headaches.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 30-year-old female enrollee requested authorization and coverage for a septoplasty. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees bilateral nasal obstruction.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 at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage for transurethral microtherapy heat treatment (TUMT).  The health plan has denied this request indicating that the requested therapy is considered experimental for treatment of the enrollees benign prostate hypertrophy.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.