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

A 46-year-old female enrollee requested authorization and coverage of Synvisc injections for treatment of early arthritis in both knees. The health plan has denied this request indicating that the requested injections 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 injections are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a six-year-old male enrollee requested authorization and coverage of Applied Behavioral Analysis (ABA) therapy.  The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees Pervasive Development 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 therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee requested authorization and coverage for treatment with herceptin.  The health plan has denied this request indicating that herceptin 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 treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee requested authorization and coverage for gastric bypass surgery.  The health plan has denied this request indicating that the requested surgery 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: Upheld Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of the medication Vioxx for the treatment of arthritis.  The health plan denied the enrollees request indicating that Vioxx 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old female enrollee requested authorization and coverage for thigh lift surgery for removal of redundant skin pursuant to successful bariatric surgery. The health plan has denied this procedure on the basis that it is considered cosmetic and 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 procedure is reconstructive in nature and is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The representatives of a 55-year-old male enrollee requested authorization and coverage for continued skilled nursing facility (SNF) care.  The health plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees traumatic brain injury.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 54-year-old female enrollee requested authorization and coverage for the medication Celebrex. The health plan has denied this request indicating that the Celebrex is not medically necessary for treatment of the enrollees fibromyalgia, degenerative joint disease, and status post knee surgery.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 55-year-old female enrollee requested authorization and coverage of the medication Vioxx for the treatment of osteoarthritis.  The health plan denied the enrollees request indicating that Vioxx 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 medication 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 Peglyated Interferon (PEG-Intron) and ribavirin for the treatment of Hepatitis C.  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 therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

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

The parents of a three-year-old male enrollee requested authorization and coverage for an adaptive toilet chair and a referral to pediatric neurologist. The Health Plan has denied this request indicating that the requested equipment and referral are not medically necessary for treatment of the enrollees congenital hypotonia.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 and equipment are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old male enrollee requested authorization and coverage for residential treatment services. The health plan has denied this request indicating that the requested services are 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 services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested authorization and coverage for surgery for treatment of sleep apnea. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage of an ABI Vest for the treatment of asthma.  The health plan denied the enrollees request indicating that the requested equipment 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 equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee requested authorization and coverage of a brain SPECT scan to confirm diagnosis of depression, anxiety and attention deficit disorder.  The health plan denied the enrolleeS request indicating that the requested scan 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 SPECT scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 25-year-old female enrollee requested authorization and coverage of the medication Yasmin for the treatment of polycystic ovarian syndrome and hirsutism.  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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of a mastopexy and buttock lift for the treatment of redundant skin tissue resulting from a substantial weight loss.  The health plan denied the enrollees request indicating that the requested procedures are 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 procedures are reconstructive in nature and are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of a laparoscopic total abdominal colectomy with ileorectal anastomosis for the treatment of megacolon and chronic inertia.  The health plan denied the enrollees request indicating that the requested procedure 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV) for the treatment of fibromyalgia and arthritis.  The health plan denied the enrollees request indicating that a POV 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 equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV) for the treatment of cervical stenosis and meningitis.  The health plan denied the enrollees request indicating that a POV 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 equipment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee requested authorization and coverage of the medication thalidomide for the treatment of prurigo nodularis.  The health plan denied the enrollees request indicating that the requested treatment is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that the requested thalidomide is likely to be more beneficial for treatment of the enrollees prurigo nodularis than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee requested authorization and coverage of further infertility services.  The health plan denied the enrollees request indicating that further infertility services are 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of surgical treatment for varicose veins.  The health plan denied the enrollees request indicating that the requested surgery 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee requested authorization and coverage of the medication Accutane for the threatment of acne.  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 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 42-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch for the treatment of obesity related comorbid conditions including gastroesophageal reflux disease, stress incontinence, and osteoarthritis.  The health plan denied the enrollees request indicating that the requested procedure is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician reviewers concluded that the requested gastric bypass surgery with duodenal switch 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 37-year-old female enrollee requested authorization and coverage of adjustable laparoscopic gastric banding (Lap-Band) surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested surgery is considered investigational.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician reviewers concluded that the Lap-Band surgery 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 61 year-old male enrollee requested authorization and coverage of lung volume reduction surgery for the treatment of emphysema.  The health plan denied the enrollees request indicating that the requested surgery is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician reviewers concluded that the lung volume reduction surgery is not likely to be more beneficial for treatment of the enrollees emphysema 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 50-year-old female enrollee requested authorization and coverage of the medication provigil for the treatment of multiple sclerosis.  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 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 parent of a 14-year-old a male enrollee requested authorization and coverage of the medication nutropin for the treatment of growth hormone deficiency.  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 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 45-year-old female requested authorization and coverage of the medication Lamisil for the treatment of onychomycosis.  The health plan denied the enrollees request indicating that the requested medication is not medically necessary.One podiatry reviewer performed a medical necessity Independent Medical Review.  The podiatry 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 60-year-old female requested authorization and coverage of Miacalcin nasal spray for the treatment of osteoporosis.  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 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 50-year-old male enrollee requested authorization and coverage of radiofrequency ablation of cervical facets for the treatment of cervogenic headaches.  The health plan denied the enrollees request indicating that the long-term efficacy of the requested procedure has not been established; therefore, the requested procedure is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical review.  Each of the three physician reviewers concluded that radiofrequency ablation is not likely to be more beneficial for treatment of the enrollees cervogenic headaches 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: Overturned Decision of Health Plan

A 26-year-old male enrollee requested authorization and coverage of surgery for the treatment of metastatic osteosarcoma.  The health plan denied the enrollees request indicating that the requested surgery 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee requested authorization and coverage of a heated humidifier for the treatment of sleep apnea.  The health plan denied the enrollee request indicating that the requested equipment 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 equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee requested authorization and coverage of a PET scan of the brain for treatment of neurotoxicity to rule out Dursban toxicity and toxic leukoencephalopathy.  The health plan denied the enrollees request indicating that a PET scan 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 PET scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity and comorbidity conditions.  The health plan denied the enrollees request indicating that the requested procedure 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 procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee requested authorization and coverage of the medication Aciphex for the treatment of severe gastroesophageal reflux disease and severe abdominal pain.  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 upheld the health plans denial on the basis that the requested medication is not medically necessary until it is established that an H2 blocker is ineffective.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested authorization and coverage of extracorporeal shock wave therapy (orthotripsy) for treatment of bone spurs on heels.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One podiatry reviewer performed a medical necessity Independent Medical Review.  The podiatry reviewer upheld the health plans denial on the basis that, because the records do not demonstrate that the patient has undergone all conservative treatments, the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 51-year-old female requested authorization and coverage of enhanced external counterpulsation (EECP) for the treatment of myocardial ischemia.  The health plan denied the enrollees request indicating that the requested treatment is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested EECP is not likely to be more beneficial for treatment of the enrollees myocardial ischemia 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.