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

A 41-year-old female enrollee requested authorization and coverage of gastric bypass. 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 on the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old female enrollee requested authorization and coverage of bilateral blepharoplasty. The Health Plan denied the request indicating that the requested procedure is cosmetic in nature and not medically necessary for treatment of the enrollees Graves 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 procedure is cosmetic in nature and not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 25-year-old male enrollee requested authorization and coverage of a GlucoWatch. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees diabetes mellitus type I.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 CHDR physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee requested authorization and coverage of a referral to a plastic surgeon for a possible panniculectomy. The Health Plan has denied this request indicating that a panniculectomy is considered cosmetic in nature and not medically necessary for treatment of the enrollees excess abdominal tissue.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial of the referral on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a 10-year-old male enrollee requested authorization and coverage of an insulin pump. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees diabetes mellitus.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee requested authorization and coverage of intradiscal electrothermal therapy. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is 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 therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee requested authorization and coverage for 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: Upheld Decision of Health Plan

A 39-year-old female enrollee requested authorization and coverage of laser treatment post scar revision. The Health Plan denied the request indicating that the requested therapy is considered cosmetic in nature and not medically necessary for treatment of the enrollees suprapubic scar.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 cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The father of a 17-year-old male enrollee requested authorization and coverage of nasal surgery. The Health Plan  denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested authorization and coverage of injectable Forteo. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoporosis.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 father of a 17-year-old female enrollee requested authorization and coverage of Rituxan. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees Evans syndrome/thrombocytopenia.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 enrollees medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees 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 enrollees 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 38-year-old male enrollee requested authorization and coverage of a continuous passive motion unit. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollee status post patellar tendon surgical repair. 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 56-year-old female enrollee requested authorization and coverage of a Stretta procedure. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).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 enrolllee'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 54-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male enrollee requested authorization and coverage of nasal surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees nasal 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: Upheld Decision of Health Plan

A 46-year-old male enrollee requested authorization and coverage of a mandibular repositioning device. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees obstructive sleep apnea.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee requested authorization and coverage of Elidel 1% cream. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees vitiligo.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 59-year-old male enrollee requested authorization and coverage of acupressure treatment. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees fibromyalgia and trapezius spasms.One acupuncture reviewer performed a medical necessity Independent Medical Review. The acupuncture 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 41-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: Upheld Decision of Health Plan

A 61-year-old female enrollee requested authorization and coverage of Humatrope. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees growth hormone level.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 44-year-old male enrollee requested authorization and coverage of a full body MRI. The Health Plan denied the request indicating that the requested MRI is not medically necessary for evaluation of the enrollee status post motor vehicle accident.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee requested authorization and coverage of Viagra. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees erectile dysfunction.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer 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

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

A 27-year-old male enrollee requested authorization and coverage of the medication Amevive. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriasis.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 41-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 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

The father of a 12-year-old male enrollee requested authorization and coverage of a referral to a dermatologist 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 eczematous dermatitis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee requested authorization and coverage of a referral to an otolaryngologist. The Health Plan denied the request indicating that the requested referral is not medically necessary for evaluation and treatment of the enrollees deviated septum and associated airway disorder.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee requested authorization and coverage of an MRI of the brain. The Health Plan  denied the request indicating that the requested MRI is not medically necessary to rule out stroke.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 65-year-old male enrollee requested authorization and coverage of thalidomide. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees recurrent malignant melanoma.Three physician reviewers performed a medical necessity Independent Medical Review. Two of the three physician reviewers concluded that the requested medication is not medically necessary for treatment of the enrollee's medical condition. One of the three physician reviewers concluded that the requested medication is medically necessary for treatment of the enrollee's medical condition. Because two of the three physician reviewers concluded that the requested medication is not medically necessary for treatment of your medical condition, the Health Plans denial was upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee requested authorization and coverage of angioplasty and stenting of the right intracranial lesions. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees intracranial lesions.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 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: Overturned Decision of Health Plan

A 59-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 experimental for treatment of the enrollees super-morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two 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 CHDR physician reviewer 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 43-year-old male enrollee requested authorization and coverage of endoscopic transforaminal lumbar discectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees herniated disc.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 60-year-old female enrollee requested authorization and coverage of Protopic. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees granuloma annulare.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 52-year-old male enrollee requested authorization and coverage of extracorporeal shockwave therapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees plantar fasciitis.Three medical professional reviewers performed an experimental/investigational Independent Medical Review. All three medical professional 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 medical professional 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 31-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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of revision gastric bypass 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 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 father of a 17-year-old female enrollee requested authorization of continued residential treatment services. The Health Plan denied the request indicating that the requested services 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 upheld the Health Plans denial on the basis that the requested services are not medically necessary.