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

A 53-year-old female requested authorization and coverage for a DEXA scan.  The health plan has denied this request indicating that the requested scan is not medically necessary for treatment of the enrollees osteoarthritis.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 29-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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage for gastric bypass surgery with duodenal switch. The health plan has denied this request indicating that the requested procedure is considered experimental for treatment of the enrollees obesity.Three physician reviewers performed an experimental/investigational independent medical review.  All three physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy.  The health plan's decision was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee requested authorization and coverage for DIEP flap breast reconstruction surgery. The health plan has denied this request indicating that the requested surgery 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested authorization and coverage for peglyated interferon (PEG-Intron).  The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees chronic hepatitis C.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 21-year-old female enrollee who has requested authorization and coverage for breast reduction surgery. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees very large breasts.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 son of a 69-year-old female enrollee requested authorization and coverage for 24-hour home hospice care.  The health plan has denied this request indicating that the requested services are 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 services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested authorization and coverage for a laparoscopic colon resection.  The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees digestive system/gastrointestinal 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee requested authorization and coverage of continued orthopedic spine treatment (OST).  The health plan denied the request, indicating that the requested services are not medically necessary for treatment of the enrollees speech therapy. One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee requested authorization and coverage of uterine artery embolization (UAE) for treatment of uterine fibroids.  The health plan denied the request, indicating that UAE is considered experimental.Each of the three physician reviewers determined that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy. The health plans denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The father of a 4-year-old male enrollee who requested authorization and coverage of the medication Lamisil. The health plan denied the request, indicating that the requested medication is not medically necessary for treatment of the enrollees candida/fungal infection.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 40-year-old female enrollee requested authorization and coverage of orthognathic surgery. The health plan denied the request, indicating that the requested surgery is not medically necessary for treatment of the enrollees dysfunctional dental malocclusion secondary to developmental maxillomandibular deformity.One oral surgical reviewer performed a medical necessity Independent Medical Review. The oral surgical 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 49-year-old male enrollee requested authorization and for discectomy and foraminotomy. The health plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees lumbar disc 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 not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested authorization and coverage for a full body DEXA scan.  The health plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees Musculoskeletal/orthopedic 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 service is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee requested authorization and coverage for hereditary nonpolyposis colon cancer (HNPCC) testing.  The health plan has denied this request indicating that the requested testing is considered experimental for treatment of the enrollees cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three-physician reviewers concluded that the requested testing is not likely to be more beneficial for treatment of the medical condition than any available standard therapy.  The health plans denial was upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 60-year-old male enrollee requested authorization and coverage of intradialytic peritoneal nutrition (IPN) for the treatment of chronic renal disease. 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 intradialytic peritoneal nutrition is not likely to be more beneficial for treatment of the enrollees chronic renal disease 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

The parents of an 18-year-old female enrollee requested authorization and coverage for breast surgery for treatment of the enrollees Scoliosis.  The health plan has denied this request indicating that the requested surgery is cosmetic in nature and not medically necessary for treatment of the enrollees Scoliosis.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The treating provider of a 58-year-old female enrollee requested authorization and coverage for thalidomide for treatment of the enrollees cancer.  The health plan has denied this request indicating that the requested treatment is considered experimental for treatment of the enrollees medical condition.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 the enrollee's condition than any available standard therapy, the health plans denial was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old male enrollee requested authorization and coverage for Nexium.  The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees gastroesophageal reflux 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old male enrollee requested continued authorization and coverage for Lamisil. The health plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees onychonycosis.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 64-year-old female enrollee requested authorization and coverage for total knee replacement surgery. The health plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees osteoarthritis. 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 female enrollee requested authorization and coverage for continued treatment with an out-of-network allergist. The health plan has denied this request indicating that it is not medically necessary for the enrollee to continue services with an out-of-network allergist of the enrollee's allergic symptoms caused by mold exposure.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 49-year-old male enrollee requested authorization and coverage for continued treatment with an out-of-network allergist. The health plan has denied this request indicating that it is not medically necessary for the enrollee to continue services with an out-of-network allergist the enrollee's allergic symptoms caused by mold exposure.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: Overturned Decision of Health Plan

A request was made on behalf of a 15-year-old female enrollee for authorization and coverage of continued residential treatment for depression and alcohol dependence.  The health plan has denied this request.One physician reviewer performed a medical necessity Independent Medical Review.  The physician upheld the health plans denial on the basis that the enrollee did not have an active diagnosis of major depression, and therefore, the requested services were not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested authorization and coverage for gastric bypass surgery. The health plan denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees obesity related comorbidities.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

The wife of a 41-year-old male enrollee requested authorization and coverage for 16 hours of daily shift nursing care. The health plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees advanced, severe, end-stage ALS.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 76-year-old male enrollee requested authorization and coverage for total ankle replacement.  The health plan has denied this request indicating that the requested treatment is considered experimental for the enrollees Musculoskeletal 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 medical condition than any available standard therapy.  The health plans denial was upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested authorization and coverage for percutaneous laser disc decompression (nucleoplasty).  The health plan has denied this request indicating that nucleoplasty is considered experimental for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three-physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollee's 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 a habituation device. The health plan has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees mild bilateral high-frequency sensorineural hearing loss and bilateral tinnitus.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 53-year-old female enrollee requested authorization and coverage for a gastric bypass consultation. The health plan has denied this request indicating that the requested consultation is not medically necessary for treatment of the enrollees co-morbid conditions of type II diabetes mellitus, asthma, and degenerative joint disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested consultation is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 71-year-old male enrollee requested authorization and coverage for proton beam therapy. The health plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees early-stage prostate 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 therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage for a homocysteine blood test. The health plan has denied this request indicating that the requested test is not medically necessary for treatment of the enrollee.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested testing is not medically necessary, as there is no evidence the patient has cardiovascular or peripheral vascular disease.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested authorization and coverage of an abdominoplasty for the treatment of lower abdominal panniculus.  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

The parents of a five-year-old male enrollee requested authorization and coverage for continued occupational, physical, and speech therapy for treatment of the enrollees autism.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 60-year-old male requested authorization and coverage for a liver transplant evaluation.  The health plan has denied this request indicating that the requested evaluation is not medically necessary for treatment of the enrollees liver 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 evaluation is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee requested authorization and coverage of the medication Provigil.  The health plan denied this request indicting the Provigil is not medically necessary for treatment of the enrollees Parkinsons 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 medication 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 breast surgery. The health plan denied the request indicating that the requested surgery is considered cosmetic in nature and not medically necessary as post-mastectomy reconstructive 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee requested authorization and coverage of continued occupational therapy to assist recovery following a stroke. The health plan denied the request indicating that the requested therapy 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old male enrollee requested authorization and coverage of a nasal endoscopy from an out-of-network provider for treatment of decreased sense of smell and taste.  The health plan denied the enrollees request indicating that it is not medically necessary for the enrollee to obtain services from the out-of-network provider.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

The parent of a 20-year-old male enrollee requested authorization and coverage of continued residential services for treatment of bipolar disorder and other conditions.  The health plan denied the enrollees request indicating that the requested services are 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage for a referral to a registered dietician in a one-on-one environment for the treatment of a history of arthritis, pleurisy, synovitis, and obesity.  The health plan denied the enrollees request indicating that the requested services are 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested authorization and coverage of a referral to a gastroenterologist for the treatment of Hepatitis C.  The health plan denied the enrollees request indicating that the requested referral 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 referral is not medically necessary.