Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee requested authorization and coverage of bariatric surgery by a laparoscopic vertical gastrectomy and duodenal switch procedure. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two 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. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested surgery 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 46-year-old male enrollee has requested authorization and coverage of varicose vein stripping and ligation. The Health Plan denied the request indicating that the procedure is not medically necessary for treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of a glucowatch. The Health Plan denied the request indicating that the glucowatch is not medically necessary for managing the enrollees diabetes mellitus.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 51-year-old female enrollee requested authorization and coverage of a duodenal switch bariatric surgery. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two 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. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old male enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two 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. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery 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 28-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two 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. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee requested authorization and coverage of the medications Peg-Intron, Epogen and Neupogen. The Health Plan denied the request indicating that the medications are not medically necessary for treatment of the enrollees 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 medications are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee requested authorization and coverage of percutaneous vertebroplasty. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the eneollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery 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 55-year-old female enrollee requested authorization and coverage of a positron emission tomography (PET) scan of her breasts. The Health Plan denied the request indicating that the requested procedure is considered experimental for evaluation of possible breast cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested PET scan 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 PET scan 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 40-year-old female enrollee requested authorization and coverage of VNUS closure and microvascular excision with ligation of perforating veins. The Health Plan denied the request indicating that the requested procedures are not medically necessary for treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedures are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee requested authorization and coverage of the medication Actiq. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The representative of an 18-year-old male enrollee requested authorization and coverage of a discogram and consideration of intradiscal electrothermal therapy (IDET) for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy 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 therapy 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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old female enrollee requested authorization and coverage of physical therapy twice a week for ten weeks. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees shoulder and clavicle problems.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of bariatric 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

The parents of a three-year-old male enrollee requested authorization and coverage of speech therapy three times per week for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees verbal apraxia.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 40-year-old male enrollee requested authorization and coverage of a series of Synvisc injections. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees knee pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee requested authorization and coverage of chiropractic care to treat a pinched nerve. The Health Plan denied the request indicating that the chiropractic care is not medically necessary.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic 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 female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees 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

The mother of a 16-month-old male enrollee requested authorization and coverage of a portable nebulizer for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees asthma. 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

The representative of a 47-year-old male enrollee requested authorization and coverage of acute rehabilitation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee requested authorization and coverage of proton beam radiation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees brain tumor.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 62-year-old female enrollee requested authorization and coverage of continued physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees 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 requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee requested authorization and coverage of surgery to repair disc disease. The Health Plan  denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees back and neck pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee requested authorization and coverage of laser stapedectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees hearing loss.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 43-year-old male enrollee requested authorization and coverage of a consultation with a neurologist who specializes in epilepsy. The Health Plan denied the request indicating that requested services are not medically necessary for treatment of the enrollees seizures.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 38-year-old male enrollee requested authorization and coverage of chiropractic treatment. The Health Plan denied the request indicating that the requested chiropractic treatment is not medically necessary for treatment of the enrollees back pain.One chiropractic reviewer performed a medical necessity Independent Medical Review. The chiropractic reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The father of a 15-year-old male enrollee requested authorization and coverage of inpatient residential services for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees developmental 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 services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 29-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two 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. One physician reviewer concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three  physician reviewers concluded that the requested surgery 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 63-year-old male enrollee requested authorization and coverage of continued treatment with the medication Serostim. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees lipodystrophy.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 41-year-old female enrollee requested authorization and coverage of the medication Actiq. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee requested authorization and coverage of cryotherapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees pain.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry 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 35-year-old female enrollee requested authorization and coverage of infertility services. The Health Plan denied the request indicating that the requested 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: Overturned Decision of Health Plan

A 31-year-old female enrollee requested reimbursement for inpatient skilled nursing facility services the enrollee received from 12/20/02 to 1/1/03. The Health Plan denied the request indicating that the services at issue were 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 services at issue were medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee requested authorization and coverage of a referral to an endocrinologist. The Health Plan  denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees diabetes.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 51-year-old female enrollee requested authorization and coverage of trigger point injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of her neck pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old male enrollee requested authorization and coverage of a referral to an orthopedist. The Health Plan  denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees shoulder pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee requested authorization and coverage of an MRI of her cervical spine. The Health Plan  denied the request indicating that the MRI is not medically necessary for evaluation of the enrollees shoulder and neck pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female requested authorization and coverage of sclerotherapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees varicose veins.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.