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

A 63-year-old male requested authorization and coverage of carotid angioplasty and stenting. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees carotid artery stenosis.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 physician reviewer concluded 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 than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old male enrollee requested authorization and coverage of a bilateral mastectomy with ultrasound and suction-assisted lipectomy. The Health Plan denied the request indicating that the procedure is cosmetic in nature and 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 cosmetic in nature and not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 68-year-old female enrollee requested authorization and coverage of nebulized tobramycin solution for inhalation with the SinuNEB system. The Health Plan denied the request indicating that the requested treatment is considered experimental for treatment of the enrollees chronic sinus and nasal symptoms.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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old male enrollee requested authorization and coverage of Disk-Cure treatment. 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: Overturned Decision of Health Plan

A 31-year-old male enrollee requested authorization and coverage of a thighplasty. The Health Plan denied the request indicating that the procedure is cosmetic in nature and not medically necessary for treatment of the enrollees excess thigh tissue.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 an increase in her monthly Zomig prescription. The Health Plan denied the request indicating that an increase in the enrollees monthly Zomig prescription is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested increase in the enrollees monthly prescription of Zomig is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a six-year-old female enrollee requested authorization and coverage of the medication Vioxx for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic recurrent multifocal osteomyelitis (CRMO).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 43-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: Overturned Decision of Health Plan

A 60-year-old female enrollee requested authorization and coverage of a colonoscopy. The Health Plan denied the request indicating that the requested colonoscopy is not medically necessary for evaluation 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 colonoscopy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The mother of a six-year-old male enrollee requested authorization and coverage of vision therapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees binocular and oculomotor dysfunction.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 therapy 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: Upheld Decision of Health Plan

A 50-year-old female enrollee 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 onychomycosis.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry 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 26-year-old female enrollee requested reimbursement for residential treatment. The Health Plan denied the request indicating that the services at issue were 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female 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 28-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 surgical and psychological evaluations.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old female enrollee requested authorization and coverage of a referral to a plastic surgeon. The Health Plan  denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees dysplastic nevi.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a five-year-old male enrollee requested authorization and coverage of continued speech therapy 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 delayed speech.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested therapy is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The parents of a six-year-old male enrollee requested authorization and coverage of ongoing treatment with EEG biofeedback therapy. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees behavioral health problems.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 therapy 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 25-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the 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 depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 42-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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage of metal-on-metal hip surface arthroplasty. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees osteoarthritis.Three physician reviewers performed a medical necessity 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 treatment 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 56-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 46-year-old female enrollee requested authorization and coverage of antibody tests, stool purges, metal toxicity tests, and hair analysis tests. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees chronic fatigue syndrome.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 36-year-old male enrollee requested authorization and coverage of vein surgery. 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 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 female enrollee requested authorization and coverage of nerve block/trigger point injections. The Health Plan denied the request indicating that the requested procedures are investigational/experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the 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. One 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.  Because the majority of physician reviewers concluded that the requested treatment 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 bariatric surgery through the duodenal switch surgical 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: Overturned Decision of Health Plan

A male enrollee requested authorization and coverage of a panniculectomy. The Health Plan denied the request indicating that the requested procedure is cosmetic in nature and not medically necessary for treatment of the enrollees abdominal panniculus.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 40-year-old male enrollee requested authorization and coverage of a craniotomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees arachnoid cyst.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee requested authorization and coverage of bariatric surgery through the duodenal switch surgical procedure. 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 61-year-old female enrollee requested authorization and coverage of Botox injections for her chronic migraine headaches. The Health Plan denied the request indicating that the requested procedure is considered investigational/experimental.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 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

The representative of a 50-year-old male enrollee requested authorization and coverage of residential treatment 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee requested authorization and coverage of an osteochondral transplant. The Health Plan  denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees chondromalacia.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 procedure is not likely to be more beneficial for treatment 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 57-year-old female enrollee requested authorization and coverage of an increase in the amount of her Zofran prescription. The Health Plan denied the request indicating that the requested increase in the amount of the enrollees Zofran prescription is not medically necessary for treatment of the enrollees nausea and vomiting.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested increase in the amount of the enrollees Zofran prescription 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 back surgery. The Health Plan denied the request indicating that the requested surgery 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested authorization and coverage of hormone pellet implants. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the enrollees hormone replacement.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.