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

The parents of a 16-year-old female enrollee requested authorization and coverage of continued acute inpatient treatment. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old male 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 medical condition.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 63-year-old female requested authorization and coverage of genetic testing. The Health Plan denied the request indicating that the requested services are 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 testing is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a 17-year-old male requested authorization and coverage of a referral to a pediatric endocrinologist 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 medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that a referral to a pediatric endocrinologist is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 59-year-old female requested authorization and coverage of treatment with thalidomide. The Health Plan denied the request indicating that treatment with thalidomide is considered experimental for treatment of the enrollees medical condition.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 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: Urgent Care
Decision: Overturned Decision of Health Plan

A 26-year-old female enrollee requested services for the treatment of her medical condition. Findings:  The physician reviewer found that there are known possible risks associated with oligohydramnios including cord compression at labor and fetal distress. The etiology of progressive oligohydramnios can also be uteroplacental insufficiency, which at term warrants delivery. Because of her malpresentation, this patient required cesarean section as the mode of delivery. Immediate cesarean section was reasonable and indicated because of the possible risks of unmonitored labor and oligohydramnios (cord compression) that could have occurred with transfer.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 16-year-old female enrollee requested reimbursement for inpatient mental health services the enrollee received from 12/15/01 to 12/20/01. The Health Plan denied the request indicating that the services in question were 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 services in question were not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee requested authorization and coverage of a referral to a neurologist. The Health Plan  denied the request indicating that the requested referral is not medically necessary for evaluation of the enrollees arm 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 32-year-old female enrollee requested authorization and coverage of uterine artery embolization. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees uterine fibroids.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 65-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV). The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees foot ulcers.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested equipment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-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 chronic 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 medication 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 the medication 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 mother of a 16-year-old female enrollee requested authorization and coverage of continued residential behavioral health services for the 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 behavioral health 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 services are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of a 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 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 28-year-old female enrollee requested authorization and coverage of continued chiropractic care. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees neck and back pain.One chiropractor reviewer performed a medical necessity Independent Medical Review. The chiropractor 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 38-year-old male enrollee requested authorization and coverage of a full-body scan. The Health Plan denied the request indicating that the requested full-body scan is not medically necessary for evaluation 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 full-body scan is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An 18-year-old female enrollee requested authorization and coverage of a shower chair/commode.  The Health Plan  denied the request indicating that the enrollee does not meet the criteria for authorization of the requested equipment.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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested authorization and coverage of Pegasys and Copegus. The Health Plan denied the request indicating that the requested therapy is 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 therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee requested authorization and coverage of 30 Foley catheters per month. The Health Plan  denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees bladder infections.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that four Foley catheters and insertion kits per month are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of an 18-year-old female enrollee requested authorization and coverage of continued residential treatment services for the 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested authorization and coverage of an MRI of the lumbar spine. The Health Plan  denied the request indicating that the requested MRI is not medically necessary for the evaluation 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 MRI is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 62-year-old male enrollee requested authorization and coverage of treatment with Celebrex and interferon alpha.  The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees metastatic renal cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two 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. One physician reviewer 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 two 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, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 68-year-old male enrollee requested authorization and coverage of the medication Zetia. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees coronary artery 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 medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-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 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 51-year-old male enrollee requested authorization and coverage of the medication Zocor. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia.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

A 30-year-old female enrollee requested authorization and coverage of prolotherapy. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees myofascial pain syndrome.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 enrollee 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 enrollee's 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 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

The mother of a 15-year-old female enrollee requested authorization and coverage of continuous use of the Ortho Evra patch for one year. The Health Plan denied the request indicating that the requested prescription is not medically necessary for treatment of the enrollees pelvic and ovarian 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 prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parent of a seven-year-old male enrollee requested authorization and coverage of speech therapy. The Health Plan denied this request indicating that the requested services are not medically necessary for treatment of the enrollees speech delay.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 77-year-old male enrollee requested authorization and coverage of the medication Avodart. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees benign prostatic hypertrophy.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 51-year-old female enrollee requested authorization and coverage of the medication Elidel. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees eczema and contact allergy to formaldehyde.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage of surface replacement arthroplasty of the left hip. The Health Plan denied the request indicating that the requested procedure is considered investigational for treatment of the enrollees osteoarthritis.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 not likely to be more beneficial for treatment of the enrollee medical condition than any available standard therapy. 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 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 female enrollee requested authorization and coverage of IVIG therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees chronic inflammatory demyelinating polyneuropathy.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 two-year-old male enrollee requested authorization and coverage of 126 hours per week of continued home nursing care. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees congenital central hypoventilation.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 54-year-old female enrollee requested authorization and coverage of a referral to an infectious disease specialist. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees skin and fungal 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 referral is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

The mother of a 21-year-old male enrollee requested authorization and coverage of functional electrical stimulation therapy.  The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees spinal cord injury. 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 CHDR 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 62-year-old male enrollee requested authorization and coverage of hyperthermia with adjunctive low-dose radiation therapy.  The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees metastatic chondrosarcoma.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 overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee requested authorization and coverage of orthognathic surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees malocclusion.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon 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 56-year-old male enrollee requested authorization and coverage of right hip surface arthroplasty. The Health Plan denied the request indicating that the requested procedure 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

The representatives of a 17-year-old male enrollee requested authorization and coverage of a standing power-operated vehicle (POV) for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested equipment is not medically necessary for assistance with the enrollees mobility.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.