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

A 31-year-old male enrollee requested authorization and coverage of disposable self-catheters or intermittent catheters. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees paraplegia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested equipment is medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-year-old female enrollee requested authorization and coverage of a gastric bypass surgery consultation. The Health Plan denied the request indicating that the requested consultation is not medically necessary for evaluation 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 consultation is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old male enrollee requested authorization and coverage of the medication Strattera. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees attention deficit disorder.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 52-year-old female enrollee requested authorization and coverage of Miacalcin nasal spray. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees osteopenia.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 39-year-old female enrollee requested authorization and coverage of daily home health services. The Health Plan  denied the request indicating that the requested services are not medically necessary for treatment of the enrollees infected surgical incision status post cesarean section.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 64-year-old male enrollee requested authorization and coverage of a colonoscopy. The Health Plan denied the request indicating that the requested procedure 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 33-year-old female enrollee requested authorization and coverage of repeat gastric bypass surgery. The Health Plan has 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 47-year-old male enrollee requested authorization and coverage of a non-glare coating of his eyeglass lenses. The Health Plan denied the request indicating that the requested eyeglass coating 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 eyeglass coating is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage of extracorporeal shockwave therapy. The Health Plan denied the request indicating that the requested therapy is considered investigational for treatment of the enrollees plantar fasciitis. Three medical professional reviewers performed an experimental/investigational Independent Medical Review. All three medical professional reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three medical professional reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 28-year-old female enrollee requested authorization and coverage of a custom wheelchair and pressure relief cushion. The Health Plan denied the request indicating that the requested equipment is not medically necessary for 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of an 11-year-old male enrollee requested authorization and coverage of a manual wheelchair to assist with the enrollees mobility. The Health Plan denied the request indicating that the requested manual wheelchair is not medically necessary to assist with the enrollees mobility. 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: Overturned Decision of Health Plan

A 37-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 52-year-old female enrollee requested authorization and coverage of the medication Neupogen. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees neutropenia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of gastric banding. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of BRCA1 and BRCA2 genetic testing. The Health Plan denied the request indicating that the requested services are not medically necessary for evaluation of a possible prophylactic oophorectomy.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 62-year-old female enrollee requested authorization and coverage of breast reduction surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees pendulous breasts.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 23-year-old female enrollee requested authorization and coverage of a CT scan of the head. The Health Plan denied the request indicating that the requested CT scan is not medically necessary for evaluation 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 CT scan is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee requested authorization and coverage of a GlucoWatch. The Health Plan denied the request indicating that the requested equipment is considered investigational for treatment of the enrollees nocturnal hypoglycemia. Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested equipment 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 equipment 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 equipment 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 29-year-old male enrollee requested authorization and coverage of removal of a keloid scar. The Health Plan denied the request indicating that the requested scar removal is considered cosmetic in nature and 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 injections are reconstructive in nature and medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee requested authorization and coverage of endovenous radiofrequency ablation. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees varicose veins. Three physician reviewers performed a medical necessity Independent Medical Review. All three physician reviewers concluded that the requested procedure is medically necessary for treatment of the enrollee's medical condition. Because all three physician reviewers concluded that the requested procedure is medically necessary for treatment of the enrollee's medical condition, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

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

The father of a 16-year-old male enrollee requested authorization and coverage of surgical correction of the enrollees gynecomastia. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees gynecomastia.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 treatment with the medication thalidomide. The Health Plan  denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees ovarian 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 medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 59-year-old male enrollee requested authorization and coverage of chemoembolization.  The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees metastatic carcinoid cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all 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 61-year-old male enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee requested authorization and coverage of Feldenkrais therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees shoulder pain status post pectoralis major injury.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: Overturned Decision of Health Plan

The mother of an 11-year-old male enrollee requested authorization and coverage of interferon injections 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 lymphangiomas.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 the treatment of the enrollees medical condition than any available standard therapy. One CHDR physician reviewer concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollees medical condition than any available standard therapy. Because two of the three physician reviewers concluded that he requested therapy is likely to be more beneficial for the treatment of the enrollees 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 48-year-old male enrollee requested authorization and coverage of the medication Anadrol. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees HIV-related symptoms.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: Overturned Decision of Health Plan

A 56-year-old female enrollee requested authorization and coverage of total ankle replacement of the right ankle. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees ankle arthritis.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee requested authorization and coverage of a CPAP. The Health Plan denied the request indicating that the requested CPAP is not medically necessary for treatment of the enrollees sleep apnea.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested device is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 10-year-old female enrollee requested authorization and coverage of vision therapy for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees vision 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 therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee requested authorization and coverage of a surface replacement arthroplasty utilizing a metal-on-metal device. 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. Two physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 30-year-old female enrollee requested authorization and coverage of radiofrequency ablation. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees cervical facet syndrome.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested therapy is likely to be more beneficial for the 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 the 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 the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old female enrollee requested authorization and coverage of an ABI Vest. The Health Plan denied the request indicating that the requested equipment is not medically necessary for the treatment of the enrollees bronchial 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 equipment is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 66-year-old male enrollee requested authorization and coverage of the medication Xenical. The Health Plan denied the request indicating that the requested medication 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 medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of a muscle stimulator.  The Health Plan denied the request indicating that the requested device is not medically necessary for the treatment of the enrollees left knee muscle weakness.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested device is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of uterine artery embolization. The Health Plan  denied the request indicating that the requested therapy 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 therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested authorization and coverage of physical therapy.  The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees degenerative joint 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 therapy is not medically necessary.