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

The parents of a 4-year-old male enrollee requested authorization and coverage of physical therapy for the treatment of autism.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old female enrollee requested authorization and coverage of injectable growth hormone for the treatment of growth hormone deficiency.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 34-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 7-year-old female enrollee requested authorization and coverage of continued speech therapy for the treatment of autism.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee requested authorization and coverage of prolotherapy for the treatment of sacroiliac joint pain.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that prolotherapy is likely to be more beneficial for treatment of the enrollees sacroiliac joint pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 66-year-old male enrollee requested authorization and coverage of the medication gleevec for the treatment of metastatic malignant melanoma.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that the medication gleevec is not likely to be more beneficial for the treatment of the enrollees metastatic malignant melanoma than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 21-year-old female enrollee requested authorization and coverage of autologous peripheral blood stem cell transplantation (APBSCT) for the treatment of systemic lupus erythematosus (SLE).  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that autologous peripheral blood stem cell transplantation (APBSCT) is likely to be more beneficial for treatment of the enrollees systemic lupus erythematosus (SLE) than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization overturned the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old male enrollee requested authorization and coverage of an insulin pump for the treatment of type I diabetes mellitus.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee requested authorization and coverage of intravenous immunoglobulin (IVIG) therapy for the treatment of conditions that have resulted from toxic mold exposure.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee requested authorization and coverage of  laparoscopic bilateral inguinal hernia repair for the treatment of an inguinal hernia.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old male enrollee requested authorization and coverage of an inpatient evaluation of his chronic peripheral neuropathic leg pain.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee requested authorization and coverage of facial collagen injections for the treatment of lipoatrophy.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old male enrollee requested authorization and coverage of a liver transplant for the treatment of hepatitis C, cirrhosis, and hepatocellular carcinoma.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 60-year-old female enrollee requested authorization and coverage of out-of-network care from a neuropsychologist for the treatment of insomnia.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 30-year-old male enrollee requested authorization and coverage of services from a non-contracted provider  for the treatment of mucinous adenocarcinoma of the abdomen.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old male enrollee requested authorization and coverage of participation in a clinical trial using iodine-131 labeled MIBG for the treatment of metastatic paraganglioma.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that participation in a clinical trial using iodine-131 labeled MIBG  is not likely to be more beneficial for treatment of the enrollees metastatic paraganglioma than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 20-year-old male enrollee requested authorization and coverage of continued inpatient services for the treatment of bi-polar disorder.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 34-year-old male enrollee requested authorization and coverage of the medication rebif for the treatment of multiple sclerosis .  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of high-dose chemotherapy followed by autologous stem cell transplant for the treatment of metastatic breast cancer.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that high-dose chemotherapy followed by autologous stem cell transplant is not likely to be more beneficial for treatment of the enrollees metastatic breast cancer than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee requested authorization and coverage of continued therapy (including paraffin baths and iontophoresis) for the treatment of the dislocation of the left, little finger.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested authorization and coverage of humatrope growth hormone for the treatment of panhypopituitarism.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested authorization and coverage of out-of-plan high dose brachytherapy for the treatment of prostate cancer.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee requested authorization and coverage of continued rehabilitation therapy for the treatment of residual facial paralysis.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested authorization and coverage of septoplasty and turbinate reduction for the treatment of nasal obstruction.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 surgery is  medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee requested authorization and coverage of a CT scan for  evaluation of possible lung cancer.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a CT scan  is not likely to be more beneficial for the evaluation of the enrollee's possible lung cancer than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage of uterine artery embolization (UAE) for the treatment of uterine fibroids.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a uterine artery embolization (UAE) is not likely to be more beneficial for treatment of the enrollees uterine fibroids than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of surgical excision of a lump in the enrollee's right eyelid.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 17-year-old male enrollee requested authorization and coverage of a CT scan for the treatment of   congenital hearing loss .  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested services are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee requested authorization and coverage of a PET scan to determine whether the enrollee is continuing to improve or if additional therapy should be instituted for the treatment of metastatic lung cancer.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old male enrollee requested authorization and coverage of percutaneous disc decompression (nucleoplasty) for the treatment of low back pain.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that percutaneous disc decompression (nucleoplasty) is not likely to be more beneficial for treatment of the enrollees low back pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of a referral to an orthopedist for the treatment of back pain.  The Health Plan denied the enrollees request indicating that the requested treatment is 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 for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old female enrollee requested authorization and coverage of a terbutaline pump for the treatment of preterm labour. The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that a terbutaline pump is not likely to be more beneficial for treatment of the enrollees preterm labour than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of uterine artery embolization (UAE) for the treatment of an uterine fibroid.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of plantar fascia release and bone spur removal for the treatment of plantar fasciitis and heel spur.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested authorization and coverage of a c-pap machine for the treatment of sleep apnea.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.