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

A 34-year-old male enrollee requested authorization and coverage of a non-myeloablative matched unrelated allogenic stem cell transplant for the treatment of Hodgkins disease.  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 non-myeloablative matched unrelated allogenic stem cell transplant is likely to be more beneficial for treatment of the enrollees Hodgkins disease 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 44-year-old male enrollee requested authorization and coverage of a referral to a neurologist for evaluation of possible ALS.  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 48-year-old male enrollee requested authorization and coverage of 16 hours of home health care a day for the treatment of ALS.  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: Upheld Decision of Health Plan

A 39-year-old female enrollee requested authorization and coverage of an endoscopic discectomy with the use of chemonucleolysis for the treatment of 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  an endoscopic discectomy with the use of chemonucleolysis is not likely to be more beneficial for treatment of the enrollees 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 29-year-old female enrollee requested authorization and coverage of a panniculectomy for the treatment of abdominal panniculus.  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 40-year-old male enrollee requested authorization and coverage of continued inpatient skilled nursing facility care during his rehabilitation.  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 46-year-old female enrollee requested authorization and coverage of laparoscopic adjustable banding 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: Overturned Decision of Health Plan

A 64-year-old male enrollee requested authorization and coverage of a DEXA scan for the treatment of osteopenia.  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 57-year-old male enrollee requested authorization and coverage of a power-operated vehicle (POV) to assist with mobility.  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

The parents of a 4-year-old female enrollee requested authorization and coverage of continued speech therapy for the treatment of speech impairment.  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 therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage of continued intravenous immunoglobulin (IVIG) therapy for the treatment of multifocal motor neuropathy.  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 therapy is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old male enrollee requested authorization and coverage of the medication Viagra for the treatment of erectile dysfunction.  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 medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 31-year-old male enrollee requested authorization and coverage of monthly protime checks for  anticoagulation therapy.  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 41-year-old female enrollee requested authorization and coverage of radiofrequency ablation 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 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 70-year-old female enrollee requested authorization and coverage of continued home health care for the treatment of her medical condition.  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 continued licensed vocational nurse (LVN) home health care for the treatment of C3-4 Tetraplegia.  The Health Plan denied the enrollees request indicating that the requested home health care 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 30-year-old female enrollee requested authorization and coverage of chronic intermittent intravenous insulin therapy (CIIIT) for the treatment of diabetes.  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 chronic intermittent intravenous insulin therapy (CIIIT) is not likely to be more beneficial for treatment of the enrollees diabetes 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

An 18-year-old female enrollee requested authorization and coverage of breast reconstruction surgery for the treatment of breast asymmetry.  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 an 8-year-old male enrollee requested authorization and coverage of speech therapy for the treatment of speech difficulty.  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 male enrollee requested authorization and coverage of the prescription medicine xenical for the treatment of 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 medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage of a sliding transfer bench, a fully electric hospital bed, and a deluxe commode transfer chair for assistance with  Parkinsons disease.  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 31-year-old male enrollee requested authorization and coverage of an inferential stimulator for the treatment of fibromyalgia and chronic fatigue syndrome.  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 an inferential stimulator  is not likely to be more beneficial for treatment of the enrollees fibromyalgia and chronic fatigue syndrome 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 14-year-old female enrollee requested authorization and coverage of a custom molded knee brace for rehabilitation.  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 orthotripsy for the treatment of plantar fasciitis.  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 14-year-old female enrollee requested authorization and coverage of scar revision surgery for the treatment of scars.  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 58-year-old female enrollee requested authorization and coverage of a gastric bypass with duodenal switch for the treatment morbid obesity.  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 gastric bypass with duodenal switch is not likely to be more beneficial for treatment of the enrollees morbid obesity 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 61-year-old male enrollee requested authorization and coverage of intensity modulated radiation therapy (IMRT) 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 59-year-old female enrollee requested authorization and coverage of intravenous zometa for the treatment of osteoporosis.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee requested authorization and coverage of orthognathic surgery for the treatment of maxillary hypoplasia.  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 male enrollee requested authorization and coverage of continued physical therapy for the treatment of cervical thoracic myofascial pain syndrome.  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: Upheld Decision of Health Plan

A 47-year-old male enrollee requested authorization and coverage of compounded verapamil for the treatment of peyronies disease.  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 compounded verapamil is not likely to be more beneficial for treatment of the enrollees peyronies disease 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 26-year-old female enrollee requested authorization and coverage of an implantation of a gastric electrical stimulator (enterra therapy)  for the treatment of diabetic gastroparesis.  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 an implantation of a gastric electrical stimulator (enterra therapy)  is likely to be more beneficial for treatment of the enrollees diabetic gastroparesis 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

The parents of a 4-year-old male 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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee requested authorization and coverage of a new below the knee molded socket prosthesis.  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 54-year-old male enrollee requested authorization and coverage of sixty-six single use urinary catheters a month for the treatment of urinary retention.  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 equipment is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 64-year-old male enrollee requested authorization and coverage of laparoscopic adjustable gastric banding (lap-band) surgery  for the treatment of morbid obesity.  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 laparoscopic adjustable gastric banding (lap-band) surgery  is not likely to be more beneficial for treatment of the enrollees morbid obesity 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 47-year-old female enrollee requested authorization and coverage of botox injections for the treatment of migraine headaches.  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 botox injections are not likely to be more beneficial for treatment of the enrollees migraine headaches 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.