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

A 19-year-old male enrollee requested authorization and coverage of a testicular implant for the treatment of a congenital or developmental defect.  The health plan denied the enrollees request indicating that the requested implant 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 implant is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage of hydrocodone for treatment of pain caused by severe intractable failed knee surgery 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 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 43-year-old female enrollee requested authorization and coverage of naltrexone for the treatment of pruritic prurigo nodularis.  The health plan denied the enrollees request indicating that the medication 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old female requested authorization and coverage of a valvuloplasty for the treatment of mitral valve stenosis.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.  Instead the health plan providers recommend a mitral valve replacement.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested valvuloplasty is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee requested authorization and coverage of the medication vicoprofen for the treatment of chronic back pain.  The health plan denied the enrollees request indicating that the requested medication 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested authorization and coverage of a tandem autologous stem cell transplant for the treatment of multiple myeloma.  The health plan denied the enrollees request indicating that the requested tandem autologous stem cell transplant 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 treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 28-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 procedure 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 procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of a gastric stimulator (Enterra Therapy) for the treatment of gastroparesis.  The health plan denied the enrollees request indicating that the requested equipment is considered investigational.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two physician reviewers concluded that the requested gastric stimulator is likely to be more beneficial for treatment of the enrollees gastroparesis than any available standard therapy.  Because two of the three physician reviewers concluded that the requested equipment 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 sleep study for the treatment of a history of sleep disturbance.  The health plan denied the enrollees request indicating that the requested study 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 service is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested authorization and coverage of three to six months of the oral antibiotics Mepron and Zithromax for the treatment of Lyme Disease.  The health plan denied the enrollees request indicating that the requested treatment plan 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 treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 17-year-old female enrollee requested authorization and coverage of accutane for the treatment of acne.  The health plan denied the enrollees request indicating that the requested medication 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested authorization and coverage of a DEXA scan and a full-body DEXA scan for the treatment of osteoarthritis.  The health plan denied the enrollees request indicating that the requested DEXA scans are 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 DEXA scans are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-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 Viagra 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 63-year-old male enrollee who requested authorization and coverage of the medication Viagra for erectile dysfunction.  The health plan denied the enrollees request indicating that viagra 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee requested authorization and coverage of Synvisc injections for the treatment of osteoarthritis of both knees.  The health plan denied the enrollees request indicating the requested injections are 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 injections are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female requested authorization and coverage of a home portable oxygen machine for treatment of chronic obstructive pulmonary disease.  The health plan denied the enrollees request indicating the requested equipment 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV) for the treatment osteoarthritis. The health plan denied the enrollees request indicating that the requested POV 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 19-year-old female enrollee requested authorization and coverage of an ACL knee brace for treatment post surgery.  The health plan denied the enrollees request indicating that the requested knee brace 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee requested authorization and coverage of the medication xenical for the treatment of morbid obesity and hyperlipidemia.  The health plan denied the enrollees request indicating that the requested medication 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee requested authorization and coverage of a laparoscopic cholecystectomy for treatment of constant pain in abdomen.  The health plan denied the enrollees request indicating that the requested procedure 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 procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 25-year-old female enrollee requested a consultation for possible gastric bypass surgery for treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested consultation 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 consultation is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 32-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET) for treatment of chronic back pain.  The health plan denied the enrollees request indicating that IDET is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three-physician reviewers concluded that IDET 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 32-year-old female enrollee requested authorization and coverage of a referral to an orthopedist for treatment of knee dislocation.  The health plan denied the enrollees request indicating that the requested referral 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 referral is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee requested authorization and coverage of a UVB light system for in-home therapy for treatment of psoriasis.  The health plan denied the enrollees request indicating that the requested in-home equipment 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 UVB light system is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 15-year-old female enrollee requested authorization and coverage of continued residential treatment for treatment of bipolar disorder.  The health plan denied the enrollees request indicating that continued residential 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 24-year-old female enrollee requested authorization and coverage of acupuncture for treatment of back pain and acne.  The health plan authorized six acupuncture treatments for the enrollees back pain, but denied authorization and coverage for acupuncture treatment of the enrollees acne indicating the requested acupuncture is not medically necessary.One acupuncture reviewer performed a medical necessity Independent Medical Review.  The acupuncture reviewer upheld the health plans denial on the basis that the requested treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee requested authorization and coverage of intravenous antibiotic therapy for treatment of lyme disease.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.Three physician reviewers performed a medical necessity Independent Medical Review.  All three physician reviewers concluded that the requested treatment is not medically necessary for treatment of the enrollees lyme disease.  Because all three physician reviewers concluded that the requested treatment is not medically necessary for treatment of the enrollees medical condition, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested authorization and coverage of surgery with a non-contracted surgeon for treatment of bilateral mastectomies.  The health plan denied the enrollees request indicating that it is not medically necessary for the enrollee to undergo surgery with a non-contracted surgeon.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee requested authorization and coverage of biofeedback for treatment of urinary incontinence.  The health plan denied the enrollees request indicating that the requested treatment is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that biofeedback is not likely to be more beneficial for treatment of the enrollees urinary incontinence 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 44-year-old female enrollee requested authorization and coverage of two pair of compression stockings for treatment of varicose veins.  The health plan denied the enrollees request indicating that the requested stockings are 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 compression stockings are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 43-year-old male enrollee requested authorization and coverage of a referral to a neurologist for treatment of arm pain. The health plan denied the enrollees request indicating that the requested referral 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 referral is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 31-year-old female enrollee requested authorization and coverage of orthognathic surgery for treatment of Mandibular Hypoplasia.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee requested authorization and coverage of adjustable silicone gastric banding (Lap-Band) surgery for treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested surgery is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollees morbid obesity than any available standard therapy.  Because two of the 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 55-year-old male enrollee requested authorization and coverage of a compounded medication for treatment of diabetes with neuropathy.  The health plan denied the enrollees request indicating that the requested medication 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee requested authorization and coverage of the medication celebrex for the treatment of osteo arthritis.  The health plan denied the enrollees request indicating that celebrex 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of an Ossatron Orthotripsy (orthotripsy) for the treatment of chronic right heel pain.  The health plan denied the enrollees request indicating that the requested orthotripsy is considered investigational.Three physician reviewers performed an experimental/investigational Independent Medical review.  Two of the three reviewers concluded that orthotripsy is not likely to be more beneficial for treatment of the enrollee's heel pain than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage of adjustable gastric (Lap-Band) surgery for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested surgery is considered experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  All three physician-reviewers concluded that the requested 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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee requested authorization and coverage of metal on-metal surface replacement hip surgery for treatment of vascular necrosis at the hip.  The health plan denied the enrollees request indicating that the requested procedure is not medically necessary.Three physician reviewers performed a medical necessity Independent Medical Review.  All three physician reviewers upheld the health plans denial on the basis that the requested surgery 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 hormone replacement therapy for the treatment of menopause.  The health plan denied the enrollees request indicating that the prescription medications are 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 medications are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The parents of a 14-year-old male enrollee requested authorization and coverage of a referral to a dermatologist for removal of a mole on the face.  The health plan denied the enrollees request indicating that the requested referral is for cosmetic services and 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 referral is not medically necessary.