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

A 57-year-old female enrollee requested authorization and coverage of the medication Provigil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees daytime sleepiness.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 40-year-old female enrollee requested authorization and coverage of extracorporeal shock wave treatment (ESWT). The Health Plan denied the request indicating that ESWT is not medically necessary for the treatment of the enrollees plantar fasciitis.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 53-year-old male enrollee requested authorization and coverage of a Stretta procedure. The Health Plan denied the request indicating that the requested procedure is considered experimental for the treatment of the enrollees gastroesophageal reflux disease (GERD).Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers 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. One physician reviewer 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 two of the three physician reviewers 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, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage of the medication Actiq.  The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 64-year-old male enrollee requested authorization and coverage of continued skilled nursing facility (SNF) services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested authorization and coverage of intradiscal electrothermal therapy (IDET). The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees back pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the 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 the treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees pain.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 the 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 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 56-year-old female enrollee requested authorization and coverage of general anesthesia services. The Health Plan  denied the request indicating that the requested services are not medically necessary for the enrollees tooth extraction.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon 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 63-year-old female enrollee requested authorization and coverage of sclerotherapy of both legs.  The Health Plan  denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees spider veins.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 48-year-old female enrollee requested authorization and coverage of physical therapy. The Health Plan denied the request indicating that the requested therapy was not medically necessary for the treatment of the enrollees neck, head, and back pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested authorization and coverage for 24 Maxalt per month. The Health Plan denied the request indicating that the requested prescription is not medically necessary for treatment of the enrollees migraine 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 prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of a referral to a center specializing in the treatment of cystic fibrosis for coordinated care. The Health Plan denied the request indicating that the requested referral is not medically necessary for treatment of the enrollees cystic fibrosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of multiple myomectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees uterine fibroids.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer 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

The mother of a five-year-old male enrollee requested authorization and coverage of either Diflucan or Lamisil for treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested medications are not medically necessary for treatment of the enrollees dysfunctional immune system.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that neither of the requested medications is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested authorization and coverage of the medication Zithromax. The Health Plan denied the request indicating that the requested medication is considered experimental for treatment of the enrollees chronic obstructive pulmonary disease (COPD).Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for the treatment of the enrollee's medical condition than any available standard therapy. One of the three physician reviewers concluded that the requested therapy is not likely to be more beneficial for 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 not 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 upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The father of a 13-year-old female enrollee requested authorization and coverage of residential treatment for the treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested services are not medically necessary for the treatment of the enrollees depression.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 46-year-old female enrollee requested authorization and coverage of revision gastric bypass. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees medical condition.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested 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

The mother of a 14-year-old female enrollee requested authorization and coverage of continued intravenous Rocephin 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 Lyme 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old female enrollee requested authorization and coverage of the medication Lamisil.  The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees onychomycosis of the toenails.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 depending upon the results of a liver function test.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 40-year-old female enrollee with chronic myelogenous leukemia requested authorization and coverage of autologous T cell collection and storage. The Health Plan denied the request.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of the medication Vioxx. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees bursitis and degenerative joint disease.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested medication is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of the medication Nexium. The Health Plan denied the request indicating that the requested medication is not medically necessary for the treatment of the enrollees gastroesophageal reflux 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested authorization and coverage of extracorporeal shock wave therapy (ESWT). The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees plantar fasciitis.One podiatry reviewer performed a medical necessity Independent Medical Review. The podiatry reviewer upheld the Health Plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a five-year-old male enrollee requested authorization and coverage of continued speech therapy.  The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees speech 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 therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 32-year-old female enrollee requested authorization and coverage of an abdominoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees abdominal hernia.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 60-year-old male enrollee requested authorization and coverage of a color Doppler ultrasound. The Health Plan denied the request indicating that the requested services are not medically necessary for the evaluation of the enrollees prostate 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 services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 47-year-old female enrollee requested authorization and coverage of enrollment in a protocol entitled Non-Myeloablative Allogenic Hematopoietic Stem Cell Transplantation Using Antithymocyte Globulin with either Melphalan and Cladribine or Total Lymphoid Irradiation. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees metastatic breast cancer.Three physician reviewers performed a medical necessity Independent Medical Review. All three physician reviewers 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 all three  physician reviewers 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, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage of bilateral blepharoplasty. The Health Plan denied the request indicating that the requested procedure is considered cosmetic and is not medically necessary for the treatment of the enrollees eyelids.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 cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee requested authorization and coverage of acupuncture.  The Health Plan denied the request indicating that the requested treatment is not medically necessary for the treatment of the enrollees pain.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested treatment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of a power-operated vehicle. The Health Plan  denied the request indicating that the requested equipment is not medically necessary for the treatment of the enrollees chronic spastic paraplegia. 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 24-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 the treatment of the enrollees 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 42-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for the treatment of the enrollees migraine headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two CHDR physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of your medical condition than any available standard therapy. One CHDR physician reviewer concluded that the requested therapy is not likely to be more beneficial for treatment of your medical condition than any available standard therapy. Because two of the three CHDR physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of your medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A sixty-one year old male enrollee requested authorization and coverage of the medication Gleevec. The Health Plan denied the request indicating that the requested medication is considered experimental for treatment of the enrollees multiple myeloma.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested surgery 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

The parents of a two-year-old female enrollee requested authorization and coverage of an umbilical cord blood stem cell transplant without total body irradiation 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 acute lymphocytic leukemia.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 enrollees 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: Upheld Decision of Health Plan

A 64-year-old female enrollee requested authorization and coverage of blepharoplasty of the left eye. The Health Plan  denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees impaired vision.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 68-year-old male enrollee requested authorization and coverage of the medication Avandamet. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees diabetes.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 47-year-old female enrollee requested authorization and coverage of inpatient residential behavioral health services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees depression and post-traumatic stress 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 services are not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old male enrollee requested authorization and coverage of continued occupational and physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the enrollees rehabilitation after a stroke.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.