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

 a 48-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 procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-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 I have determined that the requested surgery is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of Botox injections for the treatment of debilitating 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 likely to be more beneficial for treatment of the enrollees debilitating headaches 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 57-year-old female enrollee requested authorization and coverage of a home electrical stimulation unit for the treatment of pelvic floor weakness and incontinence. 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 electrical stimulation unit is not likely to be more beneficial for treatment of the enrollees pelvic floor weakness and 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 64-year-old female enrollee requested authorization and coverage of medication Fosamax at 70mg weekly 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 enrollees medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-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 procedure is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 38-year-old female enrollee requested authorization and coverage of Remicade infusion therapy for the treatment of ankylosing spondylitis.  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 Remicade infusion therapy is likely to be more beneficial for treatment of the enrollees ankylosing spondylitis 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 35-year-old female enrollee requested authorization and coverage of intravenous clindamycin for the treatment of scleroderma.  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 treatment is not medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 41-year-old female enrollee requested authorization and coverage of continued physical therapy for the treatment of cervical strain. 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 upheld the health plans denial on the basis that the requested physical therapy is medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 39-year-old female enrollee has 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 procedure is medically necessary for treatment of the patients medical condition
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male 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 the treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee has requested authorization and coverage for an MRI of the right knee for the treatment of knee 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 MRI is medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The mother of a 14-year-old male enrollee  requested authorization and coverage of liposuction for the treatment of the enrollee's gynecomastia.  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 procedure is medically necessary for the treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 12-year-old male enrollee  requested authorization and coverage of continued speech therapy for the treatment of the enrollees cri-du-chat 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 therapy is not medically necessary for treatment of the patients medical condition. _______________________________________.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee requested authorization and coverage for bilateral breast resection of lateral tissue. 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 procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 20-year-old female enrollee has requested authorization and coverage for continued treatment with a non-contracted pediatric endocrinologist for the treatment of diabetes.  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

Representatives of an eight-year-old male enrollee  requested authorization and coverage of the medication Humatrope for the treatment of a long-term history of short stature. 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 prescription is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee requested authorization and coverage of intensive outpatient therapy for the treatment of schizo-affective disorder with recurring paranoia and hallucinations .  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 50-year-old male enrollee requested authorization and coverage of  a repeat myelogram procedure for the treatment of back and 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

Parents of a 13-year-old enrollee requested authorization and coverage of vacuum assisted closure therapy for the treatment of open right tibia fracture.  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

The grandparent of a 3-year-old male enrollee requested authorization and coverage of further laboratory testing to rule out neuroimmune dysfunction syndrome. The enrollee has a diagnosis of autism spectrum disorder/pervasive developmental delay.  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 49-year-old female enrollee requested authorization and coverage of panniculectomy   and breast reduction surgery for the treatment of redundant skin in her abdomen area, mammary ptosis, and mammary hypertrophy.  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 54-year-old male enrollee requested authorization and coverage of the medication gleevec for the treatment of colo-rectal cancer that has metastasized to the lungs and liver.  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 treatment of the enrollees Colo-rectal 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: Overturned Decision of Health Plan

A 47-year-old female enrollee requested authorization and coverage of remicaide infusion therapy for the treatment of rheumatoid arthritis.  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 43-year-old female enrollee requested authorization and coverage of the medication gleevec for the treatment of metastatic colon 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 the medication gleevec is not likely to be more beneficial for treatment of the enrollees metastatic colon 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 58-year-old female enrollee requested authorization and coverage of autologous bone marrow transplant (stem cell trasplant) for the treatment of stage IIIA carcinoma of the breast.  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 bone marrow transplant (stem cell trasplant) is not likely to be more beneficial for treatment of the enrollees stage IIIA carcinoma of the breast 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 36-year-old female enrollee requested authorization and coverage of breast reduction surgery for the treatment of upper 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 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 female enrollee requested authorization and coverage of a CT scan for the treatment of an 8 mm well circumscribed left upper lobe lung nodule.  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 service is  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee requested authorization and coverage of bilateral blepharoplasty for the treatment of redundant eyelid tissue.  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 procedure is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee requested authorization and coverage of extracorporeal shock wave therapy (orthotripsy) for the treatment of plantar fasciitis in his right foot.  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 therapy is  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 59-year-old male enrollee requested authorization and coverage of 150 catheters a year to assist in urination.  Since his surgery and radiation therapy for cancer approximately four years ago, he has been unable to urinate without a great deal of strain. 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 33-year-old male enrollee requested authorization and coverage of an elective circumcision.  The enrollee believes that his lack of circumcision has caused  his wife an infection, and he does not wish to have this recur .  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 39-year-old male enrollee requested authorization and coverage of a custom powered reclining wheelchair with an electric elevating seating system 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 equipment is not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 62-year-old female enrollee requested authorization and coverage for a palatopharyngoplasty for the treatment of an airway obstruction.  The health plan denied the enrollee's 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 plan's denial on the basis that the requested palatopharyngoplasty is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage of an open MRI of the spine for the treatment of back pain.  One Physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the plan's denial on the basis that the requested prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 66-year-old male requested authorization and coverage for an MRI of his back.  The Independent Medical Review determined that the service desired was not medically necessary.  Thus, the health plan is not required to provide this service.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 41-year-old male who suffers from severe Acne Rosacea requested authorization and coverage for photoderm laser treatment.  The Independent Medical Review determined that the service was medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of open reduction internal fixation (ORIF) for the treatment of a shoulder fracture.  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 procedure is medically necessary for treatment of the patients medical condition.