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

A 41-year-old female enrollee requested authorization and coverage of Pegasys and ribavirin therapy. The Health Plan  denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees hepatitis C.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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.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: Overturned Decision of Health Plan

A 33-year-old male enrollee requested authorization and coverage of a rhinoplasty. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees nasal obstruction.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 16-year-old male enrollee requested authorization and coverage of residential treatment for treatment of the enrollees medical condition. The Health Plan  denied the request indicating that the requested services are not medically necessary for treatment of the enrollees substance abuse and behavioral health problems.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: Medical Necessity
Decision: Overturned Decision of Health Plan

The representatives of a 38-year-old male enrollee requested authorization and coverage of continued skilled nursing facility care. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage of 50 semi-weekly psychotherapy sessions for a six-month period. The Health Plan denied the request indicating that the requested therapy is not medically necessary for 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 therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The representative of a 20-year-old female enrollee requested reimbursement for partial hospitalization services the enrollee received from 6/3/03 through 6/27/03. The Health Plan denied the request indicating that the services at issue were not medically necessary for treatment of the enrollees eating 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 were not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 64-year-old female enrollee requested authorization and coverage of physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees chronic neck and shoulder 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 36-year-old female enrollee requested authorization and coverage of the medication Sporanox. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees fungal sinusitis.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

The mother of a four-year-old male enrollee requested authorization and coverage of speech therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees speech impairment.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 55-year-old male enrollee requested authorization and coverage of the medication Lotronex. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees irritable bowel syndrome.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 56-year-old female enrollee requested authorization and coverage of a custom wheelchair. The Health Plan denied the request indicating that the requested wheelchair 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 wheelchair is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of acupuncture treatments. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees right shoulder pain.One acupuncture reviewer performed a medical necessity Independent Medical Review. The acupuncture 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 43-year-old female enrollee requested authorization and coverage of botulinum toxin B injections. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees migraine headaches.Three physician reviewers performed a medical necessity Independent Medical Review. Two of the three physician reviewers concluded that the requested therapy is medically necessary for treatment of the enrollee's medical condition. One of the three physician reviewers concluded that the requested therapy is not medically necessary for treatment of the enrollee's medical condition. Because two of the three physician reviewers concluded that the requested therapy is medically necessary for treatment of the enrollee's medical condition, the Health Plans denial has been overturned.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 36-year-old male enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is considered experimental for treatment of the enrollees morbid obesity.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 treatment of the enrollee's medical condition than any available standard therapy. One of the 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. Because two of the 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, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 37-year-old female enrollee requested authorization and coverage of an MRI of the lumbar spine and an MRI of the pelvis. The Health Plan denied the request indicating that the requested MRIs are not medically necessary for the evaluation of the enrollees back pain and uterine fibroid.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that the requested MRI of the lumbar spine is medically necessary, however, the requested MRI of the pelvis is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of Z-plasty and blepharoplasty procedures. The Health Plan denied the request indicating that the requested procedures are not medically necessary for facial reconstruction post Mohs surgery and radiation treatment.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plans denial on the basis that a Z-plasty is medically necessary but a blepharoplasty is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The father of a three-year-old female enrollee requested authorization and coverage of applied behavioral analysis therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees autism.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 32-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees morbid obesity.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 depending upon the results of a psychological evaluation.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of continued residential chemical dependency treatment. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees alcoholism.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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 30-year-old female enrollee requested authorization and coverage of a capsule endoscopy. The Health Plan denied the request indicating that the requested endoscopy is not medically necessary for evaluation of the enrollees abdominal 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 procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 39-year-old female enrollee requested authorization and coverage of gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.Three physician reviewers performed a medical necessity Independent Medical Review. Two physician reviewers concluded that the requested procedure is not medically necessary for treatment of the enrollee's medical condition. One physician reviewer concluded that the requested procedure is medically necessary for treatment of the enrollee's medical condition. Because two of the three  physician reviewers concluded that the requested procedure is not medically necessary for treatment of the enrollee's medical condition, the Health Plans denial was upheld.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested authorization and coverage of the medication Enbrel. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriasis.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: Overturned Decision of Health Plan

A 57-year-old female enrollee requested authorization and coverage of a Glucowatch. The Health Plan denied the request indicating that the requested equipment is considered experimental for treatment of the enrollees hypoglycemic unawareness.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested equipment is 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 equipment is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial was overturned.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 36-year-old female enrollee requested authorization and coverage of the medication Allegra. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees allergic rhinitis.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 32-year-old female enrollee requested authorization and coverage of jaw surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees jaw 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 procedure is not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of a 16-year-old female enrollee requested authorization and coverage of inpatient behavioral health services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees bulimia.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: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee requested authorization and coverage of Zelnorm. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees irritable bowel syndrome.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 50-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is experimental for treatment of the enrollees migraine headaches.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 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 was upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested authorization and coverage of a power-operated vehicle (POV). The Health Plan denied the request indicating that the requested equipment is not medically necessary to assist with the enrollees mobility.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 37-year-old female enrollee requested authorization and coverage of a total abdominal hysterectomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees uterine fibroid.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 52-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 the treatment of the enrollees 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 medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 56-year-old male enrollee requested authorization and coverage of cataract surgery. The Health Plan denied the request indicating that the requested surgery is not medically necessary for treatment of the enrollees visual acuity.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 59-year-old female enrollee requested authorization and coverage of a referral to a plastic surgeon. The Health Plan  denied the request indicating that the requested referral is not medically necessary for the enrollees follow-up care.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: Upheld Decision of Health Plan

A 43-year-old male enrollee requested authorization and coverage of enzyme potentiated desensitization. The Health Plan denied the request indicating that the requested therapy is not medically necessary for the treatment of the enrollees anaphylaxis.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 48-year-old female enrollee requested authorization and coverage of a gastric bypass with duodenal switch. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the 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 procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for the treatment of the enrollees morbid obesity. 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 29-year-old female enrollee requested authorization and coverage of daily Vioxx 25 mg. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees systemic lupus erythematosus.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 at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee requested authorization and coverage of a prosthetic water leg. The Health Plan denied the request indicating that the requested prosthesis 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 55-year-old female enrollee requested authorization and coverage of intravenous antibiotic therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee requested authorization and coverage of high-dose chemotherapy and autologous stem cell transplant. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees breast cancer.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 therapy 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.