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

A 33-year-old female enrollee requested authorization and coverage of a PET scan of the brain followed by a whole body PET scan for the treatment of toxic leukoencephalopathy.  The health plan denied the enrollees request, indicating that the requested PET 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 PET scans are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a four-year-old male enrollee requested authorization and coverage of occupational therapy equipment for the treatment of autism.  The Health Plan denied the enrollees request indicating that the requested equipment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested equipment is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 46-year-old male enrollee requested authorization and coverage of the medication Proscar for treatment of a prostate condition. The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer 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 30-year-old male enrollee requested authorization and coverage of an Otto Bock C-Leg prosthetic leg.  The health plan denied the enrollees 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 Otto Bock C-Leg is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 55-year-old female enrollee requested authorization and coverage of radiofrequency ablation for treatment of a pulmonary malignancy.  The health plan denied the enrollees request indicating that the requested procedure is considered experimental.Three physician Reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that radiofrequency ablation is not likely to be more beneficial for treatment of the enrollees pulmonary malignancy 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: Overturned Decision of Health Plan

A 58-year-old female enrollee requested authorization and coverage of intensity modulated radiation therapy (IMRT) for treatment post salivary gland adenocarcinoma.  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.  Two of the three physician reviewers overturned the health plans denial on the basis that the requested IMRT is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female enrollee requested authorization and coverage of an increase in the quantity and dosage of her monthly Vioxx prescription for treatment of chronic myofascial pain.  The Health Plan denied the enrollees request indicating that the requested increase in quantity and dosage of the prescription 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 37-year-old male enrollee requested authorization and coverage of orthotripsy for the treatment of chronic heel pain.  The health plan denied the enrollees request indicating that the requested service is not medically necessary.One podiatrist reviewer performed a medical necessity Independent Medical Review.  The podiatrist reviewer overturned the health plans denial on the basis that the requested orthotripsy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of continued Orthopedic Spine Treatment (OST) for treatment of back pain.  The health plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 44-year-old female requested authorization and coverage of Uterine Artery Embolization (UAE) for treatment of fibroids.  The Health Plan denied the enrollee's request indicating that the procedure is experimental/investigationalThree physician reviewer performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that UAE is not 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 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 51-year-old female enrollee requested authorization and coverage of BRCA testing for genetic screening for breast cancer.  The health plan denied the enrollees request indicating that the requested testing 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 testing 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 an MRI of the brain to screen for cysticercosis.  The health plan denied the enrollees request indicating that the requested MRI 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 MRI is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 57-year-old female has requested authorization and coverage of an AMAS blood test and thermogram for treatment of pagets disease of the breast.  The health plan denied the enrollees request indicating that the requested tests 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 tests are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 44-year-old female enrollee requested authorization and coverage of proton beam therapy to the right eye for treatment of adenoid cystic carcinoma.  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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parents of a 15-year-old female enrollee requested authorization and coverage of eye surgery for treatment of strabismus.  The Health Plan has denied this request indicating that the requested surgery 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 74-year-old female enrollee requested authorization and coverage for L4-5 posterior decompression, fusion, and instrumentation with iliac crest bone graft for treatment of back pain.  The health plan denied the enrollees request indicating that the requested surgery it is not medically necessary.Once 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The spouse of a 55-year-old female enrollee requested authorization and coverage of continued skilled nursing facility services for treatment following a ruptured brain aneurysm.  The health plan denied the enrollees request indicating that skilled nursing facility services were no longer 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 57-year-old female enrollee requested authorization and coverage of gastric bypass surgery with duodenal switch for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested type of bypass is not medically necessary.  The plan recommended a Roux-en-Y gastric bypass.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested type of gastric bypass is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 44-year-old male requested authorization and coverage of surgical removal of sebaceous cysts.  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 38-year-old female enrollee requested authorization and coverage for removal of an occiptal mass performed on an inpatient basis. The Health Plan has denied this request indicating that it is not medically necessary for the occiptal mass to be removed on an inpatient basis.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: Overturned Decision of Health Plan

A 43-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 surgery 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 32-year-old female enrollee requested authorization and coverage for a continuous positive airway pressure machine (CPAP) for the treatment of sleep apnea.  The health plan denied the enrollees request indicating that the requested CPAP 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 CPAP is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 42-year-old male enrollee requested authorization and coverage of surgical repair of palate, pharynx, uvula, and removal of tonsils for treatment of sleep depravation from snoring.  The health plan denied the enrollees request indicating that the requested procedures 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 procedures are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested authorization and coverage for orthognathic surgery for the treatment of irregular facial structure.  The health plan denied the enrollees request indicating that the requested surgery is not medically necessary.One oral surgical physician reviewer performed a medical necessity Independent Medical Review.  The oral surgical reviewer overturned the health plans denial on the basis that the requested surgery is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 56-year-old female enrollee requested authorization and coverage of continued acupuncture for the treatment of fibromyalgia.  The health plan denied the enrollees request indicating that the requested acupuncture is not medically necessary An acupuncture reviewer performed a medical necessity Independent Medical Review.  The acupuncture reviewer upheld the health plans denial on the basis that the requested acupuncture treatment is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 38-year-old male enrollee requested authorization and coverage of reduction mammaplasty and panniculectomy for the treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested procedures are 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 procedures are medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old female enrollee requested authorization and coverage of the prescription medication Xenical for the treatment of morbid obesity.  The health plan denied the enrollees request indicating the requested medication in 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 Xenical is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of adjustable gastric banding for treatment of morbid obesity.  The health plan denied the enrollees request indicating that the requested procedure is considered experimental/investigational.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that the adjustable gastric banding 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 procedure 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 46-year-old male enrollee requested authorization and coverage of aortoiliac thromboendarterectomy surgery for infrarenal aortic occlusion with bilateral iliac artery occlusions. The health plan denied the enrollees request indicating that the requested surgery 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a five-year-old female enrollee requested authorization and coverage of continued speech therapy to lower the risk of choking and aspiration as well as improve nutritional intake and speech.  The health plan denied the enrollees request indicating that continued speech therapy 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 speech therapy is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of spinal cord monitoring during spinal fusion surgery for the treatment of severe back pain.  The health plan denied the enrollees request indicating that the requested spinal cord monitoring 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 monitoring is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old female enrollee requested authorization and coverage of the prescription medication Vioxx for treatment of back pain.  The enrollees health plan denied the 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 prescription is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 52-year-old male enrollee requested authorization and coverage for lumbar epidural steroid injections for severe lower back pain.  The enrollees health plan denied the 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 plan's denial on the basis that the requested treatment is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 61-year-old female enrollee requested authorization and coverage of Botox injections for the treatment of tension headaches.  The enrollees health plan denied the 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 Botox injections are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 55-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 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 surgery is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 47-year-old female requested authorization and coverage for a panniculectomy.  The enrollees health plan denied the 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 59-year-old female enrollee requested authorization and coverage of an electric wheelchair for treatment of status post cerebral vascular accident (CVA) with left hemiparesis.  The health plan denied the enrollees request indicating the Electric 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 electric wheelchair is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested authorization and coverage of Supartz injections for treatment of bilateral knee arthritis.  The enrollees health plan denied the request indicating 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 Supartz injections are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 35-year-old female enrollee requested authorization and coverage of surgery for treatment of Temporomandibular Joint (TMJ) Dysfunction.  The enrollees health plan denied the 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 58-year-old male enrollee requested authorization and coverage of blood tests for screening purposes.  The Health Plan denied the enrollees request indicating that the requested blood tests 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 blood tests are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage for the revision of previous gastric bypass surgery.  The enrollees health plan denied the request indicating the requested surgery 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage for compounded (Progesterone/Testosterone/Triest) hormone replacement cream for treatment of menopause.  The enrollees health plan denied the 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-year-old female enrollee requested authorization and coverage of the prescription medication Meridia for the treatment of obesity.  The health plan denied the enrollees request indicating that the requested meridia 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 prescription medication, Meridia, is not medically necessary.