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

The parents of a 6-year-old female enrollee requested authorization and coverage of speech therapy for the treatment of a severe speech disorder.  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 43-year-old female enrollee requested authorization and coverage of a power-operated vehicle 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: Overturned Decision of Health Plan

A 71-year-old male enrollee requested authorization and coverage of  surgical resection of the left lobe of the liver for the treatment of liver cancer.  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 38-year-old female enrollee requested authorization and coverage of a videostroboscopy for the treatment of chronic laryngitis.  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

A 61-year-old female enrollee requested authorization and coverage of  sclerotherapy for the treatment of spider varicose veins. 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 51-year-old female enrollee requested authorization and coverage of a referral to an opthomologist for the treatment of poor vision.  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: Overturned Decision of Health Plan

A 53-year-old female enrollee requested authorization and coverage of gastric bypass "roux-en-Y" 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 services are  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old male enrollee requested authorization and coverage of an out-of-plan deep brain stimulator surgery for the treatment of young onset parkinson's disease.  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

The parents of a 4-year-old female enrollee requested authorization and coverage of referral and surgery (The Leonard Procedure for Pectus Carinatum) for the treatment of pectus carinatum.  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

The parents of a 5-year-old male enrollee requested authorization and coverage of speech therapy and occupational therapy for the treatment of autism.  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 requested therapy is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 51-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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of the medication lamisil for the treatment of onychomycosis and subungal hyperkeratosis  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 patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of the prescription medication remicade (Injectable) for the treatment of recurrent idiopathic pericarditis.  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 prescription medication remicade (Injectable) is not likely to be more beneficial for treatment of the enrollees recurrent idiopathic pericarditis 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 66-year-old male enrollee requested authorization and coverage of injectable cladribine for the treatment Multiple Sclerosis. 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 injectable cladribine is not likely to be more beneficial for treatment of the enrollees Multiple Sclerosis 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 61-year-old female enrollee requested authorization and coverage of a consultation for 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 consultation is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a 7-year-old female enrollee requested authorization and coverage of speech therapy for the treatment of articulation disorder and word retrieval problem.  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 27-year-old female enrollee requested authorization and coverage of chromosomal analysis.  The enrollee has had two previous fetal demises.  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 testing is not medically necessary for treatment of the patients medical condition at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 40-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of 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: Medical Necessity
Decision: Upheld Decision of Health Plan

A 21-year-old female enrollee requested authorization of the medication Protopic 0.1% for the treatment of alopecia areata.  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 patients medical condition at this time.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 49-year-old female enrollee requested authorization and coverage of reduction mammoplasty for the treatment of chronic intertrigeneral dematosis as well as occasional pyoderma and cyst formation. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 27-year-old male enrollee requested authorization and coverage of liver activation treatment for the treatment of diabetic neuropathy, autonomic neuropathy, peripheral neuropathy, eye retinopathy, and kidney disease.  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 liver activation treatment is not likely to be more beneficial for treatment of the enrollees diabetic neuropathy, autonomic neuropathy, peripheral neuropathy, eye retinopathy, and kidney disease 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

Parents of a 11-year-old male enrollee requested authorization and coverage of occupational therapy for 16 weeks for the treatment of significant delays in fine motor/visual motor skills, motor co-ordination balance and equilibrium reactions. 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: Upheld Decision of Health Plan

A 39-year-old female enrollee requested authorization and coverage of a referral to a pain management specialist for the treatment of arthritis, calcium build up and bone spurs.  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 referral is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee requested authorization and coverage of laparoscopic placement of a gastric band for the treatment of morbid obesity.  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 laparoscopic placement of a gastric band is not likely to be more beneficial for treatment of the enrollees obesity than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 62-year-old female enrollee requested authorization and coverage of normal saline infusions for the treatment of orthostatic hypotention and arrythmias.  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: Overturned Decision of Health Plan

A 62-year-old female enrollee requested authorization and coverage to be treated by an out-of-network Oncologist for the treatment of 4th stage metastic lung cancer.  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 34-year-old female enrollee requested authorization and coverage of an adjustable gastric band for the treatment of obesity.  The health plan denied the enrollees request indicating that the requested treatment is ivestigational.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Two of the three physician reviewers concluded that an adjustaable gastric band is not likely to be more beneficial for treatment of the enrollees obesity than any available standard therapy.  Because two of the three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested authorization and coverage of participation in a phase I clinical trial using Colchicine for the treatment of stage IV liver cirrhosis. 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 participation in a phase I clinical trial using Colchicine is not likely to be more beneficial for treatment of the enrollees stage IV liver cirrhosis 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

The parent of an 18-year-old male enrollee requested authorization and coverage of discharge to home with RN shift care for the treatment of TBI (traumatic brain injury).  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 63-year-old female enrollee requested authorization and coverage of a bone stimulatorfor the treatment of charcots joints of her feet. 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 a bone stimulator is not likely to be more beneficial for treatment of the enrollees charcots joints of her feet 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 64-year-old female enrollee requested authorization and coverage of an MRI of her right breast for the treatment of breast pain  related to an implant placed post mastectomy in 1992. 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 requestedMRI is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 48-year-old male enrollee requested authorization and coverage of IDETfor the treatment of chronic lower back pain.  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 IDET is not likely to be more beneficial for treatment of the enrollees chronic lower back pain than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The grandmother of a two-year-old female enrollee requested authorization and coverage of an out of state referral and surgery for leg lengthening for the treatment of Proximal femoral focal deficiency with Coxa vara and mild congenital short femur.    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 referral is not medically necessary for treatment of the enrollees medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 60-year-old male enrollee requested authorization and coverage of continued physical therapy by a therapist and a skin graft for the treatment of a below the knee amputation. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A 37-year-old female enrollee requested authorization and coverage of IVIG intravenous immunoglobulin with an out-of-network Immunologist for the treatment of recurrent miscarriages. 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 IVIG intravenous immunoglobulin is not likely to be more beneficial for treatment of the enrollees recurrent miscarriages 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.