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

A 39-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 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 35-year-old female enrollee requested authorization and coverage of a bilateral mastopexy with breast implants. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees breast ptosis.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

The representative of a 17-year-old female enrollee  requested authorization and coverage of continued inpatient behavioral health care 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 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: Upheld Decision of Health Plan

The representative of a 19-year-old male enrollee requested authorization and coverage of transitional residential psychiatric services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees 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

A 36-year-old female enrollee requested authorization and coverage of oral surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees malocclusion.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon 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 representative of a 63-year-old female enrollee requested authorization and coverage of skilled nursing facility services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollee status post left humerus and left knee fracture.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

The father of a ten-year-old male enrollee requested authorization and coverage of the Vest Airway Clearance System for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested equipment is not medically necessary for treatment of the enrollees spastic quadriplegia.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 29-year-old female enrollee requested authorization and coverage of abdominoplasty and panniculectomy. The Health Plan denied the request indicating that the requested procedures are not medically necessary for treatment of the enrollees excess stomach tissue.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 reconstructive in nature and medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 55-year-old male enrollee requested authorization and coverage of proton beam therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees prostate cancer.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested therapy 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 a sleep study with CPAP machine. The Health Plan denied the request indicating that the requested sleep study is not medically necessary for treatment of the enrollees upper airway resistance 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 services are not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 50-year old male enrollee requested authorization and coverage of external counterpulsation therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees congestive heart failure.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 49-year-old female enrollee requested authorization and coverage of re-treatment with PEG-Interferon and ribavirin. 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 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 60-year-old female enrollee requested authorization and coverage of a Dexa scan. The Health Plan denied the request indicating that the requested Dexa scan is not medically necessary for evaluation of the enrollees osteoporosis.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested Dexa scan is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 57-year-old female enrollee requested authorization and coverage of radiofrequency ablation. The Health Plan denied the request indicating that the requested therapy is investigational for treatment of lung cancer.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two 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. One 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. Because two 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, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 43-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 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 likely 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 than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is not medically necessary for treatment of your medical condition, the Health Plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The mother of an 18-year-old female enrollee requested authorization and coverage of breast augmentation surgery for treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees asymmetrical breasts.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of a bilateral labiaplasty. The Health Plan denied the request indicating that the requested procedure is cosmetic in nature and not medically necessary for treatment of the enrollees enlarged minor labia.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is cosmetic in nature and not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 45-year-old female enrollee requested authorization and coverage of continued speech therapy, cognitive therapy, physical therapy, and aquatic therapy. The Health Plan denied the request indicating that the requested therapies are not medically necessary for treatment of the enrollees traumatic brain injury.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 physical therapy is medically necessary but speech therapy, cognitive therapy, and aquatic therapy in excess of the therapy already approved by the Health Plan is not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 23-year-old female enrollee requested authorization and coverage of the medication Depo-Provera. The Health Plan  denied the request indicating that the requested medication is not medically necessary for purposes of the enrollees contraception.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 44-year-old female enrollee requested authorization and coverage of follow-up care with a cardiologist or electrophysiologist. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollee status post cardiac pacemaker dependence.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

The mother of a 16-year-old male enrollee requested authorization and coverage of maxillary osteotomy. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees jaw deformity.One oral surgeon reviewer performed a medical necessity Independent Medical Review. The oral surgeon reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 53-year-old male enrollee requested authorization and coverage of external counterpulsation therapy. The Health Plan denied the request indicating that the requested therapy is experimental for treatment of the enrollees congestive heart failure.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two 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. One 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. Because two 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, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 38-year-old male enrollee requested authorization and coverage of Lamisil. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees onychomycosis.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 27-year-old female enrollee requested authorization and coverage of osteochondral autograft transfer with medial malleolar osteotomy of the left ankle. The Health Plan denied the request indicating that the requested procedure is investigational for treatment of the enrollees ankle pain.Three physician reviewers performed an experimental/investigational Independent Medical Review. Two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. One physician reviewer concluded that the requested procedure is not likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because two of the three physician reviewers concluded that the requested procedure is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 45-year-old male enrollee requested authorization and coverage of a sleep study. The Health Plan denied the request indicating that the requested services are not medically necessary for evaluation of the enrollees sleep apnea.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested services are not medically necessary at this time.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 35-year-old female enrollee requested authorization and coverage of cognitive therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollee status post head injury.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: Overturned Decision of Health Plan

A 51-year-old female enrollee requested authorization and coverage of Botox injections. The Health Plan denied the request indicating that the requested therapy is investigational for treatment of the enrollees neck pain and headaches.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of your medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 52-year-old female enrollee requested authorization and coverage of Botox 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 not medically necessary for treatment of the enrollee's medical condition. One of the three physician reviewers concluded that the requested therapy is medically necessary for treatment of the enrollee's medical condition. Because two of the three physician reviewers concluded that the requested therapy is not medically necessary for the treatment of the enrollee's medical condition, the Health Plans denial has been upheld.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A 44-year-old male enrollee requested authorization and coverage of Silikon 1000 injections. The Health Plan denied the request indicating that the requested therapy is considered experimental for treatment of the enrollees HIV-related lipodystrophy.Three physician reviewers performed an experimental/investigational Independent Medical Review. All three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Because all three physician reviewers concluded that the requested therapy is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy, the Health Plans denial has been overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A 48-year-old female enrollee requested authorization and coverage of abdominoplasty. The Health Plan denied the request indicating that the requested procedure is cosmetic in nature and not medically necessary for treatment of the enrollees excess skin status post gastric bypass surgery. 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 29-year-old female enrollee requested authorization and coverage of group therapy. 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

A 64-year-old female enrollee requested authorization and coverage of the medication Protopic. The Health Plan denied the request indicating that the requested medication is not medically necessary for treatment of the enrollees onychodystrophy.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 56-year-old female enrollee requested authorization and coverage of an upper GI series. The Health Plan denied the request indicating that the requested services are 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 services are not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A 50-year-old female enrollee requested authorization and coverage of gamma knife radiosurgery. The Health Plan denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees brain metastases.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 authorization and coverage of residential chemical dependency treatment services. The Health Plan denied the request indicating that the requested services are not medically necessary for treatment of the enrollees chemical dependency.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

The mother of a 16-year-old male enrollee requested authorization and coverage of continuing physical therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees spastic quadriplegia.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

The mother of an eight-year-old male enrollee requested authorization and coverage of occupational therapy for the treatment of the enrollees medical condition. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees traumatic brain injury.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

The parents of a 10-year-old female enrollee requested authorization and coverage of continued occupational therapy. The Health Plan denied the request indicating that the requested therapy is not medically necessary for treatment of the enrollees generalized epilepsy.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.