text stringlengths 1 26.3k | tags listlengths 4 5 | date_accessed stringclasses 1
value | source_url stringclasses 5
values | source_md5 stringlengths 32 32 | relative_path stringlengths 35 82 | decision stringclasses 12
values | appeal_type stringclasses 29
values |
|---|---|---|---|---|---|---|---|
Summary Reviewer 1
The patient is a 46-year-old female with a history of right hip pain. The patients hip pain has not responded to conservative treatment in addition to revision arthroscopic labral debridement, iliopsoas bursectomy, synovectomy, lysis of adhesions, and capsular release. The patient has requested auth... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 1016d4564a8a6e01d4604c1e220c00fe | ./data/processed/ca_cdi/summaries/17-5001.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
The patient is a 46-year-old female with chronic pain at the hip joint. The patients pain has reportedly been present since 2011, treated with physical therapy, steroid injections and arthroscopic labral surgeries. A diagnosis of right labral tear was made in 2011. Arthroscopic surgery was recommend... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 1016d4564a8a6e01d4604c1e220c00fe | ./data/processed/ca_cdi/summaries/17-5001.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
The patient is a 46-year-old female with chronic right hip pain. She had undergone labral repairs, debridement, and a periacetabular osteotomy and was still unable to ambulate more than one mile. She complains of pain in the anterior groin and lateral hip described as sharp, radiating, and associate... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 1016d4564a8a6e01d4604c1e220c00fe | ./data/processed/ca_cdi/summaries/17-5001.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 54-year-old male enrollee has requested authorization and coverage for Sovaldi and Olysio. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found that according ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | f1f686d639f260cb3b77abd52b615e93 | ./data/processed/ca_cdi/summaries/16-4787.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 98107fd9f4c9d6291c8de634965efcbe | ./data/processed/ca_cdi/summaries/18-6383.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 98107fd9f4c9d6291c8de634965efcbe | ./data/processed/ca_cdi/summaries/18-6383.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 98107fd9f4c9d6291c8de634965efcbe | ./data/processed/ca_cdi/summaries/18-6383.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 30-year-old male enrollee has requested reimbursement for L0637 (lumbar support brace) provided on 1/7/15. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees low back pain. The physician reviewer found that base... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 30cb923c8b025b2290db790725e00cab | ./data/processed/ca_cdi/summaries/17-6079.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 69-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis without contrast material, followed by contrast material and further sequences (CPT 72197). The Health Insurer has denied this request indicating that the requested services are no... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | aad2d31c60517b1786cd57613527f85b | ./data/processed/ca_cdi/summaries/18-6398.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 31-year-old female enrollee has requested reimbursement for inpatient mental health services provided from 11/7/17 to 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder and depression... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 5a6b66017990d3ed4daea7dd6edcf11d | ./data/processed/ca_cdi/summaries/18-6284.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 45-year-old female enrollee has requested authorization and coverage for arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance. The Health Insurer has denied this request indicating that the requested services are not medically necessary fo... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 109b82ae81ecb5b3ada2ad4b2129c8e7 | ./data/processed/ca_cdi/summaries/17-4870.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | d4c5a3a1e26c5e8fa3f871ff031284d4 | ./data/processed/ca_cdi/summaries/19-6866.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | d4c5a3a1e26c5e8fa3f871ff031284d4 | ./data/processed/ca_cdi/summaries/19-6866.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | d4c5a3a1e26c5e8fa3f871ff031284d4 | ./data/processed/ca_cdi/summaries/19-6866.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The parent of a 14-year-old female enrollee has requested reimbursement for mental health residential treatment center services provided from 11/16/16 through 12/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the e... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 313d3260e829da9e1f63b797766a1318 | ./data/processed/ca_cdi/summaries/17-6017.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that ther... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a7a1c12e446211008c0907aff03254b2 | ./data/processed/ca_cdi/summaries/18-6505.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that the ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a7a1c12e446211008c0907aff03254b2 | ./data/processed/ca_cdi/summaries/18-6505.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that ther... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a7a1c12e446211008c0907aff03254b2 | ./data/processed/ca_cdi/summaries/18-6505.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history o... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e295ef40728d9c88b55bc983111b9e18 | ./data/processed/ca_cdi/summaries/18-6434.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history o... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e295ef40728d9c88b55bc983111b9e18 | ./data/processed/ca_cdi/summaries/18-6434.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history o... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e295ef40728d9c88b55bc983111b9e18 | ./data/processed/ca_cdi/summaries/18-6434.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 65-year-old female enrollee has requested authorization and coverage for spinal surgery (CPT codes 22212, 63048, 22610, 20931, 63046, 22840, 22842, 22853, 22845, 22556, 22216, 63077, and 22614) and five (5) inpatient days. The Health Insurer has denied this request indicating that the requested ser... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 6c7428b718a9f863c6297e5a5c48f0d9 | ./data/processed/ca_cdi/summaries/18-6453.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
An 18-year-old transgender female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/19/17 through 3/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the t... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | aaee7c71ad0cb90a1c1446f1d237dd0e | ./data/processed/ca_cdi/summaries/19-6651.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 20-year-old male enrollee has requested reimbursement for substance use disorder partial hospitalization program (PHP) services provided from 10/3/17 through 10/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | be332dbc2c809a79bc6c2507b7cb024a | ./data/processed/ca_cdi/summaries/17-6141.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found that... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | fd40de0df2be50b4f833e339e3835cc8 | ./data/processed/ca_cdi/summaries/17-4929.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found ther... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | fd40de0df2be50b4f833e339e3835cc8 | ./data/processed/ca_cdi/summaries/17-4929.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found that... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | fd40de0df2be50b4f833e339e3835cc8 | ./data/processed/ca_cdi/summaries/17-4929.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The guardian of a 17-year-old male enrollee has requested reimbursement for residential treatment provided from 6/05/14 through 10/11/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health con... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 8e7df64487c92ba46ed0bd341b9d5742 | ./data/processed/ca_cdi/summaries/15-4176.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 64-year-old female who was transported by air ambulance from Brazil to Cedar Sinai Hospital (CSH) in Los Angeles, California on 1/18/20. The patient has requested reimbursement for air ambulance transport services provided on 1/18/20. The Health Insurer has denied this request and re... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | ac8f4ac1c03b1cf8aaee190a82a9b7b2 | ./data/processed/ca_cdi/summaries/20-7076.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 64-year-old male enrollee has requested authorization and coverage for functional electrical stimulation cycle ergometer. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees tetraplegia. The physician reviewer fou... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | d091c9df0b7e2b7f7c94b9a1b38a6926 | ./data/processed/ca_cdi/summaries/18-6460.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 51-year-old female enrollee has requested authorization and coverage for Vemlidy. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B virus. The physician reviewer found that according to the Amer... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c4de43a7df79809e730faf817d91cef5 | ./data/processed/ca_cdi/summaries/17-4949.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician r... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 62b8a3e19cb71cfa62df83145933950b | ./data/processed/ca_cdi/summaries/17-4975.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 62b8a3e19cb71cfa62df83145933950b | ./data/processed/ca_cdi/summaries/17-4975.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 62b8a3e19cb71cfa62df83145933950b | ./data/processed/ca_cdi/summaries/17-4975.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The parent of a 16-year-old male enrollee has requested reimbursement for mental health outpatient services provided from 11/25/15 through 5/12/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 4d9bfb7f527107abc07cc303d9f13ae0 | ./data/processed/ca_cdi/summaries/17-4796.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
The patient is a 44-year-old female who has a personal history of several malignancies including bilateral invasive lobular breast cancer at age 42, non-Hodgkins lymphoma in 1997, thyroid cancer in 1998, and a mucoepidermoid carcinoma of the trachea in 2009. Her family history is significant for a s... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a307c442fb33bec91fd90d884c77b56a | ./data/processed/ca_cdi/summaries/17-6039.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
The patient is a 44-year-old female who has had bilateral breast cancer. In addition, she has also had non-Hodgkins lymphoma and mucoepidermoid cancer. She has a strong family history of cancer, with a sister with lymphoma, sister with thyroid cancer and a paternal grandmother with uterine cancer. T... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a307c442fb33bec91fd90d884c77b56a | ./data/processed/ca_cdi/summaries/17-6039.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
The patient is a 44-year-old female with a history multiple malignancies, including breast cancer. Per the records, she had an abnormal uterine ultrasound. She has a significant family history, including a sister with non-Hodgkins lymphoma, a sister with thyroid cancer, two cousins with thyroid can... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a307c442fb33bec91fd90d884c77b56a | ./data/processed/ca_cdi/summaries/17-6039.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
The parent of a one-year-old male enrollee has requested authorization and coverage for Olumiant
1 mg tablet. The Health Insurer has denied this request and reported that the requested medication
is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found t... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a8114bb1aeb33e4be9a8f42e66f9cb8b | ./data/processed/ca_cdi/summaries/20-7214.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
The parent of a one-year-old male enrollee has requested authorization and coverage for Olumiant
1 mg tablet. The Health Insurer has denied this request and reported that the requested medication
is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found t... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a8114bb1aeb33e4be9a8f42e66f9cb8b | ./data/processed/ca_cdi/summaries/20-7214.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
The parent of a one-year-old male enrollee has requested authorization and coverage for Olumiant
1 mg tablet. The Health Insurer has denied this request and reported that the requested medication
is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found t... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | a8114bb1aeb33e4be9a8f42e66f9cb8b | ./data/processed/ca_cdi/summaries/20-7214.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The parent of a 17-year-old female enrollee has requested authorization and coverage for mammoplasty, augmentation; with prosthetic implant (19325) and breast reconstruction with other technique (19366). The Health Insurer has denied this request indicating that the requested services are not medica... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 02310bc53af7a8a7052719f7b6f0fcb3 | ./data/processed/ca_cdi/summaries/18-6410.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The parent of a 15-year-old female enrollee has requested reimbursement for psychiatric residential treatment center (RTC) services from 5/13/15 through 12/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enroll... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | ce0a944ad49f4172e5661fea01264ae5 | ./data/processed/ca_cdi/summaries/16-4568.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The parent of a five-year-old female enrollee has requested authorization and coverage for Tobii Dynavox T10 device and accessories. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollee, who has been diagnosed with c... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 2464879473824b213c99a96f15945c5a | ./data/processed/ca_cdi/summaries/17-4924.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 20df2071e58cc8c4c1180c39c0e00460 | ./data/processed/ca_cdi/summaries/16-4455.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 20df2071e58cc8c4c1180c39c0e00460 | ./data/processed/ca_cdi/summaries/16-4455.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 20df2071e58cc8c4c1180c39c0e00460 | ./data/processed/ca_cdi/summaries/16-4455.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 68-year-old female enrollee has requested reimbursement for DecisionDX Melanoma Assay provided on 2/05/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees malignant melanoma. The physician reviewer found... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c27f6c8c90c9cfde427f02cc92ed66a9 | ./data/processed/ca_cdi/summaries/17-4899.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The patient is a 23-year-old female with a history of limited cutaneous systemic sclerosis, Raynauds phenomenon, mild skin tightness, arthritis and gastrointestinal disease. Per the provider, the patient has been treated with sildenafil since 2010 with good results. On 11/20/17, she presented for foll... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 3b048ce4cbd841cefc67b0b5cca980e6 | ./data/processed/ca_cdi/summaries/18-6511.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 03be66442295f12fcb10f2f3d29e06b7 | ./data/processed/ca_cdi/summaries/16-4365.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 03be66442295f12fcb10f2f3d29e06b7 | ./data/processed/ca_cdi/summaries/16-4365.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 03be66442295f12fcb10f2f3d29e06b7 | ./data/processed/ca_cdi/summaries/16-4365.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
An 18-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) therapy provided from 9/12/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary f... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | beebcc1fb5c6ee645535986b2188d167 | ./data/processed/ca_cdi/summaries/17-4934.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis.The physician reviewer fo... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e6a0c0059be2f93096ff5234bbc1015c | ./data/processed/ca_cdi/summaries/16-4550.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis. The physician reviewer f... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e6a0c0059be2f93096ff5234bbc1015c | ./data/processed/ca_cdi/summaries/16-4550.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis. The physician reviewer f... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e6a0c0059be2f93096ff5234bbc1015c | ./data/processed/ca_cdi/summaries/16-4550.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The patient is a 61-year-old female who presented to her provider on 5/25/21 with a complaint of worsening knee pain. The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. The physician reviewer found that the current medical evidence does not sup... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | d6090aaf23cc0b4de6ec0dfffa53490f | ./data/processed/ca_cdi/summaries/21-7378.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The patient is a 58-year-old female with osteoporosis of the spine demonstrated on a recent dual-energy x-ray absorptiometry (DEXA). She also has history of hypothyroidism, hypercholesterolemia and breast cancer that has been treated with letrozole. Her provider has recommended Prolia. The patient has... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 0d4a9640c3474963594119d061c155df | ./data/processed/ca_cdi/summaries/18-6280.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 48-year-old male enrollee has requested authorization and coverage for intravenous immune globulin (IVIG). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees specific antibody dysfunction. The physician revie... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e281103cbf098eeffca14024c9365160 | ./data/processed/ca_cdi/summaries/15-4250.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 33-year-old male enrollee has requested authorization and coverage for CPT code 27299 (unlisted procedure, pelvis/hip joint). The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees hip pain. The physician reviewe... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 73045de427b7b3df65968bacf5c4902e | ./data/processed/ca_cdi/summaries/18-6404.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 51-year-old male enrollee has requested authorization and coverage for inpatient care. The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees surgical procedure. The physician reviewer found that infection of a pen... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 085f31d60c2688fd560629555d2fc409 | ./data/processed/ca_cdi/summaries/17-6081.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 57-year-old female enrollee has requested reimbursement for code 81599 (DecisionDx-Melanoma) testing provided on 1/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physic... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 90e806fe45fed9e98f142d965225d9f4 | ./data/processed/ca_cdi/summaries/19-6849.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The patient is a 42-year-old female with a history of chronic low back pain. The progress notes dated 10/7/17, document a six month history with pain in the lower back radiating into both lower extremities. Associated symptoms included numbness, tingling and loss of bladder/bowel control. The pain w... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | b14b573a2a5a81375496d72fce1198b0 | ./data/processed/ca_cdi/summaries/18-6240.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The parent of a 14-year-old male enrollee has requested reimbursement for residential mental health treatment services provided from 4/25/16 through 12/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 2d3141c7972c24e362f8af7446c4c4c1 | ./data/processed/ca_cdi/summaries/16-4778.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evalu... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 134894f6aa7578e318aa1c35427e76d7 | ./data/processed/ca_cdi/summaries/17-4920.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evalua... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 134894f6aa7578e318aa1c35427e76d7 | ./data/processed/ca_cdi/summaries/17-4920.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluat... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 134894f6aa7578e318aa1c35427e76d7 | ./data/processed/ca_cdi/summaries/17-4920.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
The parent of 10-year-old female enrollee has requested authorization and coverage for growth hormone treatment. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewe... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 4318214f402f176fa94e5fb49e36c1b7 | ./data/processed/ca_cdi/summaries/18-6160.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer A 55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 426367fd14ce7e1b067ae82b0deeb8b0 | ./data/processed/ca_cdi/summaries/17-4907.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 426367fd14ce7e1b067ae82b0deeb8b0 | ./data/processed/ca_cdi/summaries/17-4907.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physicia... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 426367fd14ce7e1b067ae82b0deeb8b0 | ./data/processed/ca_cdi/summaries/17-4907.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment at Arivaca Boys Ranch from 5/26/16 through 2/13/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral h... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 2990a9539e3ba8f55407f85630a1f6e5 | ./data/processed/ca_cdi/summaries/17-6040.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 54-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 3/31/17 through 4/07/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who sustained injuries when she ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | f853bc0f826bae3e46cf7b6a7ba7bb46 | ./data/processed/ca_cdi/summaries/18-6444.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
I have determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld. The physician reviewer found that the patient is a 53-year-old male who compl... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 634ad3e23f23e03efc1bf7d162927661 | ./data/processed/ca_cdi/summaries/18-6481.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
I have determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld. The physician reviewer found that the patient is a 53-year-old male with a h... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 634ad3e23f23e03efc1bf7d162927661 | ./data/processed/ca_cdi/summaries/18-6481.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
I have determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld. The physician reviewer found that the patient is a 53-year-old male who pres... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 634ad3e23f23e03efc1bf7d162927661 | ./data/processed/ca_cdi/summaries/18-6481.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. Th... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 75d6902e4ff74d35bff700cc510a5712 | ./data/processed/ca_cdi/summaries/17-4917.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 75d6902e4ff74d35bff700cc510a5712 | ./data/processed/ca_cdi/summaries/17-4917.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. Th... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 75d6902e4ff74d35bff700cc510a5712 | ./data/processed/ca_cdi/summaries/17-4917.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 20-year-old male enrollee has requested authorization and coverage for residential substance use disorder treatment from 2/9/16 through 3/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral he... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | bacce3ad7211e811fd853a4deccf038a | ./data/processed/ca_cdi/summaries/16-4742.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that ther... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 25d61261cdadffd7542c1e735803ca00 | ./data/processed/ca_cdi/summaries/19-6940.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 25d61261cdadffd7542c1e735803ca00 | ./data/processed/ca_cdi/summaries/19-6940.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that this... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 25d61261cdadffd7542c1e735803ca00 | ./data/processed/ca_cdi/summaries/19-6940.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 63-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1a. The physician reviewer found that ac... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 267e74174911457dd10c939843538561 | ./data/processed/ca_cdi/summaries/15-4168.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | b25c1ed0cd1637a5fc347cff56b84138 | ./data/processed/ca_cdi/summaries/15-4283.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | b25c1ed0cd1637a5fc347cff56b84138 | ./data/processed/ca_cdi/summaries/15-4283.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | b25c1ed0cd1637a5fc347cff56b84138 | ./data/processed/ca_cdi/summaries/15-4283.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the U.S... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c23b9d512176f22c07c20f3ac076e39d | ./data/processed/ca_cdi/summaries/16-4754.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the app... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c23b9d512176f22c07c20f3ac076e39d | ./data/processed/ca_cdi/summaries/16-4754.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found there i... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | c23b9d512176f22c07c20f3ac076e39d | ./data/processed/ca_cdi/summaries/16-4754.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 64-year-old male enrollee has requested reimbursement for inpatient stay at telemetry level of care provided from 5/23/18 through 5/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condi... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 5b930c1d249cb7e65891b856f483f8d6 | ./data/processed/ca_cdi/summaries/19-6796.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The parent of a 17-year-old female enrollee has requested reimbursement for surgery performed on 6/22/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees enlarged labia. A review of the record indicates tha... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 2511270f9c3865c51c00bf7beda75374 | ./data/processed/ca_cdi/summaries/18-6228.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physicia... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | eb40b7dacb12384521952a8b46cf2523 | ./data/processed/ca_cdi/summaries/17-6024.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physicia... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | eb40b7dacb12384521952a8b46cf2523 | ./data/processed/ca_cdi/summaries/17-6024.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physicia... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | eb40b7dacb12384521952a8b46cf2523 | ./data/processed/ca_cdi/summaries/17-6024.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the request ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e6c7390c866043a27a379965a2256056 | ./data/processed/ca_cdi/summaries/17-5004.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the medical ... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e6c7390c866043a27a379965a2256056 | ./data/processed/ca_cdi/summaries/17-5004.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the radiofre... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | e6c7390c866043a27a379965a2256056 | ./data/processed/ca_cdi/summaries/17-5004.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 54-year-old male has requested reimbursement for genetic testing performed on 2/04/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that Foundation One ass... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 0ae2398149c743014df8224bdee74066 | ./data/processed/ca_cdi/summaries/18-6170.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 54-year-old male has requested reimbursement for genetic testing performed on 2/04/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer.The physician reviewer found that Foundation One test... | [
"california",
"independent-medical-review",
"case-description",
"cdi"
] | 2024-02-03 | https://interactive.web.insurance.ca.gov/apex_extprd/f?p=192:1:15394748574802::NO:RP,1:: | 0ae2398149c743014df8224bdee74066 | ./data/processed/ca_cdi/summaries/18-6170.jsonl | Insurer Denial Upheld | Experimental |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.