text stringlengths 1 26.3k | tags listlengths 4 5 | date_accessed stringclasses 1
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values | source_md5 stringlengths 32 32 | relative_path stringlengths 35 82 | decision stringclasses 12
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|---|---|---|---|---|---|---|---|
Summary Reviewer 3
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 patients with refra... | [
"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 1
A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.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:: | b496a7a25558383321a679429d366ad7 | ./data/processed/ca_cdi/summaries/16-4609.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort. The physician review... | [
"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:: | b496a7a25558383321a679429d366ad7 | ./data/processed/ca_cdi/summaries/16-4609.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort. 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:: | b496a7a25558383321a679429d366ad7 | ./data/processed/ca_cdi/summaries/16-4609.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatmen... | [
"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:: | 82dd397158fb1bf8c7202e37e714bca5 | ./data/processed/ca_cdi/summaries/17-6082.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatmen... | [
"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:: | 82dd397158fb1bf8c7202e37e714bca5 | ./data/processed/ca_cdi/summaries/17-6082.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment... | [
"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:: | 82dd397158fb1bf8c7202e37e714bca5 | ./data/processed/ca_cdi/summaries/17-6082.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 43-year-old transgender female enrollee has requested authorization and coverage for electrolysis epilation, each 30 minutes. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria. 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:: | 1427831191eeb07434b6ed4995c5aa12 | ./data/processed/ca_cdi/summaries/16-4601.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 35-year-old female enrollee has requested authorization and coverage for surgical jaw reconstruction. The Health Insurer has denied this request indicating that the requested services are not medically necessary for 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:: | 5a3542cae30af29596c1a5b335988ac2 | ./data/processed/ca_cdi/summaries/16-4368.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer foun... | [
"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:: | b2d1a61998d477d3f642538d4e1e05d9 | ./data/processed/ca_cdi/summaries/15-4111.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer foun... | [
"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:: | b2d1a61998d477d3f642538d4e1e05d9 | ./data/processed/ca_cdi/summaries/15-4111.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. 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:: | b2d1a61998d477d3f642538d4e1e05d9 | ./data/processed/ca_cdi/summaries/15-4111.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 24-year-old male enrollee has requested reimbursement for Rituxan provided on 12/17/18. The Health Insurer has denied this request and reported that the medication at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that pediatric ... | [
"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:: | a786c0ef0625e6264f9179f8a94ab7e9 | ./data/processed/ca_cdi/summaries/19-6779.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation 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:: | e82cbd1d56b595bb61991b832614f8b1 | ./data/processed/ca_cdi/summaries/21-7231.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation 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:: | e82cbd1d56b595bb61991b832614f8b1 | ./data/processed/ca_cdi/summaries/21-7231.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation 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:: | e82cbd1d56b595bb61991b832614f8b1 | ./data/processed/ca_cdi/summaries/21-7231.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
The parent of a seven-year-old male enrollee has requested reimbursement for a tonsillectomy and adenoidectomy performed on 10/27/15. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees recurrent strep throat. 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:: | aac2a2fd94faf803e6b1f03b85bc604e | ./data/processed/ca_cdi/summaries/16-4661.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 51-year-old female enrollee has requested authorization and coverage for Sovaldi and ribavirin. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 2b. The physician revi... | [
"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:: | 9390017a5ff9b21b2cb34239d9f5d667 | ./data/processed/ca_cdi/summaries/15-4175.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 43-year-old female enrollee has requested reimbursement for residential treatment center services provided from 5/27/17 through 6/26/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health 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:: | caca91ca2aef55ca5d2624373aabfd0a | ./data/processed/ca_cdi/summaries/17-6068.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 50-year-old male enrollee has requested authorization and coverage for Repatha SureClick. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypercholesterolemia. The physician reviewer found that Repatha (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:: | 074df102b68398dc22d3fc7186f4b21e | ./data/processed/ca_cdi/summaries/18-6490.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The parent of a 16-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided from 1/31/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and 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:: | 0e60005c72fc787abd6f2d6fe5b324c0 | ./data/processed/ca_cdi/summaries/17-4987.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The parent of a five-year-old male enrollee has requested reimbursement for albendazole provided on 3/01/18. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees medical condition.The physician reviewer found 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:: | ac168676c982311c420b1f15ccc02d05 | ./data/processed/ca_cdi/summaries/18-6471.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. 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:: | 10c3648498bf18c731db0d9588adb92d | ./data/processed/ca_cdi/summaries/18-6169.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. 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:: | 10c3648498bf18c731db0d9588adb92d | ./data/processed/ca_cdi/summaries/18-6169.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. 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:: | 10c3648498bf18c731db0d9588adb92d | ./data/processed/ca_cdi/summaries/18-6169.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 33-year-old female enrollee has requested reimbursement for DecisionDX melanoma gene expression profiling assay. 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 review... | [
"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:: | e4b7569565597ff6d2f6487a219348ff | ./data/processed/ca_cdi/summaries/15-4205.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The parent of a 17-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment provided from 6/28/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically n... | [
"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:: | e80391534037238c2ff1499fb532c726 | ./data/processed/ca_cdi/summaries/19-6787.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 44-year-old female enrollee has requested reimbursement for positron emission tomography (PET) scan performed on 3/04/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. 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:: | 4bd7f3bbf3d1d25c3eb654871a536f56 | ./data/processed/ca_cdi/summaries/16-4523.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue wer... | [
"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:: | b4db7c965d2cc1c20cacfb264018b3c2 | ./data/processed/ca_cdi/summaries/20-7106.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue wer... | [
"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:: | b4db7c965d2cc1c20cacfb264018b3c2 | ./data/processed/ca_cdi/summaries/20-7106.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue wer... | [
"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:: | b4db7c965d2cc1c20cacfb264018b3c2 | ./data/processed/ca_cdi/summaries/20-7106.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 19-year-old male enrollee has requested reimbursement for wilderness treatment program services provided from 10/23/18 through 1/16/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral healt... | [
"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:: | 9b8160528952c76add7b36b9b395fe3c | ./data/processed/ca_cdi/summaries/20-7094.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. 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:: | 763fd0a7286c52cf03a64d96e6cb8396 | ./data/processed/ca_cdi/summaries/18-6372.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. 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:: | 763fd0a7286c52cf03a64d96e6cb8396 | ./data/processed/ca_cdi/summaries/18-6372.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. 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:: | 763fd0a7286c52cf03a64d96e6cb8396 | ./data/processed/ca_cdi/summaries/18-6372.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 29-year-old male enrollee has requested reimbursement for custom foot orthoses/inserts (L3030-NU, LT, RT) that were ordered on 1/10/15. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees medical condition. 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:: | 3d879859ffbf4d100465ef448cb895fd | ./data/processed/ca_cdi/summaries/16-4622.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
The patient is a 40-year-old female with low back pain and right L5 and S1 radiculopathy. She is status post decompression and fusion at L5-S1 with pedicle screw fixation. The physician reviewer found that the requested laminectomy, facetectomy and foraminotomy are medically necessary for the treatme... | [
"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:: | 6598b6bbba2b1a97757a2c9c9256bfcb | ./data/processed/ca_cdi/summaries/20-6993.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 15-year-old female diagnosed with major depressive disorder, recurrent, severe, alcohol use disorder, severe, and self-harm. The patient was admitted to intensive outpatient program (IOP) treatment on 1/19/17. The clinical record documents discord between the patient and her family. ... | [
"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:: | 4d523603de307b551e643eff580547ef | ./data/processed/ca_cdi/summaries/17-6013.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. 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 found ChemoFx ... | [
"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:: | 17a045b712dd54913e0dc72843fcfb1b | ./data/processed/ca_cdi/summaries/16-4337.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. 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 found Chemosens... | [
"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:: | 17a045b712dd54913e0dc72843fcfb1b | ./data/processed/ca_cdi/summaries/16-4337.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. 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 found in vitro... | [
"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:: | 17a045b712dd54913e0dc72843fcfb1b | ./data/processed/ca_cdi/summaries/16-4337.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). 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:: | 278d7e5512c6be696e8f25014fadc6b3 | ./data/processed/ca_cdi/summaries/17-6038.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). 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:: | 278d7e5512c6be696e8f25014fadc6b3 | ./data/processed/ca_cdi/summaries/17-6038.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System. The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). 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:: | 278d7e5512c6be696e8f25014fadc6b3 | ./data/processed/ca_cdi/summaries/17-6038.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 47-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 medical condition. The physician reviewer found according to the most recen... | [
"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:: | 817098986e0e52a46fb90e592682fc46 | ./data/processed/ca_cdi/summaries/15-4290.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16. 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:: | 8b721ac40184b89fd149c77ac4cb2f02 | ./data/processed/ca_cdi/summaries/16-4556.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16. 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:: | 8b721ac40184b89fd149c77ac4cb2f02 | ./data/processed/ca_cdi/summaries/16-4556.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16. 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:: | 8b721ac40184b89fd149c77ac4cb2f02 | ./data/processed/ca_cdi/summaries/16-4556.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. 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:: | 52caac4fb1e043bea24c8a0e0ae06d37 | ./data/processed/ca_cdi/summaries/18-6251.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. 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:: | 52caac4fb1e043bea24c8a0e0ae06d37 | ./data/processed/ca_cdi/summaries/18-6251.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. 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:: | 52caac4fb1e043bea24c8a0e0ae06d37 | ./data/processed/ca_cdi/summaries/18-6251.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
An 18-year-old female enrollee has requested reimbursement for psychiatric residential treatment from 11/24/14 through 1/08/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. ... | [
"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:: | cc82617d97c7a7589c50ec757e966d8a | ./data/processed/ca_cdi/summaries/16-4425.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 47-year-old male enrollee has requested authorization and coverage for Dupixent (dupilumab). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees atopic dermatitis. The physician reviewer found that the submitt... | [
"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:: | 70c2f169c900ab98c93acf181290a78e | ./data/processed/ca_cdi/summaries/18-6493.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 55-year-old female with duplex documented right great saphenous vein reflux and a vein measuring greater than 6 mm at the saphenofemoral junction and further down the thigh. She has completed conservative measures and has had previous interventions. The patient has requested authoriza... | [
"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:: | bb62db2329bfd3823ed70b709ee7ea09 | ./data/processed/ca_cdi/summaries/18-6335.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 52-year-old female with a reported history of chronic back pain dating back to 2005.The patient has requested authorization and coverage for cervical spine MRI and thoracic spine MRI. The Health Insurer has denied this request and reported that the requested services are not medicall... | [
"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:: | ea9ece02412fd83a5873ebf1faec8276 | ./data/processed/ca_cdi/summaries/20-7079.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 40-year-old male enrollee has requested reimbursement for emergency room services provided on 1/24/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the patient is a 40-year-old male who presented to... | [
"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:: | e093cdab4ff66039fad3460c97b15075 | ./data/processed/ca_cdi/summaries/17-6062.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 53-year-old female enrollee has requested has requested authorization and coverage for Sovaldi and Daklinza. 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 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:: | ad9d5035026b4559ff74382a7e48539c | ./data/processed/ca_cdi/summaries/16-4764.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 54-year-old male enrollee has requested reimbursement for inpatient admission on 6/3/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees lower abdominal pain. The physician reviewer found that impatient 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:: | a5a99fe9f439aa2a5ad86a6eee3674ef | ./data/processed/ca_cdi/summaries/17-6075.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. the physician reviewer found THE requested medication ... | [
"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:: | 7cc04f4e93c7ff0787eda2de12fcc6cb | ./data/processed/ca_cdi/summaries/16-4387.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found the patient is a 34-year-... | [
"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:: | 7cc04f4e93c7ff0787eda2de12fcc6cb | ./data/processed/ca_cdi/summaries/16-4387.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found Bicillin is a long acting... | [
"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:: | 7cc04f4e93c7ff0787eda2de12fcc6cb | ./data/processed/ca_cdi/summaries/16-4387.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. 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:: | d90e2601114ae92a32c057ac47adebfa | ./data/processed/ca_cdi/summaries/20-7148.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. 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:: | d90e2601114ae92a32c057ac47adebfa | ./data/processed/ca_cdi/summaries/20-7148.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that Mela... | [
"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:: | d90e2601114ae92a32c057ac47adebfa | ./data/processed/ca_cdi/summaries/20-7148.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
The patient is a 40-year-old female with a history of breast cancer. On 7/01/19, she underwent a bilateral mastectomy with bilateral deep inferior epigastric perforator (DIEP) flap reconstruction. The physician reviewer found that the DIEP flap was for breast reconstruction and was medically necessar... | [
"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:: | a1b3a3b70a256299364498e2ce359e71 | ./data/processed/ca_cdi/summaries/20-7206.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician rev... | [
"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:: | 18cfe03479673956619c5dd8dd030a78 | ./data/processed/ca_cdi/summaries/19-6591.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician rev... | [
"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:: | 18cfe03479673956619c5dd8dd030a78 | ./data/processed/ca_cdi/summaries/19-6591.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician rev... | [
"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:: | 18cfe03479673956619c5dd8dd030a78 | ./data/processed/ca_cdi/summaries/19-6591.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
The patient is a 17-year-old female with migraine headaches, postural orthostatic tachycardia syndrome, and significantly elevated lactate. Her headaches have been treated with several medications, with some reduction in pain, but she continues to miss school for the associated symptoms of nausea an... | [
"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:: | 1005f55f2bbc9a984cc64793823a55c2 | ./data/processed/ca_cdi/summaries/18-6253.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
The patient is a 17-year-old female with a medical history significant for daily migraine headaches refractory to standard outpatient management, periods of nausea and dizziness, and a diagnosis of postural orthostatic tachycardia syndrome (POTS). The records documented concern for an underlying mit... | [
"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:: | 1005f55f2bbc9a984cc64793823a55c2 | ./data/processed/ca_cdi/summaries/18-6253.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
The patient is a 17-year-old female with a history of migraines and postural orthostatic tachycardia syndrome. The provider noted that the patient has a constellation of multisystem involvement consistent with a diffuse metabolic disorder with abnormal lactate and pyruvate levels. The records docume... | [
"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:: | 1005f55f2bbc9a984cc64793823a55c2 | ./data/processed/ca_cdi/summaries/18-6253.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
An 18-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 6/23/17 through 7/16/17. 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:: | c7c1dae53bbc2b0361dd1964b597e28a | ./data/processed/ca_cdi/summaries/18-6381.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 57-year-old male who presented to the emergency department of Mercy Medical Center in Redding, California with complaints of nausea, vomiting, decreased oral intake and epigastric abdominal pain radiating to the back. The patient has requested reimbursement for air ambulance transpo... | [
"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:: | 6cc24e3cbd868400bde6ff79ae48eae5 | ./data/processed/ca_cdi/summaries/21-7379.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 29-year-old female with Crohnas disease. The patient has requested authorization and coverage for Stelara (ustekinumab IV solution 130 mg/26 ml (5 mg/ml). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatmen... | [
"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:: | e4a8761229e3f3ae547b92afb59a6aa7 | ./data/processed/ca_cdi/summaries/21-7253.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. 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 Foundatio... | [
"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:: | 75ea199b042b497a4a16e2b15da5197f | ./data/processed/ca_cdi/summaries/19-6731.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. 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 understan... | [
"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:: | 75ea199b042b497a4a16e2b15da5197f | ./data/processed/ca_cdi/summaries/19-6731.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. 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 next-gene... | [
"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:: | 75ea199b042b497a4a16e2b15da5197f | ./data/processed/ca_cdi/summaries/19-6731.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 1
A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical conditio... | [
"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:: | 536245dfe30e2f0e90c2cceff00dc98e | ./data/processed/ca_cdi/summaries/19-6753.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical conditio... | [
"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:: | 536245dfe30e2f0e90c2cceff00dc98e | ./data/processed/ca_cdi/summaries/19-6753.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical conditio... | [
"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:: | 536245dfe30e2f0e90c2cceff00dc98e | ./data/processed/ca_cdi/summaries/19-6753.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 49-year-old female enrollee has requested authorization and coverage for endoluminal ablation. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees varicose veins. The physician reviewer found that the document... | [
"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:: | 12119ce1b704a742db9d8cc4a7c32239 | ./data/processed/ca_cdi/summaries/16-4772.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 33-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg tablets 60/30 days. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollee/s medical condition. 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:: | b44c63f4d14fc62d7f3dcdb010ba49c2 | ./data/processed/ca_cdi/summaries/19-6676.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 70-year-old male enrollee has requested reimbursement for an attended sleep study performed on 1/9/17. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees obstructive sleep apnea (OSA). The physici... | [
"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:: | 90fca40478d2b0b46339e7a4a2a314c1 | ./data/processed/ca_cdi/summaries/18-6285.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 19-year-old male enrollee has requested reimbursement for 84999 performed on 10/17/18. 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 physician reviewer found that this patien... | [
"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:: | e20dfe7c8b521ccb59b3cca7df38f263 | ./data/processed/ca_cdi/summaries/19-6782.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer
A 33-year-old female enrollee has requested reimbursement for the residential mental health treatment services provided from 3/2/17 through 3/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral... | [
"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:: | 37ee59a251a5c6816f64b3b634a20f59 | ./data/processed/ca_cdi/summaries/18-6184.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 64-year-old female enrollee has requested reimbursement for knee injections provided on 6/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees knee pain. The physician reviewer found that this patient pre... | [
"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:: | fe5f5574845b0d353978ab1679ed1a1b | ./data/processed/ca_cdi/summaries/19-6593.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
A 20-year-old male enrollee has requested reimbursement for residential treatment, partial hospitalization program services and intensive outpatient program services provided from 3/6/15 through 5/3/15. The Health Insurer has denied this request indicating that the services at issue were not 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:: | fb04913e15fed614472bc0b51b2979f9 | ./data/processed/ca_cdi/summaries/16-4586.jsonl | Insurer Denial Upheld | Medical Necessity |
Summary Reviewer 1
The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and post... | [
"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:: | 230f6cee75838fc02675b048a0f942fc | ./data/processed/ca_cdi/summaries/17-4905.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and postu... | [
"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:: | 230f6cee75838fc02675b048a0f942fc | ./data/processed/ca_cdi/summaries/17-4905.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and post... | [
"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:: | 230f6cee75838fc02675b048a0f942fc | ./data/processed/ca_cdi/summaries/17-4905.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer
A 91-year-old male enrollee has requested reimbursement for services provided from 3/13/18 through 3/16/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees acute on chronic diastolic heart failure. 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:: | a347a2aca8ecdc2c4f0ae64c44abe558 | ./data/processed/ca_cdi/summaries/19-6635.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The parent of a five-year-old male enrollee has requested authorization and coverage for Gammagard 20 gm infused every four weeks for one year, 40 units per dose for a total of 520 units. The Health Insurer has denied this request and reported that the requested services 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:: | 51fa0d3e613dcd742cf5427eb61a250f | ./data/processed/ca_cdi/summaries/19-6729.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer 1
A 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. 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 standard treatmen... | [
"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:: | 36e8df529fa9886b7424c990edfc1081 | ./data/processed/ca_cdi/summaries/20-6951.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 2
A 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. 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 medical evidence ... | [
"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:: | 36e8df529fa9886b7424c990edfc1081 | ./data/processed/ca_cdi/summaries/20-6951.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 3
A 32-year-old female enrollee has requested authorization and coverage for Gamunex-C. 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 there is support for ... | [
"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:: | 36e8df529fa9886b7424c990edfc1081 | ./data/processed/ca_cdi/summaries/20-6951.jsonl | Insurer Denial Overturned | Experimental |
Summary Reviewer 1
A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found 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:: | 63ee7db7e7b11bc304bc3dca9853912c | ./data/processed/ca_cdi/summaries/17-4818.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 2
A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found accor... | [
"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:: | 63ee7db7e7b11bc304bc3dca9853912c | ./data/processed/ca_cdi/summaries/17-4818.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer 3
A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found 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:: | 63ee7db7e7b11bc304bc3dca9853912c | ./data/processed/ca_cdi/summaries/17-4818.jsonl | Insurer Denial Upheld | Experimental |
Summary Reviewer
A 42-year-old male enrollee has requested authorization and coverage for the prescription medication Skyrizi 150 mg syringe. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physi... | [
"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:: | f25a63bbe8560373d59dfcc9c0f6fe7c | ./data/processed/ca_cdi/summaries/20-7072.jsonl | Insurer Denial Overturned | Medical Necessity |
Summary Reviewer
The patient is a 65-year-old male who underwent laboratory testing on 8/11/20. The patient has requested reimbursement for magnetic resonance elastography performed on 10/07/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for 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:: | 0959a485d076278e25f25083003da1f8 | ./data/processed/ca_cdi/summaries/21-7247.jsonl | Insurer Denial Overturned | Medical Necessity |
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