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Persius
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imr-appeals

This data repository houses manually labeled, and pseudo-labeled background spans corresponding to real external appeal adjudications for coverage denials from U.S. health insurance cases. The data is referenced by and described in a more general work documented here: https://github.com/TPAFS/hicric.

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Downloads last month: 18

text stringlengths 60 2.6k	decision stringclasses 2 values	appeal_type stringclasses 8 values	full_text stringlengths 206 13.1k	sufficiency_id int64 0 1
The patient is a 38-year-old transgender male. In a letter dated 8/23/22, the provider reported that the patient had a diagnosis of gender dysphoria and recommended masculinizing body contouring procedures. The patient has requested authorization and coverage for 15839-22 excision, excessive skin and subcutaneous ti...	Overturned	Medical Necessity	Summary Reviewer The patient is a 38-year-old transgender male. In a letter dated 8/23/22, the provider reported that the patient had a diagnosis of gender dysphoria and recommended masculinizing body contouring procedures. The patient has requested authorization and coverage for 15839-22 excision, excessive skin ...	1
A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 4/29/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.	Upheld	Experimental	Summary Reviewer 3 A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 4/29/15. 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...	0
The parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for occupational therapy services provided on 11/19/16 through 12/21/16, and forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessa...	Overturned	Medical Necessity	Summary Reviewer The parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for occupational therapy services provided on 11/19/16 through 12/21/16, and forward. The Health Insurer has denied this request indicating that the services at issue were not and are n...	1
A 50-year-old male enrollee has requested reimbursement for Decision-Dx Melanoma testing performed on 11/14/19. 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.	Upheld	Medical Necessity	Summary Reviewer A 50-year-old male enrollee has requested reimbursement for Decision-Dx Melanoma testing performed on 11/14/19. 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 physician reviewer...	0
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.	Upheld	Medical Necessity	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...	0
patient is a 28-year-old female with a medical history including fibromyalgia, migraines and chronic fatigue. She is requesting naltrexone HCl for the treatment of fibromyalgia and migraine pain.	Upheld	Medical Necessity	Summary Reviewer The patient is a 28-year-old female with a medical history including fibromyalgia, migraines and chronic fatigue. She is requesting naltrexone HCl for the treatment of fibromyalgia and migraine pain. The physician reviewer found that Fibromyalgia is a chronic pain disorder with treatment directe...	1
A 60-year-old male enrollee has requested reimbursement for platelet-rich plasma injections performed on 3/11/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees plantar fasciitis.	Upheld	Experimental	Summary Reviewer 2 A 60-year-old male enrollee has requested reimbursement for platelet-rich plasma injections performed on 3/11/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees plantar fasciitis. The physician reviewe...	1
A 57-year-old female enrollee has requested authorization and coverage for duloxetine 60 mg, #60 per 30 days. The Health Insurer has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees fibromyalgia.	Upheld	Medical Necessity	Summary Reviewer A 57-year-old female enrollee has requested authorization and coverage for duloxetine 60 mg, #60 per 30 days. The Health Insurer has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees fibromyalgia. The physician reviewer ...	1
A 66-year-old female enrollee has requested reimbursement for laboratory testing (CPT code 84999) provided on 9/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. the records indicate that this patient...	Upheld	Experimental	Summary Reviewer 3 A 66-year-old female enrollee has requested reimbursement for laboratory testing (CPT code 84999) provided on 9/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician revie...	1
A 51-year-old female enrollee has requested reimbursement for mental health residential treatment from 5/13/15 through 6/07/15. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees alcohol use disorder. In this case, the p...	Overturned	Medical Necessity	Summary Reviewer A 51-year-old female enrollee has requested reimbursement for mental health residential treatment from 5/13/15 through 6/07/15. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees alcohol use disorder. ...	1
A 46-year-old male enrollee has requested authorization and coverage for Repatha. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia. The records note a history of hyperlipidemia, intolerance to statin medications...	Upheld	Medical Necessity	Summary Reviewer A 46-year-old male enrollee has requested authorization and coverage for Repatha. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia. The physician reviewer found that the submitted documentatio...	1
An 18-year-old male enrollee has requested reimbursement for residential treatment services from 8/04/15 through 12/10/15. The Health Insurer has denied this request indicating that the not medically necessary for treatment of the enrollees behavioral health conditions. Based upon the records, this patient was able t...	Upheld	Medical Necessity	Summary Reviewer An 18-year-old male enrollee has requested reimbursement for residential treatment services from 8/04/15 through 12/10/15. The Health Insurer has denied this request indicating that the not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found...	1
A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. This pat...	Upheld	Experimental	Summary Reviewer 1 A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical ...	1
A 63-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 2/04/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. that this patient had lymphadenopathy that was suspici...	Upheld	Experimental	Summary Reviewer 2 A 63-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 2/04/21. 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 tha...	1
The patient is a 62-year-old male who presented to his provider on 4/16/21. The records noted recurrent and progressive low back pain, bilateral hip pain and leg pain associated with spinal stenosis. The patient has requested reimbursement for epidural injections performed on 5/05/21. The Health Insurer has denied this...	Upheld	Medical Necessity	Summary Reviewer The patient is a 62-year-old male who presented to his provider on 4/16/21. The records noted recurrent and progressive low back pain, bilateral hip pain and leg pain associated with spinal stenosis. The patient has requested reimbursement for epidural injections performed on 5/05/21. The Health Insu...	1
The parent of a 17-year-old transgender female enrollee has requested reimbursement for gender reaffirming surgery performed on 7/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The records document a ...	Overturned	Medical Necessity	Summary Reviewer The parent of a 17-year-old transgender female enrollee has requested reimbursement for gender reaffirming surgery performed on 7/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The p...	1
The patient is a 52-year-old female who presented to her provider on 3/17/22. The patient reported pain in her left knee that she rated at an eight out of a scale of ten. The patient has requested reimbursement for Synvisc from 6/15/22 through 6/29/22. The Health Insurer has denied this request and reported that the...	Overturned	Medical Necessity	Summary Reviewer The patient is a 52-year-old female who presented to her provider on 3/17/22. The patient reported pain in her left knee that she rated at an eight out of a scale of ten. The patient has requested reimbursement for Synvisc from 6/15/22 through 6/29/22. The Health Insurer has denied this request an...	1
A 50-year-old male enrollee has requested authorization and coverage for Prevymis (letermovir). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is status post heart transplant. This patient underwent a recent heart transp...	Upheld	Medical Necessity	Summary Reviewer A 50-year-old male enrollee has requested authorization and coverage for Prevymis (letermovir). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is status post heart transplant. The physician reviewer fou...	1
A 52-year-old female enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition.	Upheld	Experimental	Summary Reviewer 3 A 52-year-old female enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that proton thera...	0
A 41-year-old male enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. In this case, the patient presents with GERD based on pH recording. His G...	Overturned	Experimental	Summary Reviewer 2 A 41-year-old male enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found according to Lipham and ...	1
The patient is a 42-year-old female who presented with a history of blood in her stool for at least six months. The patients medical history also includes nephrolithiasis. The colonoscopy note dated 10/13/17 reports finding of a 15 mm rectal polyp removed with snare cautery polypectomy, a 5 mm rectal polyp removed with...	Overturned	Medical Necessity	Summary Reviewer The patient is a 42-year-old female who presented with a history of blood in her stool for at least six months. The patients medical history also includes nephrolithiasis. The colonoscopy note dated 10/13/17 reports finding of a 15 mm rectal polyp removed with snare cautery polypectomy, a 5 mm rectal ...	1
The parent of a 14-year-old male enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10 mg/2mL (5 mg/mL) subcutaneous pen injector. 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. ...	Overturned	Medical Necessity	Summary Reviewer The parent of a 14-year-old male enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10 mg/2mL (5 mg/mL) subcutaneous pen injector. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees ...	1
A 52-year-old male enrollee has requested authorization and coverage for Entyvio (J3490). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.	Upheld	Medical Necessity	Summary Reviewer A 52-year-old male enrollee has requested authorization and coverage for Entyvio (J3490). 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 Entyvio (vedolizumab...	0
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.	Upheld	Medical Necessity	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...	1
A 59-year-old female enrollee has requested reimbursement for A0431 ambulance service - conventional air services - transport one way provided on 12/1/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees sore throat and fever. ...	Overturned	Medical Necessity	Summary Reviewer A 59-year-old female enrollee has requested reimbursement for A0431 ambulance service - conventional air services - transport one way provided on 12/1/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees sore...	1
The patient is a 48-year-old female who presented for a colonoscopy on 12/29/21. The patient has requested reimbursement for monitored anesthesia care provided during colonoscopy on 12/29/21.	Upheld	Medical Necessity	Summary Reviewer The patient is a 48-year-old female who presented for a colonoscopy on 12/29/21. The patient has requested reimbursement for monitored anesthesia care provided during colonoscopy on 12/29/21. The physician reviewer found that according to the American Society of Anesthesiologists gui...	1
A 21-year-old female enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization level of care provided from 9/29/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enr...	Upheld	Medical Necessity	Summary Reviewer A 21-year-old female enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization level of care provided from 9/29/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for ...	0
The patient is a 64-year-old female. Notes dated 9/12/22 reported that the patient had eosinophilic esophagitis, complicated by stricture, status post dilation, resulting in esophageal perforation requiring esophagectomy. The patient has requested authorization and coverage for a Botox (onabotulinum toxin A) injecti...	Overturned	Medical Necessity	Summary Reviewer The patient is a 64-year-old female. Notes dated 9/12/22 reported that the patient had eosinophilic esophagitis, complicated by stricture, status post dilation, resulting in esophageal perforation requiring esophagectomy. The patient has requested authorization and coverage for a Botox (onabotulin...	1
A 43-year-old male enrollee has requested authorization and coverage for thermal destruction of intraosseous basivertebral nerve first two bodies, lumbar or sacral. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees m...	Overturned	Experimental	Summary Reviewer 2 A 43-year-old male enrollee has requested authorization and coverage for thermal destruction of intraosseous basivertebral nerve first two bodies, lumbar or sacral. The Health Insurer has denied this request and reported that the requested services are investigational for the treatm...	1
The patient is a 59-year-old male who sustained left ear trauma while riding his bicycle. The patient has requested reimbursement for otoplasty performed on 10/14/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. photo...	Upheld	Medical Necessity	Summary Reviewer The patient is a 59-year-old male who sustained left ear trauma while riding his bicycle. The patient has requested reimbursement for otoplasty performed on 10/14/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of t...	1
A 43-year-old male enrollee has requested reimbursement for the left eye corneal collagen cross-linking provided on 7/21/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees progressive keratoconus.	Overturned	Experimental	Summary Reviewer 2 A 43-year-old male enrollee has requested reimbursement for the left eye corneal collagen cross-linking provided on 7/21/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees progressive keratoconus. The ph...	1
The parent of an eight-year-old male enrollee has requested authorization and coverage for Omnitrope (somatropin) 100 mg cartridge, 0.8 mg per day. 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.	Overturned	Medical Necessity	Summary Reviewer The parent of an eight-year-old male enrollee has requested authorization and coverage for Omnitrope (somatropin) 100 mg cartridge, 0.8 mg per day. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medic...	1
A 30-year-old female enrollee has requested reimbursement for air ambulance transportation provided on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has a history of spinal muscular atrophy. that this patient h...	Upheld	Medical Necessity	Summary Reviewer A 30-year-old female enrollee has requested reimbursement for air ambulance transportation provided on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has a history of spinal muscular atrophy. ...	1
A 63-year-old female enrollee has requested authorization and coverage for Forteo. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoporosis. this patient has severe osteoporosis and multiple gastrointestinal issues. dent...	Upheld	Medical Necessity	Summary Reviewer A 63-year-old female enrollee has requested authorization and coverage for Forteo. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoporosis. The physician reviewer found that this patient has severe oste...	1
A 57-year-old male enrollee has requested reimbursement for electromagnetic navigational bronchoscopy performed on 9/29/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung nodule.	Overturned	Experimental	Summary Reviewer 2 A 57-year-old male enrollee has requested reimbursement for electromagnetic navigational bronchoscopy performed on 9/29/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung nodule. The physician re...	1
A 59-year-old female insured has requested authorization and coverage for Rinvoq 45 mg tablets (30 tablets every 30 days). The Health Insurer has denied this request indicating that the requested medication is considered investigational for the treatment of the insured's Chron's disease. The records reflect that th...	Overturned	Experimental	Summary Reviewer 3 A 59-year-old female insured has requested authorization and coverage for Rinvoq 45 mg tablets (30 tablets every 30 days). The Health Insurer has denied this request indicating that the requested medication is considered investigational for the treatment of the insured's Chron's disease. The phys...	1
patient is a 52-year-old male with asthma. The patient has requested authorization and coverage for Nucala auto injector pen.	Overturned	Medical Necessity	Summary Reviewer The patient is a 52-year-old male with asthma. The patient has requested authorization and coverage for Nucala auto injector pen. The physician reviewer found that Nucala is U.S. Food and Drug Administration (FDA) approved and supported by the medical evidence for the management of severe asthma in ...	1
A 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. percutaneously in the interspinous...	Upheld	Experimental	Summary Reviewer 2 A 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician r...	1
A 50-year-old female enrollee has requested authorization and coverage for Balversa 4 mg tablets (two tablets per day). The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the insureds urothelial carcinoma. This patient has been treated ...	Overturned	Experimental	Summary Reviewer 2 A 50-year-old female enrollee has requested authorization and coverage for Balversa 4 mg tablets (two tablets per day). The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the insureds urothelial carcinoma. The physi...	1
A 52-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator provided on 1/24/19. The Health Insurer has denied this request indicating that the device at issue was investigational for the treatment of the enrollees medical condition. that this patient had a recent myocardial infar...	Overturned	Experimental	Summary Reviewer 1 A 52-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator provided on 1/24/19. The Health Insurer has denied this request indicating that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found...	1