Persius/hicric huggingface dataset:
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating 
that the requested services are considered investigational for treatment of the insureds chronic 
low back pain. The physician reviewer found that basivertebral nerve ablation is a minimally 
invasive outpatient procedure allowing for a quick recovery. The procedure is implant-free and 
preserves  spinal  integrity  by  negating  need  for  extensive  tissue  exposure  and  disruption. 
Additionally, basivertebral nerve ablation fills a treatment gap for patients with chronic low back 
pain and preserves future treatment options. In one study, patients with chronic low back pain 
who underwent basivertebral nerve ablation reported significant improvement in pain and 
function with well documented long-term effectiveness and durability (Fischgrund, et al.). This 
patient  presents  with  more  than  six  months  of  chronic  axial  low  back  pain.  MRI  results 
demonstrated changes at disc space endplates L4-5. This patient has undergone more than six 
months of conservative treatment consisting of intradiscal steroid injection, home exercise and 
physical therapy. Gabapentin, meloxicam and methocarbamol have failed to provide sufficient 
and  durable  relief.  This  patient  does  not  warrant  more  invasive  treatment,  such  as 
decompression and fusions, as there are no reported severe symptoms of lumbar radiculopathy. 
Given these findings the requested intraosseous basivertebral nerve ablation (CPT code 64628) 
is likely to be more beneficial than any other available standard treatments for the patients 
medical condition.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 36-year-old male with a history of lumbar radiculopathy; lumbar spondylosis; disc 
degeneration  of  the  lumbar  spine;  and  lumbar  stenosis  with  neurogenic  claudication.  The 
providers examination on that date revealed negative straight leg raise bilaterally and normal 
sensation with decreased strength in bilateral hip flexion and ankle dorsiflexion. The providers 
treatment plan included an L5-S1 axial lumbar interbody fusion (ALIF) and posterior spinal fusion 
(PSF). The Health Insurer has denied the requested services as not medically necessary for the 
treatment of the patient. Therefore, the Health Insurer has denied coverage for the requested 
services. This denial is the subject of this appeal and determination. The physician reviewer found 
that medical literature establishes that a trial of conservative therapy may be considered for patients 
with low-grade spondylolisthesis presenting with radiculopathy and/or pseudo-claudication. These 
options  may  include  physical  therapy,  epidural  steroid  injection,  and  pain  medications.  If 
unresolved, surgical options may include decompression alone or decompression and fusion 
(Bydon,  et  al.).  Further  collaboration  was  provided  by  Eismont  and  colleagues  who  found 
Treatment begins with a trial of nonsurgical methods, including physical therapy, NSAIDs [non-
steroidal anti-inflammatory drugs], and epidural corticosteroid injections. Surgical treatment with 
decompression and fusion is recommended for patients who do not respond to this initial regimen. 
Further,  this  view  was  accepted  by  Chan  and  colleagues  who  indicated  that  patients  with 
symptomatic lumbar spondylolisthesis should first be treated with conservative management 
strategies  including  non-narcotic  and  narcotic  pain  medications,  epidural  steroid  injections, 
transforaminal injections, and physical therapy. In this case, a review of the record does not reveal 
a trial and failure of recent, reasonable, comprehensive, and less invasive conservative care 
measures. The patient is noted to have had a recent course of physical therapy; however, it is not 
clearly documented. Additionally, there is limited documentation supporting treatment with recent 
epidural steroid injections. Moreover, dynamic flexion and extension films were not provided in 
order to assess the amount of movement at the requested surgical level. Furthermore, detailed 
documentation  is  not  evident  regarding  potential  impending  or  inevitable  temporary  intra-
operative instability. In addition, there are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical setting. Therefore, the requested L5-S1 
ALIF and PSF are not medically necessary for the treatment of the patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 46-year-old female who presented to her provider on 8/23/21. The examination 
findings included that the patients sensation was grossly intact. The patient has requested 
reimbursement for CPT 97016-GP application of vasopneumatic device provided on 9/08/21, 
9/09/21, 9/13/21, 9/15/21, 9/20/21, 9/22/21, 9/28/21 and 9/29/21. The physician reviewer 
found that the submitted documentation fails to demonstrate the medical necessity of the device 
at issue.  In a letter dated 8/23/21, the provider cited 33 studies. All journal articles cited were 
reviewed. Additionally, an independent literature review was performed. Of the journal articles 
provided for review, none discussed the use of vasopneumatic compression for complex regional 
pain syndrome. Smart and colleagues recommended a multimodality approach to treat complex 
regional pain syndrome. However, despite the numerous treatment options they discuss, they 
do not discuss the use of vasopneumatic compression. Similarly, Harden and colleagues do not 
mention vasopneumatic compression in the treatment of complex regional pain syndrome. There 
is  a  lack  of  peer-reviewed  published  literature  that  has  a  control  group  demonstrating 
improvement in complex regional pain syndrome when compared with standard treatment 
options. Guidelines support a combination of medication, physical modalities, interventional, and 
psychological treatment to address complex regional pain syndrome. There is a paucity of 
literature  support  for  the  use  of  vasopneumatic  compression  for  complex  regional  pain 
syndrome.  Furthermore,  the  documents  provided  indicated  that  the  vasopneumatic 
compression  was  intended  to  address  edema  and  paresthesia,  but  neither  of  these  were 
identified in the records provided. Therefore, CPT 97016-GP application of vasopneumatic device 
provided on 9/08/21, 9/09/21, 9/13/21, 9/15/21, 9/20/21, 9/22/21, 9/28/21 and 9/29/21 was 
not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 30-year-old male who presented to his provider on 9/20/22. The patient has 
requested authorization and coverage for pantoprazole sodium tablet DR 20 mg twice daily. The 
physician reviewer found that the submitted documentation does not support the medical 
necessity of the requested medication regimen. There is a lack of well-designed, randomized 
controlled trials supporting the requested dosing frequency as safe and effective for treatment 
of  this  patients  condition.  In  this  case,  the  records  do  not  indicate  that  the  patient  has 
gastrointestinal bleeding of the esophagus, ulcerogenic disease, stricture, narrowing of the 
esophagus, or Barrett's esophagus that may warrant such dosing. While a Prior Authorization 
Request  Form  for  Prescription  Drugs  reported  that  the  patient  had  tried  treatment  with 
omeprazole, it does not appear that the patient has tried and failed other proton pump inhibitors 
such as lansoprazole, rabeprazole, and dexlansoprazole within the respective class and at dosing 
frequencies approved by the U.S. Food and Drug Administration (FDA). Therefore, pantoprazole 
sodium tablet DR 20 mg twice daily is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 12-year-old female who presented to her provider on 2/22/23. The patients 
parent  has  requested  authorization  and  coverage  for  Genotropin  12  milligram  (mg) 
subcutaneous (SQ) injection cartridge. The Health Insurer has denied this request and reported 
that the requested medication is not medically necessary for the treatment of this patient. The 
physician reviewer found that the submitted documentation does not support the medical 
necessity of the requested medication. The U.S. Food and Drug Administration (FDA) approves 
the use of somatotropin therapy for the treatment of ISS, defined as a height z-score of 2.25 in 
the absence of identifiable pathology. In this case, the patients original clinical presentation and 
subsequent clinical course were most consistent with ISS in the context of a family history 
positive for short stature. Just prior to initiation of daily GH therapy, the patient met generally 
accepted diagnostic criteria for ISS. However, after nearly three and a half years of daily GH 
therapy, the patients most recent PAH after cessation of daily GH therapy had improved 
minimally and still overlapped the normal range for North American women. Given that this 
patients PAH has been normal and consistent with her familial growth pattern, both before and 
after empiric GH therapy for over three years, the requested medication is not medically 
indicated. Therefore, Genotropin 12 milligram (mg) subcutaneous (SQ) injection cartridge is not 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 12-year-old male who has been diagnosed with idiopathic isolated growth 
hormone (GH) deficiency by a pediatric endocrinologist. The patients parent has requested 
authorization and coverage for Norditropin (somatropin) 10 mg in 1.5 ml. The physician reviewer 
found that this patient lacks any of several key diagnostic criteria for GH deficiency, such as height 
z-score below 2, growth velocity z-score below 2, delayed bone age, IGF-I z-score below 2, or 
IGFBP-3 z-score below 2.  His most recently documented height on the growth chart was within 
the normal range (approximately 15th percentile), and his predicted adult height is within the 
normal range for North American men (above 64).  He failed two standard GH provocative tests, 
but this criterion alone is insufficient to diagnose GH deficiency or to justify GH therapy. His 
pituitary gland may have been relatively small compared to his pubertal peers, yet there was no 
other anatomic abnormality observed by the radiologist. Standard care for the evaluation of 
pediatric short stature includes direct measurements of both parental heights using a calibrated, 
wall  mounted  stadiometer  whenever  possible.  This  patient  does  not  meet  sufficient  and 
generally accepted diagnostic criteria for GH deficiency. Therefore, Norditropin (somatropin) 10 
mg in 1.5 ml is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 26-year-old male who presented to his provider on 1/28/22 with diagnoses of 
recurrent, severe major depressive disorder, generalized anxiety disorder, and insomnia. The 
patient has requested reimbursement for adult mental health transcranial magnetic stimulation 
from 1/31/22 through 3/28/22. The Health Insurer has denied this request and reported that the 
services at issue were not medically necessary for the treatment of this patient. The physician 
reviewer found that the submitted documentation supports the medical necessity of the services 
at issue. McClintock and colleagues note that there is an abundance of data pertaining to the safety 
and efficacy of transcranial magnetic stimulation for individuals with major depressive disorder. 
In this case, the patient has treatment refractory depression, having failed more than three 
antidepressant trials in addition to psychotherapy. An evaluation by a psychiatrist resulted in a 
recommendation of transcranial magnetic stimulation. The patient was in an episode of recurrent, 
severe major depressive disorder. Given the patients lack of response to traditional medication 
and psychotherapy treatment, transcranial magnetic stimulation was the appropriate next step in 
the decision-making algorithm for treatment refractory depression. Therefore, adult mental health 
transcranial magnetic stimulation from 1/31/22 through 3/28/22 were medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 15-year-old male with a history of short stature and decreased growth velocity. 
The provider has recommended treatment with GH therapy. The Health Insurer has denied the 
requested treatment as not medically necessary for treatment of the patients medical condition. 
This denial is the subject of this appeal and determination. The physician reviewer found that 
current medical literature and guidelines from the Pediatric Endocrine Society recommend the use 
of GH to normalize adult height and avoid extreme shortness in pediatric patients with GH 
deficiency (Grimberg, et al.). In determining whether a patient has GH deficiency, a variety of 
factors should be considered, including GH stimulation testing, pituitary hormone testing, IGF-1 
testing, growth velocity, bone age, mean parental height, obesity, and height standard deviation. 
This  patients  records  document  a  history  of  short  stature  with  decreased  growth  velocity. 
However, a diagnosis of GH deficiency for this patient is not supported by the documentation 
provided  for  review.  Although  the  patient  has  a  decreased  growth  velocity  and  failed  GH 
stimulation testing, his predicted adult height is above his mean parental height and is within the 
normal range for age and gender. Additionally, the patient has a low-normal IGF-1 and a growth 
velocity of 4.5 cm per year in the last year. All told, the requested Genotropin is not medically 
necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 54-year-old female with a history of non-allergic rhinitis, previously diagnosed 
nasal  septal  deviation,  asthma  and  recurrent  acute  sinusitis.  The  patient  has  requested 
authorization and coverage for computed tomography (CT) scan of the sinuses. The physician 
reviewer found that the current medical literature supports the requested CT scan of the sinuses 
in this case. The American Academy of Allergy, Asthma and Immunology (AAAAI) Practice 
Parameters for the management of sinusitis discusses that if a patient fails antibiotics and other 
adjunctive  measures  such  as  inflammation  control  with  systemic  steroids,  nasal  sprays 
(azelastine and fluticasone) and Singulair, a sinus CT would be indicated. This patient also has 
progressive sinus disease that has affected her ability to smell and does not have positive skin 
testing to indicate that allergies would be the main driving factor for her recurrent inflammation. 
She also does have documented septal deviation which could contribute to her rhinitis and 
sinusitis. In addition, the Rhinitis 2020 AAAAI practice parameter update does consider symptoms 
including facial pain, pressure, decreased sense of smell and post-nasal drainage to be an 
indication for sinus CT. Therefore, the requested CT scan of the sinuses is medically necessary for 
the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 79-year-old female who presented to her provider on 7/11/22. The records noted a 
diagnosis of BRAF V600E mutated papillary thyroid cancer with lung metastasis. The patient has 
requested authorization and coverage for the medications Braftovi SGM and Mektovi SGM. The 
Health Insurer has  denied  this request  and reported  that the  requested medications are not 
medically necessary for the treatment of this patient. This denial is the subject of this appeal and 
determination. The physician reviewer found that the submitted documentation does not support 
the medical necessity of the requested medications. Iodine refractory metastatic papillary thyroid 
cancer is an incurable disease, but systemic therapy can help prolong survival. Anti-angiogenic 
kinase inhibitors are approved for thyroid cancer and recommended by multiple societies including 
the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology 
(ESMO), and American Thyroid association (ATA) for systemic therapy. In this case, the records 
do not appear to note that the patient was  previously treated with anti-angiogenic kinase inhibitors, 
having instead been treated with BRAF inhibitors. BRAF V600E mutations may be seen in 
papillary thyroid cancer, and current medical literature notes activity of BRAF inhibitors in thyroid 
cancer. The U.S. Food and Drug Administration (FDA)  approves the use  of  dabrafenib in 
combination with trametinib for unresectable or metastatic solid tumors with the BRAF V600E 
mutation. Another combination that may be used for the treatment of patients with BRAF V600E 
is binimetinib and encorafenib, although this combination is not FDA approved for the treatment 
of papillary thyroid cancer. In this case, as the patient is not tolerating the approved BRAF directed 
therapy but has other options for systemic therapy, specifically anti-angiogenic kinase inhibitors, 
the requested medications are not medically indicated. Therefore, the medications Braftovi SGM 
and Mektovi SGM are not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1
A 49-year-old female has requested authorization and coverage for 22857 [total disc 
arthroplasty (artificial disc), two-day inpatient stay]. 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
the disc arthroplasty procedure has been in use for over a decade. Current medical 
literature demonstrates that its outcomes are superior to fusion. In a randomized, 
controlled, multicenter trial, Gornet and colleagues concluded that the group 
receiving lumbar disc arthroplasty consistently demonstrated statistical superiority
versus fusion on key clinical outcomes including improved physical function, reduced
pain, and earlier return to work. In reviewing the five-year outcomes, the authors 
reported that lumbar disc arthroplasty is a safe and effective treatment. Therefore,
22857 [total disc arthroplasty (artificial disc), two-day inpatient stay] is likely 
to be more beneficial for treatment of the patient's condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 64-year-old male insured has requested reimbursement for laboratory testing performed on 
5/13/22. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insureds acute deep vein thrombosis (DVT). The 
physician reviewer found that current guidelines from the American College of Chest Physicians 
(ACCP) recommend treatment with extended duration anticoagulation after unprovoked venous 
thromboembolism unless the risk of bleeding is high or is contrary to the patients values and 
preferences (Palareti, et al.). In addition, a recent meta-analysis included 24 studies summarizing 
13,571 patients, of which heterozygous Factor V Leiden mutation was identified in 2,840 patients 
(Eppenberger, et al.). The authors concluded that against the background of established risk 
factors, the Factor V Leiden mutation plays only a marginal role in the risk assessment for 
recurrent venous thromboembolism and does not change anticoagulation management. As in 
this patients case, the hypercoagulable work-up for Factor V Leiden and Prothrombin G20210A 
gene mutation was not recommended in the setting of an unprovoked venous thromboembolism 
as it only confers a marginal risk compared to other known factors and does not change 
anticoagulation management. Therefore, the laboratory testing performed on 5/13/22 was not 
likely to be more beneficial for evaluation of the patients medical condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 64-year-old male insured has requested reimbursement for laboratory testing performed on 
5/13/22. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insureds acute deep vein thrombosis (DVT). The 
physician reviewer found that deep vein thrombosis and pulmonary embolism may be caused by 
hereditary  thrombophilias.  The  increased  risk  is  worth  knowing  especially  in  situations  of 
prolonged immobility such as surgery, long car trips, or long airplane flights. These complications 
may be prevented by appropriate interventions and the avoidance of certain drugs which are 
prothrombic.  There  are  several  known  genetic  factors  that  can  cause  thrombophilia.  The 
G20210A mutation increases risk of deep vein thrombosis about three-fold but nearly 20-fold in 
compound  heterozygous  patients  with  Factor  V  Leiden.  Similarly,  patients  with 
hyperhomocysteinemia and Factor V Leiden are at increased risk for deep vein thrombosis. In 
this case, the patient underwent Factor V Leiden genetic testing, which was likely to be more 
beneficial than an activated Protein C resistance assay, which is complicated and can result in 
spurious results (Kadauke, et al.; Exner, et al.). Thus, the genetic testing performed in this 
patients work-up for hypercoagulable states was appropriate. All told, the laboratory testing 
performed on 5/13/22 was likely to be more beneficial for evaluation of the patients medical 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 64-year-old male insured has requested reimbursement for laboratory testing performed on 
5/13/22. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insureds acute deep vein thrombosis (DVT). The 
physician reviewer found that currently recommended indications for thrombophilia testing 
include  idiopathic  or  recurrent  venous  thromboembolism,  a  first  episode  of  venous 
thromboembolism at before 40 years of age, a family history of venous thromboembolism, 
venous thrombosis in an unusual vascular territory, and neonatal purpura fulminans or warfarin-
induced skin necrosis (Nakashima and Rogers). As noted in the medical literature, when two or 
more  of  these  thrombosis  characteristics  are  present,  thrombophilia  testing  should  be 
considered. In this patients case, the patient meets only one of the requirements in that he has 
a possible idiopathic unprovoked deep vein thrombosis. However, in the absence of a family 
history  concerning  for  a  familial  hypercoagulable  state,  Factor  V  Leiden  mutation  and 
prothrombin G20210A gene mutations were highly unlikely to be detected. Given these findings, 
the laboratory testing performed on 5/13/22 was not likely to be more beneficial for evaluation 
of the patients medical condition than any available standard therapy.