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

Summary Reviewer  
The patient is a 68-year old male with a history of diabetes, hypertension and hyperlipidemia. 
The patient has requested reimbursement for hospital services provided from 11/13/21 
through 11/15/21. The physician reviewer found that based on the records, this patient had 
significant cardiac risk. The documentation noted recently diagnosed rapid atrial fibrillation 
with persistent symptoms despite initiation on rate control medication (metoprolol) and 
anticoagulation (Xarelto) as an outpatient. Moreover, unexplained left ventricular dysfunction 
is noted. His troponin was elevated, suggesting possible non ST segment elevation myocardial 
infarction. The patients heart rate has not adequately controlled on medical therapy and 
congestion had developed on chest x-ray despite outpatient therapy. In this clinical setting, 
inpatient admission is medically indicated to establish better rate control and to evaluate for 
acute coronary ischemia. Current guidelines support inpatient admission in this setting. 
Therefore, hospital services provided from 11/13/21 through 11/15/21 were medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
The parent of a seven-year-old female enrollee has requested authorization and coverage for 
Xeljanz 5 mg tablet. The Health Insurer has denied this request and reported that the requested 
medication is investigational for the treatment of the enrollees alopecia. The physician reviewer 
found that the U.S. Food and Drug Administration (FDA) approves the use of one Janus kinase 
(JAK) inhibitor, Olumiant (generic name baricitinib), for the treatment of adult patients with 
severe alopecia areata. Pediatric-onset alopecia areata, including alopecia universalis, tends to 
be more severe and carries a worse prognosis than adult-onset disease. While there are no FDA 
approved treatments for alopecia areata in pediatric patients, current medical literature supports 
the use of oral JAK inhibitors, such as Xeljanz, as resulting in an improvement of Severity of 
Alopecia Tool (SALT) scores. Kennedy Crispin and colleagues report that tofacitinib is a safe and 
effective treatment for severe alopecia areata. Toussi and colleagues note that alopecia areata 
has substantial psychosocial impact on patients and results in reduced health-related quality of 
life, which should be addressed as an active part of treatment. In this case, given the patients 
response to Xeljanz, including hair regrowth and improvement of psychiatric comorbidities, the 
requested medication is likely to be more beneficial than the several other treatments that she 
has already tried and failed. Therefore, Xeljanz 5 mg tablet is likely to be more beneficial for 
treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
The parent of a seven-year-old female enrollee has requested authorization and coverage for 
Xeljanz 5 mg tablet. The Health Insurer has denied this request and reported that the requested 
medication is investigational for the treatment of the enrollees alopecia. The physician reviewer 
found that there is a large body of growing evidence that JAK inhibitors, including tofacitinib, are 
efficacious and safe for the treatment of alopecia areata. The FDA recently approved the use of 
Olumiant, a JAK inhibitor, for the treatment of alopecia areata. Given this FDA approval, the use 
of JAK inhibitors for the treatment of alopecia areata is considered standard therapy. Current 
medical literature supports the improvement of alopecia treated with tofacitinib. Ibrahim and 
colleagues report that oral tofacitinib is a successful treatment for alopecia areata. Liu and 
colleagues conclude that tofacitinib should be considered for the treatment of severe alopecia 
areata, alopecia totalis, and alopecia universalis. In this case, the patient has extensive alopecia 
areata. Given that this patient has tried and failed multiple therapies including topical steroids, 
minoxidil, and topical tofacitinib, and systemic prednisone, and has responded well to tofacitinib, 
it is likely that Xeljanz will be more beneficial than any other standard treatment. Therefore, 
Xeljanz 5 mg tablet is likely to be more beneficial for treatment of the patients condition than 
any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
The parent of a seven-year-old female enrollee has requested authorization and coverage for 
Xeljanz 5 mg tablet. The Health Insurer has denied this request and reported that the requested 
medication is investigational for the treatment of the enrollees alopecia. The physician reviewer 
found that available treatment options for alopecia areata are quite limited, especially in the case 
of  diffuse/multifocal  involvement,  where  standard  therapies  such  as  topical  steroids, 
intralesional Kenalog, contact immunotherapy, and conventional immunosuppressants are often 
less than satisfactory and associated with side effects. There is substantial evidence, including 
from clinical trials, supporting the use of oral JAK kinase inhibitors such as tofacitinib for the 
treatment of alopecia areata. In an open label pilot study, Jabbari and colleagues reported that 
eight out of twelve patients treated with tofacitinib demonstrated equal to or greater than 50% 
hair regrowth as measured by SALT scores. In a retrospective study of patients with alopecia 
areata treated with tofacitinib, Liu and colleagues that 77% achieved a clinical response, with 
58% of patients achieving a greater than 50% change in SALT score. Guo and colleagues report 
that tofacitinib seems to be a promising drug for the treatment of alopecia areata with only mild 
adverse effects. In this clinical setting, an oral JAK inhibitor, such as Xeljanz, is likely to be more 
beneficial for the treatment of this patient than therapy with contact immunotherapy and 
systemic steroids, which carry considerable short and long term side effects, especially given that 
this patient has already responded well to Xeljanz. Therefore, Xeljanz 5 mg tablet is likely to be 
more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
The parent of a six-year-old male insured has requested reimbursement for Coronavirus COVID-
19 (SARS-CoV-2) respiratory panel performed on 11/8/22. The Health Plan has denied this request 
indicating that the requested services are considered investigational for evaluation of the insureds 
respiratory illness with concern for SARS-CoV-2 infection. The physician reviewer found that the 
use of respiratory panels to diagnose the cause of respiratory symptoms remains of unclear value 
when  compared  to  other  tests  including  COVID-19  polymerase  chain  reaction  (PCR).  The 
recommendations in the medical literature support testing when a patient is immunocompromised, 
at high risk of complications from the infection, and when testing could be used to direct therapy. 
This patients records fail to adequately document that the patient was immunocompromised, at 
high risk of complications from the infection, or that testing was being performed to direct therapy. 
As noted by Calderaro and colleagues, The implementation of molecular methods with syndromic 
panels has the potential to be a powerful decision-making tool for patient management despite 
requiring appropriate use of the test in different patient populations. However, there is a lack of 
data to support a clinical indication for the Coronavirus COVID-19 (SARS-CoV-2) respiratory 
panel for diagnosis of this patient in lieu of COVID-19 PCR testing. All told, the Coronavirus 
COVID-19 (SARS-CoV-2) respiratory panel performed on 11/8/22 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 Overturned

Summary Reviewer 2 
 
The parent of a six-year-old male insured has requested reimbursement for Coronavirus COVID-
19 (SARS-CoV-2) respiratory panel performed on 11/8/22. The Health Plan has denied this request 
indicating that the requested services are considered investigational for evaluation of the insureds 
respiratory illness with concern for SARS-CoV-2 infection. The physician reviewer found that 
this patient reportedly presented to his provider in November 2022 with complaints of viral 
symptoms including myalgias, congestion, and lethargy. The provider noted that the patients 
symptoms were concerning for an acute viral syndrome. Considering the time of the year and the 
patients recent exposure to ill contacts the was a reasonable concern for a viral etiology. As such, 
testing for multiple viral etiologies is the standard of care for this clinical scenario. In addition, co-
infections are common and could also be diagnosed with this method. The patient underwent 
testing with BioFire 2.1 Respiratory Panel, which is a common testing modality. Leber and 
colleagues  noted  that  the  BioFire  FilmArray  Respiratory  Panel  2  (RP2)  is  a  multiplex in 
vitro diagnostic  test  for  the  simultaneous  and  rapid  detection  of  22  pathogens  from  a 
nasopharyngeal swab sample. The authors reported that the RP2 testing system was shown to be 
reliable, with very few failures (99.3% success on the initial test attempt), and rapid, with results 
available in approximately 45 minutes, which is shorter than that of the FilmArray RP. Given this 
support, the Coronavirus COVID-19 (SARS-CoV-2) respiratory panel performed on 11/8/22 was 
likely to be more beneficial for evaluation of the patients medical condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
The parent of a six-year-old male insured has requested reimbursement for Coronavirus COVID-
19 (SARS-CoV-2) respiratory panel performed on 11/8/22. The Health Plan has denied this request 
indicating that the requested services are considered investigational for evaluation of the insureds 
respiratory illness with concern for SARS-CoV-2 infection. The physician reviewer found that on 
review of the current medical literature, the BioFire 2.1 Respiratory Panel was appropriate for use 
in this patients clinical setting. The accurate diagnosis of COVID is essential for infection control 
and prevention. When a patients household has immunosuppressed or elderly patients, an accurate 
diagnosis is needed for quarantine. Also, this information is helpful to monitor for multisystem 
inflammatory syndrome (MIS-C), which is a potential complication of COVID in pediatric patients 
that can manifest four to six weeks after the initial COVID infection (Kabeerdoss, et al.). Proper 
diagnosis  helps  create  a  timeline  for  monitoring  pediatric  patients  for  the  constellation  of 
symptoms associated with MIS-C. For these reasons, the Coronavirus COVID-19 (SARS-CoV-2) 
respiratory panel performed on 11/8/22 was likely to be more beneficial for evaluation of the 
patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 53-year-old female. In a letter dated 12/13/22, the provider reported that the patient 
was diagnosed in April 2022 with primary melanoma of the cervix with an erythroblastic oncogene 
B (ERBB)2 V777L mutation.). The patient has requested authorization and coverage for Tukysa 
(tucatinib) 150 mg #120/30 days. The Health Insurer has denied this request and reported that the 
requested medication is 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 medication. The use of 
Tukysa (generic name tucatinib) is not approved by the U.S. Food and Drug Administration (FDA) 
for the treatment of melanoma, nor is it supported by the National Comprehensive Cancer Network 
(NCCN) guidelines for the treatment of cutaneous melanoma or major drug compendia. While 
Gottesdiener and colleagues note that there is some limited data to support the use of other HER2 
treatment such as trastuzumab ematansine, given that current medical literature does not support 
the use of Tukysa for ERBB2 related melanoma, the requested medication is not medically 
indicated. Therefore, Tukysa (tucatinib) 150 mg #120/30 days is not medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 64-year-old female with a longstanding history of eczema. The patient has 
requested authorization and coverage for Dupixent. The physician reviewer found that the 
submitted documentation supports the medical necessity of the requested medication. This 
patient has chronic recalcitrant eczema which has failed topical treatment. Dupilumab has been 
approved by the U.S. Food and Drug Administration (FDA) for patients with atopic eczema that 
warrants systemic treatment. This medication has been demonstrated to be safe and effective in 
this clinical setting. Therefore, Dupixent is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 55-year-old male who presented with symptoms compatible with obstructive 
sleep apnea (OSA). The patient has requested reimbursement for an oral device/appliance 
provided on 11/12/20. The physician reviewer found that American Academy of Sleep Medicine 
(AASM) guidelines state that oral appliance therapy is an option to treat obstructive sleep apnea 
when  CPAP  therapy  is  declined  or  cannot  be  tolerated.  The  AASM  guidelines  state,  We 
recommend  that  sleep physicians  consider prescription  of oral  appliances,  rather than  no 
treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or 
prefer alternate therapy. Therefore, the oral device/appliance provided on 11/12/20 was 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 61-year-old female who presented to her provider on 8/18/22. The patient has 
requested  authorization  and  coverage  for  tonsillectomy  and  adenoidectomy    surgery  for 
removal of growth on tonsil. The physician reviewer found that submitted documentation does 
not support the medical necessity of the requested service. Patel and colleagues report that adult 
tonsillectomy may be indicated for infections, biopsies, tonsillar stones, and obstructive sleep 
apnea. Bowers and Schaitkin note that mucoceles may be managed with surgical excision, 
marsupialization,  laser  ablation,  cryotherapy,  intralesional  steroid  injection,  and  sclerosing 
agents. Given that current medical literature does not support tonsillectomy and adenoidectomy 
for  treatment  of  a  superficial  mucocele,  the  requested  service  is  not  medically  indicated. 
Therefore, tonsillectomy and adenoidectomy  surgery for removal of growth on tonsil is not 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A  46-year-old  female  enrollee  has  requested  authorization  and  coverage  for  bone  marrow 
aspiration (38220). 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 tibial fracture and nonunion is a known complication of tibial tubercle 
osteotomy surgery. Achieving healing of established long bone nonunions is difficult, and standard 
treatment includes both internal fixation and grafting.  Grafting with the patients own bone has 
long been considered the most effective way of achieving healing. Konda and colleagues noted, 
Given the high union rate, autogenous iliac crest bone grafting for tibial nonunion remains the 
gold standard for this difficult condition. However, surgically removing bone from the iliac crest 
carries its own complications, and more recently multiple peer-reviewed scientific studies have 
compared bone marrow aspirate and concentration as a way of transplanting live bone cells to 
stimulate fracture nonunion healing without surgical removal of bone. Multiple studies in various 
clinical settings, including treatment of long bone nonunions, hindfoot fusions and spinal fusions, 
have found bone marrow aspirate to be equally effective to surgical harvest of bone with the 
advantage of less patient pain and risks of complications related to harvest of bone. In this case, 
the provider has recommended bone marrow aspirate as an alternative to harvest of bone graft for 
the treatment of the patients established tibial nonunion. Bone grafting for established nonunion 
is a component of standard treatment of tibial nonunion. Thus, the bone marrow aspirate is 
medically appropriate. The proposed bone marrow aspirate is not in addition to standard treatment, 
rather it is an alternative to more traditional surgical harvest of bone with the advantage of being 
more minimally invasive and carrying less risk of complications. Iliac bone marrow aspirate is 
likely to be more beneficial than treatment of the patients tibial nonunion without autogenous 
bone grafting. Therefore, the requested bone marrow aspiration (38220) is likely to be more 
beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 21-year-old male without a significant past medical history who presented to the 
emergency department with complaints of severe abdominal pain and diarrhea. The patient has 
requested reimbursement for inpatient admission at California Hospital Medical Center Los 
Angeles from 6/26/21  through 6/28/21. The physician reviewer found that the submitted 
documentation fails to demonstrate the medical necessity of the services at issue. Inpatient care 
is necessary when the patients signs, symptoms, and general medical condition can only be 
managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an 
inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient 
setting. In this case, the patients symptoms had improved after treatment in the emergency 
department. He was hemodynamically stable at the time of admission and did not require any 
urgent procedures. The patient was admitted in stable condition and could have been treated at 
a lower level of care. Therefore, inpatient admission at California Hospital Medical Center Los 
Angeles from 6/26/21 through 6/28/21 was not medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 50-year-old female with ZZ phenotype severe alpha-1-antitrypsin deficiency. The 
patient has requested authorization and coverage for Prolastin-C 1,000 mg/20 ml (J0256). The 
physician reviewer found that the submitted documentation fails to demonstrate the medical 
necessity of the requested medication. Prolastin-C augmentation treatment is not medically 
indicated because the patient does not have any evidence of airflow obstruction on pulmonary 
function testing. The GOLD guidelines cited below indicate that patients most likely to benefit 
from Prolastin-C should have a forced expiratory volume in one second (FEV1) between 35 to 
65% of predicted. Therefore, Prolastin-C 1,000 mg/20 ml (J0256) is not medically necessary for 
the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 42-year-old female who presented to her provider on 3/9/22. The records indicated 
that the patient noted left thyroid swelling in January 2020. The patient has requested authorization 
and coverage for additional thyroid tissue removal surgery. The Health Insurer has denied this 
request and reported that the requested service is 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 supports the medical necessity of the requested service. The 
decision to pursue surgical intervention, either total thyroidectomy or lobectomy, is typically based 
on the results of a preoperative biopsy in the form of a fine-needle aspiration (FNA). In this case, 
the FNA was suggestive of a follicular neoplasm. The dilemma with this diagnosis is that cancer 
can only be definitively established on gross tissue architecture, which has historically necessitated 
excision of at least the lobe of the thyroid containing the suspicious nodule. However, recent 
advances in genetic sequencing have augmented this algorithm. If genetic evaluation of the FNA 
establishes a low ROM, many practitioners forgo removal of the thyroid in favor of observation. 
In this case, as the genetic testing was noted as suspicious, with a ROM of 50%, performing at 
least a lobectomy was appropriate. In many cases of well differentiated thyroid carcinoma, such 
as papillary and follicular, lobectomy alone is sufficient for treatment. However, certain factors 
necessitate returning to the operating room to remove the opposite thyroid lobe in a completion 
thyroidectomy. One of these factors is the size of the cancerous nodule. The American Thyroid 
Association (ATA) guidelines for the management of differentiated thyroid carcinoma notes that 
for nodules greater than four centimeters, total thyroidectomy is recommended when a FNA is 
suggestive of carcinoma, or a completion thyroidectomy when carcinoma is ultimately diagnosed 
on lobectomy, as in this case, due to a higher-than-acceptable risk of recurrence (ROR) when the 
cancerous nodule is greater than four centimeters. In a systematic review investigating risk factors 
for recurrence in follicular thyroid carcinoma, Grnland and colleagues found that the overall rate 
of  recurrence  was  13.6%,  with  64.8%  of  recurrences  representing  distant  metastasis,  and 
specifically identified a size greater than four centimeters as a statistically significant risk factor 
for recurrence. In this clinical setting, given that current medical literature supports completion 
thyroidectomy to mitigate the patients risk of recurrence of follicular thyroid carcinoma most 
effectively, the requested service is medically indicated. Therefore, additional thyroid tissue 
removal surgery is medically necessary for the treatment of this patient.