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

Summary Reviewer  
 
The patient is a 62-year-old male with a history of an elevated prostate specific antigen (PSA) of 
12.7 ng/mL and prostate cancer. The patient was recommended to undergo combined androgen 
deprivation therapy with radiation therapy directed at the prostate, pelvic lymph nodes, and 
metastatic disease within the bone. The physician reviewer found that this patient has a history 
of Gleason score 8 prostate cancer. The patients provider has recommended treatment with 
proton beam radiation therapy to treat the prostate, pelvic lymph nodes, and adjacent bony 
metastases. The patients presentation is consistent with oligometastatic disease, which is 
metastatic disease but in few a localized sites within the body. Currently, there are data in the 
medical literature supporting aggressively treating the oligometastatic sites with improved 
disease outcomes. Per the National Comprehensive Cancer Network (NCCN) guidelines, the 
utilization of proton beam as the treatment modality is not supported for the routine treatment 
of patients with prostate cancer. Proton beam has unique properties compared standard photon 
or  x-ray  beam  in  its  ability  to  deposit  radiation  dose.  However,  there  is  a  lack  of  data 
demonstrating that the use of proton beam will result in any significant improvement in clinical 
outcome (Royce and Efstathiou). Thus, proton therapy is strongly indicated in settings where 
severe toxicities would result if normal tissue constraints cannot be met by photon beam. 
Additional studies have not demonstrated clinically significant improvements in survival or 
normal tissue toxicities over photon beam when treating prostate cancer (Royce, et al.). In 
addition, proton therapy may be appropriate in cases of unusual anatomy or in cases of re-
irradiation  of  adjacent  tissues.  On  review  of  this  patients  records,  there  is  a  lack  of 
documentation of unusual anatomy or previous radiation in the target area. Given these findings, 
the requested proton beam radiation therapy is not medically necessary for treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 69-year-old male who presented to his provider on 8/5/21. The patient has 
requested reimbursement for insertion of multi-component, inflatable penile prosthesis, including 
placement of pump cylinders, and reservoir on 3/22/23. The Health Insurer has denied this request 
and reported that the service at issue was not medically necessary for the treatment of this patient 
and is not reconstructive in nature. This denial is the subject of this appeal and determination. The 
physician reviewer found that he submitted documentation supports the medical necessity of the 
service at issue. The American Urological Association (AUA) guidelines for the treatment of 
erectile dysfunction support the placement of a penile prosthesis for the treatment of organic 
erectile dysfunction. In this case, given that the patient has tried and failed first and second line 
therapies for erectile dysfunction, the service at issue was medically indicated. Therefore, insertion 
of multi-component, inflatable penile prosthesis, including placement of pump cylinders, and 
reservoir on 3/22/23 was medically necessary for the treatment of this patient. The California 
reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as 
surgery performed to correct or repair abnormal structures of the body caused by congenital 
defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the 
following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In 
this case, the condition was caused by disease, prostate cancer, and its treatment, which disrupted 
the nerves responsible for erectile function, resulting in organic erectile dysfunction. The abnormal 
nerve function was due to disease, prostate cancer, and its treatment. The service at issue was 
meant to improve function by improving organic erectile dysfunction and restored erectile function 
for the patient. Therefore, insertion of multi-component, inflatable penile prosthesis, including 
placement of pump cylinders, and reservoir on 3/22/23 was reconstructive in nature for treatment 
of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 53-year-old female with a history of abdominal pain. The patient presented on 
3/6/23 for an evaluation of her recurrent abdominal pain radiating to her back, along with nausea, 
vomiting, and weight loss. The patient underwent the recommended CT scan on 3/8/23. The Health 
Insurer has denied the services at issue as not medically necessary for the evaluation of the patients 
medical condition. This denial is the subject of this appeal and determination. The physician 
reviewer found that according to the American College of Radiology (ACR) guidelines for the 
evaluation of patients with abdominal pain, a contrast-enhanced CT scan of the abdomen and 
pelvis is appropriate. Imaging plays a key role in this setting to help direct management and 
treatment. A CT scan of the abdomen and pelvis has been proven to improve the final diagnosis 
and management of patients presenting with abdominal pain. In this case, the patient presented 
with abdominal pain, nausea, and vomiting. A prior CT scan demonstrated colitis. The ACR 
guidelines indicate that a CT scan is appropriate in this setting. Therefore, the CT scan performed 
on 3/8/23 was medically necessary for the evaluation of the patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 34-year-old male with a history of weight loss of 40 pounds, chronic diarrhea, 
and hair loss since 2017. The records indicate that the patients provider ordered a molecular-
based panel for gastrointestinal pathogens for a workup of possible underlying infectious causes 
of his constellation of symptoms. The physician reviewer found that at issue is whether CPT 
87507 - infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen 
performed on 1/2/23 was medically necessary for the evaluation of this patient. Multiple studies 
have demonstrated that molecular panel testing for gastrointestinal pathogens is associated with 
an increased detection of potential pathogens and co-infections as compared with conventional 
testing. The medical literature and several expert societies have specifically recommended 
multiplex gastrointestinal panels for patients with persistent or chronic diarrhea. Next generation 
sequencing-based  testing  of  DNA  and  RNA  has  similarly  shown  promise  in  identifying 
gastrointestinal  pathogens  undetected  by  conventional  testing.  In  this  case,  the  patient 
presented with ongoing symptoms of concern, including chronic diarrhea, weight loss, and hair 
loss, despite extensive negative testing with conventional infectious diseases diagnostics. Thus, 
the patient may have had an infectious pathogen not detected by conventional testing. Overall, 
there is sufficient support in the peer-reviewed literature and from expert societies indicating 
the efficacy of testing with a molecular-based gastrointestinal pathogen panel in this patients 
clinical setting. Therefore, CPT 87507 - infectious agent detection by nucleic acid (DNA or RNA); 
gastrointestinal pathogen performed on 1/2/23 was medically necessary for the evaluation of 
this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 58-year-old male enrollee has requested authorization and coverage for proton beam radiation 
therapy (PBT). The Health Insurer has denied this request and reported that the requested service is 
investigational for the treatment of the enrollees locally advanced esophagus cancer. The physician 
reviewer found that PBT 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 
 
A 58-year-old male enrollee has requested authorization and coverage for proton beam radiation 
therapy (PBT). The Health Insurer has denied this request and reported that the requested service is 
investigational for the treatment of the enrollees locally advanced esophagus cancer. The physician 
reviewer found that PBT is not 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 
 
A 58-year-old male enrollee has requested authorization and coverage for proton beam radiation 
therapy (PBT). The Health Insurer has denied this request and reported that the requested service is 
investigational for the treatment of the enrollees locally advanced esophagus cancer. The physician 
reviewer found that PBT is likely to be more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 31-year-old female enrollee has requested reimbursement for evaluation of arterial inflow and 
venous  outflow  of  abdomen,  retroperitoneum,  scrotal  contents  and/or  pelvic  organs  and 
detailed  fetal  ultrasound,  fetal  doppler  echocardiography  and  umbilical  artery  doppler 
velocimetry on 3/11/22 and 5/10/22. The Health Insurer has denied this request and reported 
that the services at issue were investigational for the evaluation of the enrollees high risk 
pregnancy.  The  physician  reviewer  found  that  Doppler  ultrasonography  is  a  noninvasive 
technique used to assess the hemodynamic components of vascular resistance in pregnancies 
complicated by fetal growth restriction. There is currently a lack of evidence that umbilical artery 
Doppler velocimetry provides information about fetal well-being in fetuses with normal growth. 
In this case, the records did not demonstrate that the patients pregnancy was complicated by 
fetal growth restriction. Both theoretic models and large clinical studies suggest that initiating 
antepartum fetal testing at 32 weeks of gestation or later is appropriate for most at-risk patients. 
In this case, the dates of service at issue were at 12.5 weeks and at 21.2 weeks of gestation. The 
patient had chronic hypertension that was well-controlled and gestational diabetes. For patients 
with hypertension that is well-controlled on medication, as in this case, standard therapy based 
on American College of Obstetricians and Gynecologists (ACOG) guidelines is weekly testing 
beginning at 32 weeks gestation with nonstress tests and a biophysical profile. For patients with 
gestational diabetes, a single third-trimester ultrasound examination at 36 to 39 weeks to 
estimate fetal weight, regardless of degree of metabolic control or requirement for insulin or oral 
antihyperglycemic medications, is recommended. While a Doppler ultrasound may be indicated 
in the case of intrauterine growth restriction (IUGR), the records did not document that this was 
the case in this patient. Therefore, evaluation of arterial inflow and venous outflow of abdomen, 
retroperitoneum, scrotal contents and/or pelvic organs and detailed fetal ultrasound, fetal 
doppler echocardiography and umbilical artery doppler velocimetry on 3/11/22 and 5/10/22 was 
not likely to have been more beneficial for evaluation of the patients condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
A 31-year-old female enrollee has requested reimbursement for evaluation of arterial inflow and 
venous  outflow  of  abdomen,  retroperitoneum,  scrotal  contents  and/or  pelvic  organs  and 
detailed  fetal  ultrasound,  fetal  doppler  echocardiography  and  umbilical  artery  doppler 
velocimetry on 3/11/22 and 5/10/22. The Health Insurer has denied this request and reported 
that the services at issue were investigational for the evaluation of the enrollees high risk 
pregnancy. The physician reviewer found that the ultrasound on 3/11/22 was standard care for 
the measurement of nucal translucency and has been shown to be a useful marker of risk for  aneuploidy and cardiac defects. The ultrasound on 5/10/22 was standard for the evaluation of 
fetal  anatomy.  Therefore,  evaluation  of  arterial  inflow  and  venous  outflow  of  abdomen, 
retroperitoneum, scrotal contents and/or pelvic organs and detailed fetal ultrasound on 3/11/22 
and 5/10/22 were standard therapy and likely to have been more beneficial for evaluation of the 
patients condition. In this clinical setting, the uterine and umbilical artery dopplers were not 
likely to have been more beneficial for the evaluation of this patient at the gestational ages when 
they were performed, as they were extraneous services. There is a lack of data showing that 
uterine artery Doppler measurements are clinically beneficial for improving outcomes. While 
umbilical artery Doppler measurements may be indicated in certain clinical situations, the 
records did not document any such indications in this case. Therefore, evaluation of arterial 
inflow and venous outflow of abdomen, retroperitoneum, scrotal contents and/or pelvic organs 
were likely to have been more beneficial for evaluation of the patients condition than any 
available standard therapy, but the fetal doppler echocardiography and umbilical artery doppler 
velocimetry on 3/11/22 and 5/10/22 were not likely to have been more beneficial for evaluation 
of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 49-year-old female insured has requested authorization and coverage for thermal destruction of 
intraosseous basivertebral nerve including all imaging guidance; first two vertebral bodies, lumbar 
(CPT 64628). The insureds symptoms are having a significant impact on activities of daily living 
such as household chores, leisure activities, sleeping, and work. Medications have included 
acetaminophen,  Celebrex,  meloxicam,  naproxen,  and  muscle  relaxants.  The  Health  Insurer 
indicates the requested services are considered investigational for the treatment of the insureds 
medical condition. Therefore, the Health Plan has denied coverage for the requested treatment. 
This denial is the subject of this appeal and determination. The physician reviewer found that a 
randomized controlled trial evaluating the effectiveness of intraosseous radiofrequency ablation of 
the basivertebral nerve to standard care for the treatment of chronic low back pain in a specific 
subgroup of patients suspected to have vertebrogenic-related symptomatology was conducted 
(Khalil, et al.). The authors noted that there was a clear statistical superiority for all primary and 
secondary patient-reported outcome measures in the radiofrequency ablation patients outcomes 
compared with the standard of care. Moreover, Fischgrund and colleagues concluded that patients 
with  chronic  low  back  pain  who  underwent  treatment  with  radiofrequency  ablation  of  the 
basivertebral nerve reported clinically meaningful improvements in both Oswestry Disability 
Index (ODI) and Visual Analog Scale (VAS) scores at two-year follow-up. The International 
Society for the Advancement of Spine Surgery noted that basivertebral nerve ablation can be 
beneficial for patients with chronic low back pain that has not improved despite at least six months 
of non-surgical management and with Modic changes on at least one endplate on MRI (Lorio, et 
al.). In this case, the patient has had a history of chronic low back pain that has persisted for several 
years and has been refractory to multiple modes of standard care including physical therapy, 
exercise, anti-inflammatory medications, and spine injections. Multiple randomized controlled 
trials comparing basivertebral nerve ablation to the current standard of care support the procedure 
as superior in improving pain scores and disability scores. For these reasons, the requested thermal 
destruction of intraosseous basivertebral nerve including all imaging guidance; first two vertebral 
bodies, lumbar (CPT 64628) is likely to be more beneficial for the treatment of the patients 
medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 49-year-old female insured has requested authorization and coverage for thermal destruction of 
intraosseous basivertebral nerve including all imaging guidance; first two vertebral bodies, lumbar 
(CPT 64628). The insureds symptoms are having a significant impact on activities of daily living 
such as household chores, leisure activities, sleeping, and work. Medications have included 
acetaminophen,  Celebrex,  meloxicam,  naproxen,  and  muscle  relaxants.  The  Health  Insurer 
indicates the requested services are considered investigational for the treatment of the insureds 
medical condition. Therefore, the Health Plan has denied coverage for the requested treatment. 
This denial is the subject of this appeal and determination. The physician reviewer found that 
overall, the data from the current peer-reviewed medical literature on basivertebral nerve ablation 
report long-term improvement in pain and function in well selected patients. One study from 
Fischgrund  and  colleagues  reported  that  at  two-year  follow-up,  patients  treated  with  radiofrequency ablation of the basivertebral nerve for chronic low back pain exhibited sustained 
clinical benefits. The authors concluded that basivertebral nerve ablation is supported as a 
durable, minimally invasive treatment for the relief of chronic low back pain. In addition, Khalil 
and colleagues found that minimally invasive radiofrequency ablation of the basivertebral nerve 
ablation led to significant improvement of pain and function at three months in patients with 
chronic vertebrogenic related low back pain.  As low back pain is known to arise from numerous 
etiologies, careful diagnosis and patient selection for those with vertebrogenic pain as the primary 
source of symptomatology is essential for optimal outcomes. Within the records available for 
review, there is documentation of chronic low back pain described as vertebrogenic pain. The 
treating provider has recommended thermal destruction of the intraosseous basivertebral nerve. 
The medical records indicate that the patient has tried and failed multiple conservative treatments 
including physical therapy, medial branch blocks, trigger point injections, lumbar facet injection, 
and medications such as acetaminophen, Celebrex, meloxicam, and naproxen. Based on the 
support in the medical literature, the requested thermal destruction of intraosseous basivertebral 
nerve including all imaging guidance; first two vertebral bodies, lumbar (CPT 64628) is likely to 
be more beneficial for the treatment of the patients medical condition than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
A 49-year-old female insured has requested authorization and coverage for thermal destruction of 
intraosseous basivertebral nerve including all imaging guidance; first two vertebral bodies, lumbar 
(CPT 64628). The insureds symptoms are having a significant impact on activities of daily living 
such as household chores, leisure activities, sleeping, and work. Medications have included 
acetaminophen,  Celebrex,  meloxicam,  naproxen,  and  muscle  relaxants.  The  Health  Insurer 
indicates the requested services are considered investigational for the treatment of the insureds 
medical condition. Therefore, the Health Plan has denied coverage for the requested treatment. 
This denial is the subject of this appeal and determination. The physician reviewer found that per 
the peer-reviewed medical literature, basivertebral nerve ablation is a safe and effective treatment 
modality  for  well-selected  patients  with  chronic  low  back  pain  that  has  failed  adequate 
conservative measures. One study from Khalil and colleagues study was terminated prematurely 
due to the clear superiority of Intracept, allowing cross-over of control arm patients to the Intracept 
arm. Fischgrund and colleagues found that patients treated with basivertebral nerve ablation 
experienced significant improvement in pain and function out to a mean of 6.4 years, confirming 
the long-term effectiveness and durability of basivertebral nerve ablation. This patient presents 
with a long history of chronic severe low back pain with severe limitations of activities of daily 
living. Therapeutic attempts to manage the patients symptoms have included multiple analgesic 
medications, radiofrequency ablation of medial branch nerves, physical therapy, trigger point 
injections, and acupuncture. The patients imaging studies support treatment with minimally 
invasive  basivertebral  nerve  ablation.  The  patients  records  do  not  document  any  signs  or 
symptoms of severe radiculopathy or myelopathy, and there are no imaging findings to warrant 
treatment with disc replacement or fusion. The patients presentation along with MRI findings 
meet the criteria for treatment with basivertebral nerve ablation. For these reasons, the requested 
thermal destruction of the intraosseous basivertebral nerve including all imaging guidance; first  two vertebral bodies, lumbar (CPT 64628) is likely to be more beneficial for the treatment of the 
patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 13-year-old male who presented to his provider on 3/4/22. The patients parent 
has requested authorization and coverage for Nutropin AQ Nusprin 10 injector. The physician 
reviewer found that at issue is whether Nutropin AQ Nusprin 10 injector is medically necessary 
for the treatment of this patient. The submitted documentation does not support the medical 
necessity of the requested medication. Somatotropin may be indicated for pediatric use for 
specific conditions, including pediatric growth hormone deficiency so long as epiphyses, or 
growth  plates,  remain  open.  Generally  accepted  diagnostic  criteria  define  isolated  growth 
hormone deficiency as either growth velocity with a z-score below 2.0 standard deviation score 
(SDS) or a height z-score below 2.25 SDS, along with subnormal response to two standard 
growth hormone stimulation tests. In this case, the patients clinical presentation and course are 
most consistent with normal variations of growth and development and with the familial pattern 
of growth and development. The records do not document that this patient meets the generally 
accepted indications for growth hormone therapy. The submitted records also did not discuss 
brain magnetic resonance imaging (MRI), generally performed  prior to initiation of somatotropin 
in children and adolescents to exclude intracranial lesions, or direct measurements of parental 
heights. Based on all of these factors, the medication is not indicated. Therefore, Nutropin AQ 
Nusprin 10 injector is not medically necessary for the treatment of this patient.