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

Summary Reviewer 2   
The parent of a five-year-old male enrollee has requested reimbursement for immunoglobulin G 
(IgG) food testing performed on 9/27/21. 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 that food-specific IgG level does not predict 
food hypersensitivity and may actually be a marker of earlier development of tolerance. Food-
specific IgG tests typically yield multiple positive results and may represent a normal immune 
response to food. In one study, children with atopic dermatitis and egg and/or milk allergy who 
had higher levels of IgG4 to milk and egg proteins were more likely to be tolerant to these foods 
by 4.5 years of age compared with children with lower IgG4 levels. In another study, resolution 
of cows milk allergy was associated with increasing IgG4 level. In addition, IgG4 increased in 
patients who successfully underwent oral immunotherapy for milk or peanut allergy. Therefore, 
food-specific IgG should not be used as a tool to diagnose food allergy, and the positive food 
should not be eliminated from the diet based upon results of these tests. Use of food-specific IgG 
level does not predict true food hypersensitivity. The standard evaluation of food allergy consists 
of blood immunoglobulin E (IgE) level for foods and skin testing. IgE immunoassays are in vitro 
assays  used  to  identify  food-specific  IgE  in  the  serum.  These  tests  are  widely  available. 
Immunoassays have demonstrated very high positive predictive accuracy in children for several 
of the major food allergens. Values have been established for egg, milk, peanut, tree nuts, and 
fish that correspond to a positive predictive accuracy of 95 percent.  Skin testing for food-specific 
IgE is used in the diagnosis of IgE-mediated food allergies.  A positive skin test to a particular food 
indicates the possibility that the patient has a true allergy to that food. A negative skin test result 
indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95 
percent predictive accuracy. Therefore, IgG food testing performed on 9/27/21 was not likely to 
have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
The parent of a five-year-old male enrollee has requested reimbursement for immunoglobulin G 
(IgG) food testing performed on 9/27/21. 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 that the IgG food testing is not considered to be 
a clinically useful, relevant, or valid method for evaluating for food allergy or food intolerance. 
Lavine and colleagues noted, Making the diagnosis of a specific food allergy may include the 
following: a full medical history, physical examination, skin prick testing, carefully selected food-
specific IgE levels and oral food challenges to suspected food allergens in some instances. Per 
the authors, Research from the early 1980s reported a potential mechanism for IgG4 to trigger 
basophil histamine release, suggesting a role in the allergic response. Subsequent research 
clarified that this relation was not limited to IgG4 and in fact involved IgE-receptor cross-linking 
through a receptor complex found on the basophil membrane. This supports clinical observations  that neither total IgG nor IgG4 levels correlate with food allergy as shown on double-blind 
placebo-controlled food challenges. The authors stated, Physicians should caution patients 
about the controversy surrounding testing for food sensitivity. Recent position papers from 
European and American allergy and immunology societies have emphasized the limitations and 
potential misuse of IgG4 testing, indicating that these tests are not appropriate for making a 
diagnosis of food allergy.  Updated guidelines for the diagnosis and management of food allergy 
list food-specific IgG4 measurement as an unstandardized and unproven procedure, along with 
other tests such as hair analysis, cytotoxicity assays or electrodermal (Vega) testing. Sampson 
and colleagues noted, Unproved tests, including allergen-specific IgG measurement, cytotoxicity 
assays, applied kinesiology, provocation neutralization, and hair analysis, should not be used for 
the evaluation of food allergy. In sum, there is a lack of support for the services at issue in this 
clinical setting. Therefore, IgG food testing performed on 9/27/21 was not likely to have been 
more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 44-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/28/21. The Health Insurer has denied this request and reported that the services 
at issue were investigational for the evaluation of the enrollees melanoma. The physician 
reviewer found that the use of gene expression profiling (GEP) testing according to specific 
American Joint Committee on Cancer (AJCC) melanoma stage (before or after sentinel lymph 
node biopsy) requires further prospective investigation in large, contemporary datasets of 
unselected patients. Prognostic GEP testing to differentiate melanomas at low versus high risk 
for metastasis should not replace pathologic staging procedures. Moreover, since there is a low 
probability of metastasis in stage I (T1) melanoma and a higher proportion of false-positive 
results,  GEP  testing  should  not  guide  clinical  decision-making  in  this  subgroup.  National 
Comprehensive Cancer Network guidelines do not support the use of GEP tests in this clinical 
setting. Therefore, DecisionDx-Melanoma testing performed on 7/28/21 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 44-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/28/21. The Health Insurer has denied this request and reported that the services 
at issue were investigational for the evaluation of the enrollees melanoma. The physician 
reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous 
melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for 
those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be 
amenable to excision but this suggests a high risk for the development of metastatic disease in 
the future. Such patients may be observed or treated with interferon-alpha. The data on 
DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node 
biopsy. There has also been some lack of consistency between various genes being used as 
biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the 
treatment algorithm beyond standard staging techniques. This is also the consensus opinion of 
the  National  Comprehensive  Cancer  Network  guidelines.  Therefore,  DecisionDx-Melanoma 
testing performed on 7/28/21 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 3 
  A 44-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/28/21. The Health Insurer has denied this request and reported that the services 
at issue were investigational for the evaluation of the enrollees melanoma. The physician 
reviewer found that the pathology from the left upper back shows a T1a cutaneous melanoma. 
Gene  expression  profile  (GEP) testing,  such  as  DecisionDx-Melanoma testing,  can assist  in 
differentiating a precancerous lesion from melanoma and also help risk stratify for cancer 
recurrence,  although  it  is  unclear  if  this  performs  better  than  standard  methods  such  as 
histopathologic features and sentinel lymph node biopsy. Further, National Comprehensive 
Cancer Network guidelines do not recommend routine laboratory testing or imaging for stage IA 
disease, after full wide excision of the melanoma, so surveillance would not be altered in this 
case. Therefore, DecisionDx-Melanoma testing performed on 7/28/21 was not likely to have been 
more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 53-year-old female with a history of unilateral primary osteoarthritis of the right 
hip  and  associated  severe  right  hip  pain.  The  provider  recommended  treatment  with  an 
arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), 
with or without autograft or allograft, and associated bed day. The physician reviewer found that 
at issue is whether the requested arthroplasty, acetabular and proximal femoral prosthetic 
replacement (total hip arthroplasty), with or without autograft or allograft, and associated bed 
day are medically necessary for the treatment of this patient. According to Rahm and colleagues, 
A total hip arthroplasty is indicated in end-stage hip osteoarthritis with a high degree of 
persistent suffering when conservative treatment has failed. In this case, the patient presents 
with a history of unilateral primary osteoarthritis of the right hip and associated right hip pain, 
stiffness, and tenderness. However, there is a lack of documentation of a formal diagnostic 
imaging  study to  corroborate  that the patients  hip  osteoarthritis is at relative end-stage. 
Therefore, the requested arthroplasty, acetabular and proximal femoral prosthetic replacement 
(total hip arthroplasty), with or without autograft or allograft, and associated bed day are not 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 59-year-old female who presented to her provider on 5/20/22 with newly diagnosed 
non-small cell lung cancer (NSCLC). The patient has requested reimbursement for chemotherapy 
treatment from 6/2/22 through 1/26/23. The Health Insurer has denied this request and reported 
that the services at issue were 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 supports the medical necessity of the services at issue. The treatment of advanced 
NSCLC may involve either targeted therapy or a combination of a platinum-based cytotoxic 
chemotherapy along with pembrolizumab. In a trial of patients with metastatic NSCLC, without 
targetable mutations and without prior treatment, Gadgeel and colleagues reported that first-line 
pembrolizumab  plus  pemetrexed-platinum  significantly  improved  overall  survival  and 
progression-free survival  compared  with  placebo plus  pemetrexed-platinum in  patients  with 
metastatic nonsquamous nonsmall-cell lung cancer. In this case, the combination used was 
standard therapy and completely different from the atezolizumab/bevacizumab combination tried 
initially. The National Comprehensive Cancer Network (NCCN) guidelines on the treatment of 
NSCLC strongly support the chemotherapy that was used in this clinical setting. Therefore, 
chemotherapy treatment from 6/2/22 through 1/26/23 was medically necessary for the treatment 
of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 56-year-old female. The patient has requested authorization and coverage for 
transcranial magnetic stimulation (TMS) treatment services. The Health Insurer has denied this 
request and reported that the requested services 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 supports the medical necessity of the requested services. In this 
case, the patient has tried and failed first-line medications including fluoxetine, sertraline, and 
fluvoxamine, as well as clomipramine, a second-line agent. The patient has also tried and failed 
duloxetine and escitalopram. From a therapy standpoint, the patient has failed CBT and exposure 
therapy; both in combination with medications. The patient's OCD symptoms are chronic, severe, 
and resistant to treatment. Given that current medical literature supports the use of the TMS as an 
evidence-based intervention for selected, treatment-resistant patients such as in this clinical setting, 
the requested services are medically indicated. Therefore, TMS treatment services are medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 24-year-old female enrollee has requested authorization and coverage for lower esophageal 
myotomy, transoral (peroral endoscopic myotomy) (POEM) and one inpatient day. The Health 
Plan has denied this request indicating that the requested service is investigational for the 
treatment of the enrollees medical condition. The physician reviewer found  that there is 
sufficient  support  for  the  requested  service  in  this  clinical  setting.  The  American 
Gastroenterological Association best-practice guideline states that if the expertise is available, 
POEM should be considered as treatment option comparable with laparoscopic Heller myotomy 
for any of the achalasia syndromes. The American Society for Gastrointestinal Endoscopy has 
recently published a statement based on available evidence, stating that POEM is a potential 
attractive option for the treatment of achalasia that offers a minimally invasive endoscopic 
approach to myotomy with the potential for a durable response to therapy. Clinical studies and 
trials  have  shown  comparable  efficacy  with  surgery  when  expertise  in  POEM  is  available. 
However,  despite  comparable  efficacy,  POEM  is  significantly  less  invasive  than  surgical 
intervention, resulting in less postoperative pain and a more rapid recovery. In this patient with 
symptoms including dysphagia and regurgitation, as well as failure of pneumatic dilation, the use 
of POEM is supported by current medical literature and guidelines. Therefore, lower esophageal 
myotomy, transoral POEM and one inpatient day is likely to be more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 24-year-old female enrollee has requested authorization and coverage for lower esophageal 
myotomy, transoral (peroral endoscopic myotomy) (POEM) and one inpatient day. The Health 
Plan has denied this request indicating that the requested service is investigational for the 
treatment of the enrollees medical condition. The physician reviewer found that the efficacy and 
safety of POEM has been compared with that of laparoscopic Heller myotomy (LHM). In a 
randomized trial of 221 patients with all subtypes of achalasia, POEM and LHM with Dors 
fundoplication were equally successful in controlling symptoms at two years. Compared with 
LHM, POEM was associated with a lower rate of severe adverse events (2.7 versus 7.3 %). 
Schlottmann and colleagues performed a meta-analysis of over 7,000 patients with all 3 subtypes 
of achalasia in over 70 cohort studies. The authors noted that POEM was more effective than 
LHM in relieving dysphagia. Therefore, lower esophageal myotomy, transoral POEM and one 
inpatient day is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
  A 24-year-old female enrollee has requested authorization and coverage for lower esophageal 
myotomy, transoral (peroral endoscopic myotomy) (POEM) and one inpatient day. The Health 
Plan has denied this request indicating that the requested service is investigational for the 
treatment of the enrollees medical condition. The physician reviewer found that this patient has 
a longstanding history of achalasia and has had symptoms of dysphagia, regurgitation and weight 
loss.  She has undergone various tests including, esophageal manometry, and pH testing, which 
are collectively suggestive of a diagnosis of achalasia. Her symptoms have been refractory to 
therapy with esophageal dilatation. The provider has recommended the POEM procedure.  In 
reviewing the literature, there is a lack of well-designed randomized controlled trials that have 
proven the safety and efficacy of the requested therapy. Therefore, lower esophageal myotomy, 
transoral POEM and one inpatient day is not likely to be more beneficial than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 57-year-old female who previously submitted a request for an 
independent medical review (IMR) for reimbursement for positron emission 
tomography (PET) scan with computed tomography (CT) for attenuation performed 
on 3/02/20 and 9/01/20.  The physician reviewer found that the letter 
requesting a re-review cited the policy of the NIA, which describes 
aSubsequent Treatment Strategy (Indications for an Oncological FDG PET 
SCAN).a(cid:157)  However, the complete quote from the NIA guidelines was not noted 
in the letter of appeal. Specifically, the complete quote from the NIA 
guidelines states, aRestaging or monitoring response to active treatment, 
and/or a single evaluation after completion/cessation of therapy not to be 
performed within four weeks of completion of therapy (ideally FDG PET is 
delayed two to three months after surgical therapy, two to three months after 
radiation therapy if locoregional assessment is the imaging goal), and/or 
evaluation for suspicion of recurrence due to new or changing signs/symptoms. 
(Asymptomatic surveillance is not approvable) (NCCN, 2018).a(cid:157) Thus, the NIA 
guidelines are in agreement with the NCCN guidelines that state that 
asymptomatic surveillance is not approvable. Therefore, the additional 
documentation does not change the original IMR determination. The requested 
PET scan with CT for attenuation performed on 9/01/20 was not medically 
necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 49-year-old female enrollee has requested reimbursement for polymerase 
chain reaction (PCR) testing performed on 4/29/19. The Health Insurer has 
denied this request and reported that the services at issue were 
investigational for the evaluation of the enrollees medical condition. 
The physician reviewer found that there is sufficient support for the 
services at issue in this clinical setting. Patients with vaginitis can 
be evaluated and treated with an examination, microscopy and/or cultures 
depending on the patients symptoms and findings. The exact process 
depends on the provider and the resources available at that particular 
office. This patient reported persistent odor for one month. No discharge 
was noted on examination, and nitrazine was noted to negative. 
 be 
Evaluation with PCR testing was consistent with standard of care in this 
setting. Therefore, PCR testing performed on 4/29/19 was likely to have 
been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 49-year-old female enrollee has requested reimbursement for polymerase 
chain reaction (PCR) testing performed on 4/29/19. The Health Insurer has 
denied this request and reported that the services at issue were 
investigational for the evaluation of the enrollees medical condition. 
The physician reviewer found that PCR testing has been compared to 
traditional testing for vaginitis. The literature supports the use of PCR 
testing because it results in significantly higher sensitivity and 
negative predictive value than clinical diagnosis or clinical testing. 
The test may be used to detect more than one cause for vaginitis. PCR 
testing is a means of accurate detection that allows for appropriate 
treatment. The medical evidence supports the services at issue this 
 in 
patients case. Therefore, PCR testing performed on 4/29/19 was likely to 
have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A 49-year-old female enrollee has requested reimbursement for polymerase 
chain reaction (PCR) testing performed on 4/29/19. The Health Insurer has 
denied this request and reported that the services at issue were 
investigational for the evaluation of the enrollees medical condition. 
The physician reviewer found that for a patient who presents with 
symptoms of abnormal vaginal discharge, an examination of the vaginal 
discharge including microscopic evidence of infection can lead to a 
definitive diagnosis.  In the case where microscopy is not available, 
commercial diagnostic testing methods, including PCR testing, are used 
for confirming the clinical suspicion of bacterial vaginosis, vaginal 
candidiasis, or trichomonas vaginitis.  Furthermore, PCR testing  be 
can 
utilized for detecting both gonorrhea and chlamydia. Microscopy is no 
longer widely available in clinic settings, and practices are now relying 
on this testing to diagnose and treat vaginitis. Current studies reported 
sensitivities and specificities of over 96 percent for the detection of  Neisseria gonorrhoeae and Chlamydia trachomatis. Therefore, PCR testing 
performed on 4/29/19 was likely to have been more beneficial than any 
available standard therapy.