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

Summary Reviewer 3 
A 46-year-old female insured has requested authorization and coverage for lymphedema surgery 
and two inpatient bed days. The Health Insurer has denied this request indicating that the requested 
services  are  considered  investigational  for  treatment  of  the  insureds  lymphedema.  
The physician reviewer found that an exhaustive review of the current medical literature pertaining 
for microsurgical treatment of lymphedema reveals that this procedure has been performed for 
many years with a high degree of success. Basta and colleagues published a meta-analysis of 27 
studies with 91% of patients showing improvement of their symptoms in their lymphovenous 
microsurgery and tissue transplantation. The patient has tried multiple nonsurgical interventions 
without substantial improvement. Given the rigorous scientific review lymphedema surgeries with 
demonstrated success, the requested lymphedema surgery is likely to provide the patient with an 
improved health outcome when compared to standard therapies. For these reasons, the requested 
lymphedema surgery and two inpatient bed days is likely to be more beneficial for treatment of 
the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 55-year-old male insured has requested authorization and coverage for thermal destruction of 
the intraosseous basivertebral nerve, including the first two vertebral bodies, lumbar or sacral, 
Intracept procedure (CPT 64628). The Health Insurer has denied this request indicating that the 
requested services are considered investigational for the treatment of the insureds chronic back 
pain.  The  physician  reviewer  found  that  the  Intracept  procedure  is  a  minimally  invasive 
outpatient procedure allowing for quick recovery and is implant-free. This patients provider has 
recommended treatment with the Intracept procedure to address a history of severe chronic low 
back pain that has persisted for over six months. In this case, the patient experienced relief from 
the majority of his pain with a hip bursa injection. Although the patients MRI does show Modic 
endplate changes, it is most likely that the patients pain generator lies away from the L5-S1 disc 
space. Overall, there is a lack of support in the peer-reviewed medical literature or guidelines to 
support the long-term safety and efficacy of the Intracept procedure in this patients clinical 
setting (Fischgrund, et al.; Truumees, et al.). All told, the requested thermal destruction of the 
intraosseous basivertebral nerve, including the first two vertebral bodies, lumbar or sacral, 
Intracept procedure (CPT 64628) is not likely to be more beneficial for the treatment of the 
patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 64-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 8/14/19. 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 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. Therefore, DecisionDx-Melanoma 
testing performed on 8/14/19 was not likely to have been more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 64-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 8/14/19. 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 the use of gene expression profiling (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 melanoma and a 
higher proportion of false-positive result, GEP testing should not guide clinical decision making 
in this group. Commercially available GEPs, such as DecisionDx-Melanoma testing, are 
marketed as being able to classify cutaneous melanoma into separate categories used on risk of 
metastasis. However, it remains unclear where these GEP platforms provide clinically 
actionable prognostic information when used in addition to or in comparison with known 
clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor 
location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel lymph 
node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-
up schedules has not been established. Various (mostly retrospective) studies of prognostic GEP 
testing suggest its role as an independent predictor of worse outcome, although not superior to 
Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is 
reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation 
studies are required to more accurately define the clinical utility of molecular testing prior to 
widespread implementation of GEP for prognostication of cutaneous melanoma, and in  particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy and 
adjuvant treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 8/14/19 
was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 64-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 8/14/19. 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 the staging and prognosis of cutaneous melanoma has classically been 
determined by applying the system spelled out by Balch. Mitotic index may add a bit to these 
statistics. DecisionDx-Melanoma testing is an assay of 31 genes in a particular melanoma. It then 
places that particular melanoma into either Class 1 or 2, with somewhat different risks of 
metastasis by five years. It is not clear how the five-year DecisionDx-Melanoma data compares 
to the ten-year Balch data. Most importantly, it has not been shown that one can use the 
DecisionDx-Melanoma data to make important clinical decisions, such as the need for sentinel 
node biopsy or the use of adjuvant therapy. Therefore, DecisionDx-Melanoma testing performed 
on 8/14/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 39-year-old female enrollee has requested authorization and coverage for cervical transection 
and avulsion of extraspinal nerve. 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  per  the  submitted  documentation,  the  provider  has 
recommended endoscopic rhizotomy to address axial neck pain. In this case, the levels being 
requested are C2-3 and C3-4. The provider noted that the patient is status post C3-5 fusion. 
Percutaneous radiofrequency ablation is considered the gold standard treatment for axial neck 
and back pain caused by facet joint pathology. However, fluoroscopically guided percutaneous 
radiofrequency ablation does not allow for direct visualization of the targeted medial branch 
nerves. It has been suggested that endoscopic visualization will provide better outcomes due to 
the ability to directly visualize the targeted nerves. It should be noted that radiofrequency 
ablation is not generally performed on previously fused levels. In this case, one of the levels being 
requested appears to have been previously fused. The study by Yeung and colleagues was a 
retrospective non-randomized study. It did not include direct comparison with radiofrequency 
ablation or intra-articular facet steroid injection. Additionally, it did not address the procedure in 
the cervical spine or address performing this procedure on previously fused levels. Meloncelli 
and  colleagues  performed  a  prospective  cohort  study.  This  study  did  not  include  direct 
comparison with radiofrequency ablation or intra-articular facet steroid injection. Additionally, it 
did not address the procedure in the cervical spine or address performing this procedure on 
previously fused levels. Xue and colleagues performed a randomized controlled trial comparing 
radiofrequency ablation with endoscopic rhizotomy. The outcomes were similar until the 6 and 
12 month follow-ups, at which point the experimental group had statistically significant reduction 
in pain. However, this study involved a small sample size and short follow-up time. The long-term 
efficacy needs further follow-up studies. Additionally, there was no identification of improved 
functional outcomes from endoscopic rhizotomy. Furthermore, the study did not address the 
procedure in the cervical spine or address performing this procedure on previously fused levels. 
At this time, the current medical evidence has not established the superior efficacy of the 
requested services in this setting. Therefore, cervical transection and avulsion of extraspinal 
nerve is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 39-year-old female enrollee has requested authorization and coverage for cervical transection 
and avulsion of extraspinal nerve. 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 this patient has a significant history of neck pain and was 
diagnosed with cervical spondylosis. She had excellent pain relief following medial branch blocks  of the C2-C3 and C3-C4 facets bilaterally. These blocks are performed to determine if the patients 
pain is facet mediated. Standard therapy for facet mediated neck pain includes radiofrequency 
neurotomy  (ablation).  Most  high  quality  studies  for  percutaneous  cervical  medial  branch 
radiofrequency neurotomy demand at least 70% relief from medial branch blocks of a given 
cervical facet before proceeding to radiofrequency neurotomy. Duration of pain relief typically 
lasts over a year. Endoscopic rhizotomy is a more recent treatment option for facet mediated 
pain. It is typically performed in the lumbar spine. A review of the current peer-reviewed 
literature did not yield studies on cervical endoscopic rhizotomy for neck pain, let alone a study 
comparing endoscopic rhizotomy versus radiofrequency neurotomy for cervical facet mediated 
pain.  Du  and  colleagues  performed  a  comparison  study  of  endoscopic  rhizotomy  versus 
radiofrequency ablation for lumbar facet mediated pain. This study was open label (low quality) 
and both methods demonstrated significant benefit of pain relief from baseline. The endoscopic 
rhizotomy  had  slightly  better  pain  relief  when  compared  to  the  standard  radiofrequency 
neurotomy group. However, the generalizability of this study to comparing endoscopic rhizotomy 
versus radiofrequency neurotomy is not valid or reliable. The article provided by the treating 
provider is another low quality study discussing the endoscopic rhizotomy procedure for lumbar 
facet mediated pain. Given the lack of supportive peer-reviewed literature, cervical transection 
and avulsion of extraspinal nerve is not likely to be more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 39-year-old female enrollee has requested authorization and coverage for cervical transection 
and avulsion of extraspinal nerve. 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 submitted records fail to demonstrate the superior efficacy 
of the requested services in this patients case. The records do not document behavior therapy 
despite significant research to support its use. Moreover, the research that is being listed by the 
requesting provider to support the procedure for the neck pain is a pilot study for the lumbar 
spine doing an endoscopic rhizotomy not a cervical transection and avulsion of extraspinal nerve. 
A review of the difference between studies is warranted. Leon and colleagues noted, The choice 
of the intervention for a pilot study should be based on theory, mechanism of action, a case 
series, or animal studies that justify a rationale for therapeutic effect...Despite the convention, 
pilot studies do not provide useful information regarding the population effect size because the 
estimates are quite crude owing to the small sample sizes. Basing a decision to proceed or 
terminate evaluation of a particular intervention on pilot data is perilous because there is a very 
good chance that the decision will be derived from false positive or false negative results. Per 
the authors, A pilot study is not a hypothesis testing study and therefore safety and efficacy are 
not  evaluated...In  summary,  pilot  studies  are  a  necessary  first  step  in  exploring  novel 
interventions and novel applications of interventions. Nothing submitted shows that cervical  transection and avulsion of extraspinal nerve has undergone the rigors of scientific research to 
move it from investigational research to standard of care. Nevertheless, all other treatments for 
neck pain have not been exhausted. Therefore, cervical transection and avulsion of extraspinal 
nerve is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 59-year-old male who presented with hematochezia in August 2021. The patient 
has requested authorization and coverage for PET imaging with concurrent CT skull base to mid-
thigh. The physician reviewer found that there is sufficient support for the requested services in 
this clinical setting. According to the National Comprehensive Cancer Network (NCCN) guidelines, 
PET/CT has a limited sensitivity but high specificity, and may be considered when there is an 
equivocal finding. When hepatocellular carcinoma is detected by CT or magnetic resonance 
imaging (MRI) and has increased metabolic activity on PET/CT, higher intralesional standardized 
uptake value (SUV) is a marker of biologic aggressiveness and might predict less optimal response 
to  locoregional  therapies.  Sensitivity  is  a  metric  for  the  screening  of  cancer,  but  for 
discriminating responses, the specificity may be most relevant.  The original disease showed 
significant FDG uptake. There were multiple sites of disease making the interpretation of follow-
up imaging very complex. The use PET/CT is medically necessary for further care. Therefore, the 
requested PET imaging with concurrent CT skull base to mid-thigh is medically necessary for the 
evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 51-year-old female with a history of osteoporosis. The patient has requested 
authorization and coverage for Evenity (romosozumab-aqqg) injection 105 mg/1.17 mL. 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  supports  the  medical  necessity  of  a  portion  of  the  requested 
medication. Khosla and Hofbauer explain, Osteoporosis is an enormous and growing public 
health problem. Once considered an inevitable consequence of ageing, it is now eminently 
preventable and treatable.  Cremers and colleagues report that bisphosphonates have been the 
standard therapy for osteoporosis. Regarding recent progresses in the treatment of osteoporosis, 
Li and colleagues note that in patients with high or very high risk for fracture, sequential or 
combined therapies may be considered with the initial drugs being anabolic agents such as 
teriparatide and romosozumab. The U.S. Food and Drug Administration (FDA) approves the use 
of Evenity (generic name romosozumab) for the treatment of osteoporosis. Evenity is a strong 
anabolic medication, in contrast to the bisphosphonates, which have anti-resorptive effects. In a 
study of postmenopausal women with osteoporosis who were at high risk for fracture, Saag and 
colleagues report that treatment with Evenity for 12 months followed by alendronate resulted in 
a significantly lower risk of fracture than alendronate alone. McClung notes that  beginning 
treatment with an anabolic agent, such as Evenity, in patients at very high or imminent risk of 
fracture an effective and appropriate treatment plan. Therefore, Evenity (romosozumab-aqqg) 
injection 105 mg/1.17 mL for 12 months is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is  a  27-year-old male who was  admitted  for  hospitalization  on  8/13/21  after 
presenting  with  progressively  worsening  abdominal  pain  with  vomiting.  The  patient  has 
requested reimbursement for inpatient admission (hospital treatment services) from 8/13/21 
through 8/15/21. The physician reviewer found that at issue is whether inpatient admission 
(hospital treatment services) from 8/13/21 through 8/15/21 was medically necessary for the 
treatment of this patient. The submitted documentation does not support the medical necessity 
of the services at issue. Inpatient care may be necessary when a patients signs, symptoms, and 
general medical condition can only be managed safely in an acute inpatient setting, when a 
patient requires diagnostic studies in an inpatient setting, or when it is necessary for the patient 
to remain in an acute inpatient setting. In this case, the patient was hemodynamically stable and 
afebrile at admission. After treatment in the emergency department, the patients symptoms of 
pain and vomiting improved. The records did not indicate that the patient required any urgent 
procedures or surgical intervention. He did not have any significant electrolyte disturbances. He 
was treated with a nasogastric tube for a short time but able to tolerate oral nutrition shortly 
after  admission.  His  symptoms  improved  quickly  with  treatment  and  he  did  not  have 
complications. Given that this patient was in stable condition at admission and could have been 
treated at a lower level of care, the services at issue were not medically indicated. Therefore, 
inpatient  admission  (hospital  treatment  services)  from  8/13/21  through  8/15/21  was  not 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 57-year-old female insured has requested reimbursement for a blood test performed on 
3/7/23. The Health Insurer has denied this request indicating that the service at issue was 
considered investigational for the evaluation of the insureds rheumatoid arthritis. The physician 
reviewer found that this patient presented with a history of rheumatoid arthritis, for which she 
underwent evaluation with a Vectra DA blood test. Scoring tools such as the Disease Activity 
Score 28 CRP (DAS 28-CRP), the Clinical Disease Activity Index (CDAI), and the Simplified Disease 
Activity Index (SDAI) are supported by the medical literature and routinely utilized for the 
assessment of rheumatoid arthritis disease activity in both clinical trials and in real clinical 
practice settings. There is a lack of medical literature or evidence suggesting that the Vectra DA 
test is more effective in establishing the level of rheumatoid arthritis disease activity experienced 
by a patient than the standard therapies noted above. For these reasons, the blood test 
performed on 3/7/23 was not likely to have been more beneficial for the evaluation of the 
patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
A 57-year-old female insured has requested reimbursement for a blood test performed on 
3/7/23. The Health Insurer has denied this request indicating that the service at issue was 
considered investigational for the evaluation of the insureds rheumatoid arthritis. The physician 
reviewer found that there are a lack of established medical trials comparing the use and efficacy 
of the Vectra DA blood test with standard clinical disease activity assessments, including the DAS 
28-CRP, for patients with rheumatoid arthritis. Further study is required to validate the efficacy 
of multi-biomarker blood tests. The National Institute for Health and Care Excellence (NICE) 
recommends monthly monitoring of C-reactive protein and disease activity until remission or low 
disease activity, measured by DAS 28 scoring. NICE does not mention biomarker tests in its 
recommendations. Overall, there is insufficient evidence to support the use of multi-biomarker 
blood tests such as the Vectra DA blood test for the evaluation of this patients rheumatoid 
arthritis. Given these findings, the blood test performed on 3/7/23 was not likely to have been 
more beneficial for the evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
A 57-year-old female insured has requested reimbursement for a blood test performed on 
3/7/23. The Health Insurer has denied this request indicating that the service at issue was 
considered investigational for the evaluation of the insureds rheumatoid arthritis. The physician 
reviewer found that the American College of Rheumatology (ACR) does not recommend the use 
of Vectra DA testing for the diagnosis of rheumatoid arthritis or to measure disease activity, as 
there is a lack of definitive evidence finding a beneficial effect on health outcomes (England, et  al.). Johnson and colleagues report that Vectra DA testing demonstrates weak correlations with 
established scoring options including the SDAI and CDAI. According to the authors, further 
assessment of the performance characteristics of Vectra DA testing is warranted. All told, the 
blood test performed on 3/7/23 was not likely to have been more beneficial for the evaluation 
of the patients condition than any available standard therapy.