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

Summary Reviewer 1 
 
A 52-year-old female enrollee has requested reimbursement for BCR-ABL gene rearrangement 
quantitative polymerase chain reaction (PCR) testing, BCR-ABL fluorescent in situ hybridization 
(FISH) performed on 11/21/22. The physician reviewer found that Myeloproliferative syndromes 
are clonal disorders that present as chronic myeloid leukemia (CML), chronic myelomonocytic 
leukemia (CMML), polycythemia vera, or essential thrombocythemia, or primary myelofibrosis. 
CMML has both myelodysplastic and myeloproliferative features but can also present with high 
monocyte counts (Orazi and Germing; Emanuel). CML is defined by the presence of the BCR-ABL 
rearrangement, whereas CMML has been associated with a distinct set of tyrosine kinase gene 
rearrangements and point mutations. This patients records document high monocyte counts in 
October 2022, which supports an indication for the BCR-ABL PCR and FISH testing performed in 
this patients case. All told, the BCR-ABL gene rearrangement quantitative PCR testing, BCR-ABL 
FISH performed on 11/21/22 was 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 52-year-old female enrollee has requested reimbursement for BCR-ABL gene rearrangement 
quantitative polymerase chain reaction (PCR) testing, BCR-ABL fluorescent in situ hybridization 
(FISH) performed on 11/21/22. The physician reviewer found that evaluation of a blood count 
with review of peripheral smear may warrant further testing with BCR-ABL. However, this 
patients records do not include clinical documentation to support an indication for BCR-ABL PCR 
or FISH testing. Elevated peripheral blood cell counts, such as leukocytosis, thrombocytosis, and 
polycythemia, are often the presenting symptom in a patient with a myeloproliferative neoplasm 
(MPN). Since cythemias are nonspecific and may reflect either a reactive or neoplastic process, 
diagnostic  work-up  requires  integration  of  numerous  diagnostic  modalities.  Wong  and 
Pozdnyakova noted that, Although certain mutations are preferentially enriched in specific MPN 
types, none of these mutations are disease defining; therefore, a thorough work-up should 
always include a bone marrow biopsy for morphologic evaluation and diagnosis. Moreover, 
patients with rheumatoid arthritis can present with elevated white blood counts for a variety of 
reasons and does not merit the BCR-ABL PCR and FISH testing performed in this patients 
evaluation in lieu of standard testing. Therefore, the BCR-ABL gene rearrangement quantitative 
PCR testing, BCR-ABL FISH performed on 11/21/22 was not 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 3 
A 52-year-old female enrollee has requested reimbursement for BCR-ABL gene rearrangement 
quantitative polymerase chain reaction (PCR) testing, BCR-ABL fluorescent in situ hybridization 
(FISH) performed on 11/21/22. The physician reviewer found that the records provided for 
review  document  that  this  patient  presents  with  mild  leukocytosis  and  neutrophilia.  Per  Ogunleye and colleagues a diagnosis of CML is often suspected when there is leukocytosis with 
left shift and basophilia. The authors reported that, Confirmation of the diagnosis requires a 
demonstration of BCR-ABL by PCR. However, there is no report of significant basophilia or 
eosinophilia seen on peripheral blood differential. In addition, the patients records do not report 
any symptoms suggestive of CML such as night sweats, unintentional weight loss, or early satiety. 
Thus, the concern for CML in this patients clinical setting remains low. For these reasons, the 
BCR-ABL gene rearrangement quantitative PCR testing, BCR-ABL FISH performed on 11/21/22 
was not likely to be more beneficial for treatment of the patients medical condition than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 62-year-old male. Notes dated 9/7/21 reported that the patient presented with 
scrotal swelling and pain. The patient has requested reimbursement for an inpatient day from 
9/8/21 to 9/9/21. 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 does 
not support the medical necessity of the service at issue. Generally, a patient with orchitis that does 
not have urosepsis or require surgery is treated as an outpatient or, at most, under 24-hour 
observation. In this case, however, the records note that as the patient had failed an outpatient 
course of oral antibiotics, a brief intravenous course needed to be applied prior to outpatient 
continuance of care. Given that 24-hour observation, as opposed to an actual inpatient admission, 
was appropriate the records did not document complications or that other special procedures were 
needed, the services at issue were not medically indicated. Therefore, inpatient day from 9/8/21 to 
9/9/21 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
The parent of a 13-year-old female enrollee has requested reimbursement for needle 
electromyography (EMG) of anal or urethral sphincter, any technique; needle 
electromyography, each extremity; and electroencephalogram performed on 6/10/20. The 
Health Insurer has denied this request and reported that the services at issue were 
investigational for the treatment of the enrollees medical condition. The physician reviewer 
found that the medical evidence supports the services at issue in this clinical setting. This 
patient was being treated for adolescent idiopathic scoliosis. She underwent a thoracoscopic 
anterior spinal tethering. This procedure involved a high risk of significant complications. The 
use of electromyographical monitoring has been found beneficial to help prevent further injury 
during this procedure. Therefore, needle electromyography (EMG) of anal or urethral sphincter, 
any technique; needle electromyography, each extremity; and electroencephalogram 
performed on 6/10/20 was likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
The  parent  of  a  13-year-old  female  enrollee  has  requested  reimbursement  for  needle 
electromyography (EMG) of anal or urethral sphincter, any technique; needle electromyography, 
each extremity; and electroencephalogram performed on 6/10/20. The Health Insurer has denied 
this request and reported that the services at issue were investigational for the treatment of the 
enrollees medical condition. The physician reviewer found that there is sufficient support for the 
services at issue in this clinical setting. In the article by Levin and colleagues, intraoperative neural 
monitoring for pediatric scoliosis correction is described as the standard of care. Buckwalter and 
colleagues noted that not only does intraoperative neural monitoring identify complications in a 
relatively  high  proportion  of  patients,  but  it  also  allows  for  corrective  action  to  prevent 
permanent neurologic injury. The neuromonitoring was standard of care in this patients case. 
Therefore, needle electromyography (EMG) of anal or urethral sphincter, any technique; needle 
electromyography, each extremity; and electroencephalogram performed on 6/10/20 was likely 
to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
The  parent  of  a  13-year-old  female  enrollee  has  requested  reimbursement  for  needle 
electromyography (EMG) of anal or urethral sphincter, any technique; needle electromyography,  each extremity; and electroencephalogram performed on 6/10/20. The Health Insurer has denied 
this request and reported that the services at issue were investigational for the treatment of the 
enrollees medical condition. The physician reviewer found that EMG of the anal sphincter and 
urethral sphincter are sensitive and specific methods for the diagnosis of loss of bowel and 
bladder  function  during  scoliosis  surgery,  in  addition  to  the  other  monitors  such  as 
somatosensory evoked potentials and motor evoked potentials. In combination with other 
monitors, they are a part of intraoperative neurophysiologic monitoring which is an essential part 
of scoliosis surgery and prevents iatrogenic neurological complications in real time. Therefore, 
needle  electromyography  (EMG)  of  anal  or  urethral  sphincter,  any  technique;  needle 
electromyography, each extremity; and electroencephalogram performed on 6/10/20 was likely 
to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 24-year-old male enrollee has requested reimbursement for an implantable interstitial glucose 
sensor on 1/7/22. The Health Insurer has denied this request and reported that the device at 
issue was investigational for the treatment of the enrollees type 1 diabetes. The physician 
reviewer found that the Eversense is an implantable real time continuous glucose monitoring 
(CGM) device which recently became available.  The Eversense CGM has an accuracy comparable 
to other real-time CGM devices.  Unlike other available CGM systems, the Eversense system 
requires a finger stick glucose measurement approximately every 12 hours for recalibration in 
order to accurately measure the concentration of interstitial tissue fluid glucose. Furthermore, a 
trained health care worker needs to surgically remove the Eversense sensor after 90 days in the 
United States. While the patients glycemic control has improved with the Eversense CGMS, there 
is lack of evidence in current medical literature that an implantable sensor is more beneficial than 
standard CGM systems. Therefore, an implantable interstitial glucose sensor on 1/7/22 was not 
likely to have been more beneficial for treatment of the patients condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 24-year-old male enrollee has requested reimbursement for an implantable interstitial 
glucose sensor on 1/7/22. The Health Insurer has denied this request and reported that the 
device at issue was investigational for the treatment of the enrollees type 1 diabetes. The 
physician reviewer found that blood glucose monitoring is essential to diabetes management. 
Options for blood glucose monitoring include self-monitoring of blood sugars (SMBG) with 
fingersticks and use of a glucometer or via use of a rtCGM or isCGM. As compared with SMBG, 
rtCGM and isCGM technology have been shown to improve glycemic control in patients with 
type 1 and type 2 diabetes mellitus. The American Diabetes Association Professional Practice 
Committee notes, Real-time continuous glucose monitoring or intermittently scanned 
continuous glucose monitoring should be offered for diabetes management in adults with 
diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are 
capable of using devices safely (either by themselves or with a caregiver). There are several 
available CGMS including the Eversense CGMS. Historical data from the system can be used 
nonadjunctively to replace SMBG for making diabetes treatment decisions, although it requires 
two fingersticks daily with SMBG for calibration. There is a lack of guidance advocating use of 
one type of CGM over another and mixed data on the benefits of one CGM over another. Jafri 
and colleagues evaluated 23 adults with type 1 diabetes over six weeks comparing the 
Eversense, DexCom G5, and FreeStyle Libre Pro. The authors found that the Eversense achieved 
the lowest overall mean absolute relative difference (MARD) in glucose values. However, in an 
evaluation of 11 patients with type 1 diabetes who initially were at home and on day three, 
moved to a monitored setting for four days, Boscari and colleagues reported the DexCom G5 
was more accurate in monitoring blood sugars than the Eversense. The authors noted that  during the period of intense monitoring, the DexCom G5 showed overall smaller MARD than 
the Eversense, concluding that the DexCom 5 was more accurate than the Eversense for 
glucose monitoring. While CGM devices are widely popular as a means of monitoring blood 
sugars for the management of diabetes and are beneficial in improving glycemic control, there 
is a lack of data in current medical literature evaluating all types of CGMs available and small 
trials have shown contradictory results. In this clinical setting, an implantable interstitial glucose 
sensor was not likely to have been more beneficial for treatment of the patients medical 
condition than any available standard therapy such as with rtCGM and/or isCGM. Therefore, an 
implantable interstitial glucose sensor on 1/7/22 was not likely to have been more beneficial 
for treatment of the patients condition than any available standard therapy
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 33-year-old female who presented to a hospital in Clovis, New Mexico on 7/26/22 
with complaints of severe abdominal and epigastric pain which radiated to her back. The patient 
was transferred by air ambulance on 7/27/22, as she required observation and monitoring should 
her condition worsen. The patient was transferred to the receiving facility without complications. 
The Health Insurer has denied the services at issue as not medically necessary for the treatment of 
the patients medical condition. This denial is the subject of this appeal and determination. The 
physician reviewer found that air medical transport is considered medically necessary when the 
patients condition is life-threatening such that any form of transportation other than an ambulance 
would be medically contraindicated, the time needed to transport by ground poses a threat to the 
patients survival, and the patient is transported to the nearest hospital with appropriate facilities 
for treatment. When transferring a patient from one hospital to another, the air medical transport 
criteria must be met, and the initial hospital must not have the required services and facilities 
available to treat the patient. In this case, the patient presented on 7/26/22 with severe abdominal 
pain. The patient was at risk of gallbladder rupture and required further evaluation with ERCP. 
The initial hospital did not have the required services and facilities available to treat the patient. 
The initial hospital reached out to several nearby hospitals and transported the patient to the nearest 
hospital with appropriate facilities available for treatment. Overall, the patient met the criteria for 
air ambulance transportation as her condition was unstable and as she required observation and 
monitoring should her condition worsen. Given these findings, the air ambulance transportation 
performed on 7/27/22 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 52-year-old male with a primary brain tumor. The physician reviewer found that 
the  submitted  documentation  does  not  support  the  medical  necessity  of  the  requested 
medication. In this case, the patient has an exceptionally rare glioma subtype called pleomorphic 
xanthoastrocytoma.  These  gliomas  have  a  60%  to  70%  prevalence  of  mutations  in  BRAF, 
particularly  the  V600E  mutation.  This  clinical  situation  is  also  unusual  in  that  the  tumor 
metastasized outside the cranium. The unusual nature of this clinical situation and the overall 
rarity of the tumor means that there is a lack of randomized clinical trials to refer to for supportive 
evidence when deciding on treatment strategies. However, current medical literature does 
support the safety and efficacy of combined BRAF/MEK inhibition in gliomas, especially the 
pleomorphic  xanthoastrocytoma  subtype.  Kata  and  colleagues  report  that  case  series  and 
literature review indicate that dual-drug therapy with BRAF and MEK inhibitors for recurrent and 
anaplastic  pleomorphic  xanthoastrocytoma  with  BRAF  V600E  mutation  may  delay  tumor 
progression without unexpected adverse effects. The National Comprehensive Cancer Network 
(NCCN) guidelines include BRAF/MEK inhibitors in the treatment of gliomas that are recurrent or 
progressive. In this case, the patient requires therapy for recurrent disease with a new metastatic 
site. The oncologist has prescribed dual BRAF/MEK inhibition in the form of binimetinib and 
encorafenib. However, these inhibitors have only been studied in melanoma, with limited 
experience in gliomas. The NCCN guidelines suggest combinations of dabrafenib/trametinib or 
vemurafenib/cobimetinib. In this clinical setting, given that the prescribed dual BRAF/MEK 
inhibition is not supported by the NCCN guidelines, the requested medication is not medically 
indicated. Therefore, Braftovi 75 mg and Mektovi 15 mg are not medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 57-year-old male with plaque psoriasis and psoriatic arthritis and a history of end 
stage renal failure status post kidney transplant. The patient has requested authorization and 
coverage for Otezla 30 mg tablets, taken twice daily. 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 supports the medical necessity of the requested medication. 
Takamura and colleagues report that combination therapy of apremilast and biologics could be a 
safe, effective option for the management of patients with psoriasis showing biologic fatigue. In 
this case, the patient is out of other treatment options as interleukin-23 (IL-23) inhibitors do not 
work well for arthritis, and the records note that the patient has had recurrent infections on other 
biologics. Otezla does not carry an infection risk. Given that the patient has failed all other 
conventional therapy, has numerous comorbid issues, and as the records document that he has been 
stable on the current combination of apremilast and ustekinumab, the requested medication is 
medically indicated. Therefore, Otezla 30 mg tablets, taken twice daily, are medically necessary 
for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 47-year-old male with a periodic fever syndrome clinically consistent with a 
diagnosis of tumor necrosis factor associated periodic syndrome (TRAPS). The patient has 
requested authorization and coverage for llaris (canakinumab) injection 150 mg/ml, #1/56 day. 
The physician reviewer found that the submitted documentation supports the medical necessity 
of the requested medication. TRAPS is a rare autoinflammatory disorder caused by genetic 
variations in the tumor necrosis factor receptor 1 (TNFR1) gene. Symptoms of TRAPS can include 
recurrent fever, myalgias and chest pain. A diagnosis of TRAPS is established based on history 
and physical examination after other causes of fever, such as infection, malignancy and other 
autoimmune diseases, have been excluded. There are no specific laboratory tests, outside of 
genetic testing, that can assist with establishing the diagnosis of TRAPS, and genetic testing is not 
consistently conclusive. Preventing recurrent attacks from uncontrolled TRAPS is important in 
reducing the risk of amyloidosis development, a complication of this disorder. Treatment with 
TRAPS includes NSAIDs, which only result in symptom relief in 75% of patients and do not 
effectively  control  disease  related  inflammation.  Corticosteroids  can  provide  a  short-term 
reduction in inflammation for patients with TRAPS. IL-1 inhibition with canakinumab is effective 
and is currently the only approved treatment for TRAPS. De Benedetti and colleagues conducted 
a randomized trial  to evaluate the efficacy and safety of canakinumab in patients with the 
following  periodic  fever  syndromes:  colchicine-resistant  familial  Mediterranean  fever, 
mevalonate kinase deficiency, and TRAPS. At week 16, significantly more patients with TRAPS 
receiving canakinumab had a complete treatment response compared to placebo, 45% versus 
8%. In addition, the inclusion of patients whose canakinumab dose was increased to 300 mg every 
four weeks led to a complete treatment response in 73% of study participants with TRAPS.  
Furthermore, after the 16-week period, disease control was maintained in 53% of persons with 
TRAPS using canakinumab every eight weeks. In this case, the patient did not have an adequate 
treatment response to NSAIDs or prednisone in the past. Treatment with canakinumab was noted 
to be effective therapy for this patients TRAPS per the submitted medical record. As indicated 
by the randomized trial above, canakinumab is effective and appropriate for the treatment of 
this patients disorder. Further delay of appropriate treatment with canakinumab can have 
serious health consequences for this patient, as the development of amyloidosis is a serious 
complication of this disease. Therefore, llaris (canakinumab) injection 150 mg/ml, #1/56 day is 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 23-year-old female who presented to her provider on 4/27/22. The patient has 
requested reimbursement for air ambulance transport on 5/6/22. The physician reviewer found 
that at issue is whether air ambulance transport on 5/6/22 was medically necessary for the 
treatment of this patient. The submitted documentation supports the medical necessity of the 
service  at  issue.  In  this  case,  the  patient  had  an  extremely  low  body  mass  index  with 
hyponatremia, hypotension, and renal dysfunction due to severe anorexia nervosa. In the course 
of air ambulance transfer, the patient required numerous intravenous medications including 
Ativan, Zofran, and Fentanyl due to anxiety, nausea, and abdominal pain. The patient had non-
epileptiform seizure activity just prior to the flight and enroute to the receiving hospital. She 
continued to be hypotensive throughout the flight and required continuous cardiac monitoring. 
Given the significant morbidity and mortality associated with medical ramifications of severe 
malnutrition and anorexia nervosa, and this patients clearly compromised medical state leading 
up to the transfer to specialized care and enroute, the service at issue was medically indicated to 
safely  transfer  the  patient.  Therefore,  air  ambulance  transport  on  5/6/22  was  medically 
necessary for the treatment of this patient.