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

Summary Reviewer 2 
A 27-year-old female insured has requested reimbursement for the respiratory virus panel 
testing (CPT 87633, 87798, 87798-59) provided on 7/21/22. The Health Insurer has denied this 
request indicating that the services at issue were considered investigational for evaluation of the 
insureds  respiratory  illness  and  shortness  of  breath.  The  physician  reviewer  found  that 
respiratory panel molecular testing is considered the standard of care for the diagnosis of 
respiratory viral infections in an acute care setting (Wu and Tang). Compared to other methods 
of  analysis,  the  respiratory  panel  molecular  testing  modality  has  a  better  sensitivity  and 
specificity. Conventional methods of analysis required a significant time period to process. 
However, respiratory panel molecular testing enables the identification of pathogens in hours as 
opposed to days for traditional cultures (Markussen, et al.). Thus, the respiratory panel molecular 
testing performed to diagnose the patients condition was appropriate. All told, the respiratory 
virus panel testing (CPT 87633, 87798, 87798-59) provided on 07/21/22 was likely to have been 
more beneficial than any other available standard treatment for the evaluation of the patients 
condition.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3  A 27-year-old female insured has requested reimbursement for the respiratory virus panel 
testing (CPT 87633, 87798, 87798-59) provided on 7/21/22. The Health Insurer has denied this 
request indicating that the services at issue were considered investigational for evaluation of the 
insureds respiratory illness and shortness of breath. The physician reviewer found that viral 
pathogens  are  often  the  most  common  cause  of  respiratory  infections  which  include 
rhinoviruses, respiratory syncytial virus, influenza virus, parainfluenza virus, adenovirus and 
coronaviruses. A review of the standard of care indicates that treatment is generally supportive 
and symptomatic. Further, antibiotics are rarely utilized, and antiviral treatment is recommended 
only for patients with symptoms who are at high risk for complications. A review of medical 
literature indicates that identifying the specific viral cause of an upper respiratory infection is not 
likely to change the approach to treatment. Several standard methods available for diagnosis 
include molecular methods, rapid tests, and microbiologic culturing. Influenza-specific assays 
may be indicated for patients presenting with fever and flu-like syndrome. Otherwise, viral 
polymerase chain reaction testing is generally not indicated. In this case, the patient presented 
with complaints of cough, shortness of breath and malaise. A review of the record establishes 
that the patient had typical symptoms of an upper respiratory tract infection. The patients vital 
signs were stable and the initial treatment included a nebulized breathing treatment that was 
effective to alleviate symptoms. The patient was also provided a diagnostic work-up which 
indicated a normal white blood cell (WBC) count and a normal chest x-ray. Overall, the respiratory 
viral panel testing was not expected to change the patients plan of care more than standard 
testing. Therefore, the respiratory virus panel testing (CPT 87633, 87798, 87798-59) provided on 
07/21/22  was  not  likely  to  have  been  more  beneficial  than  any  other  available  standard 
treatment for the evaluation of the patients condition.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 50-year-old female enrollee has requested authorization and coverage for Balversa 4 mg 
tablets (two tablets per day). The Health Insurer has denied this request indicating that the 
requested medication is considered investigational for treatment of the insureds urothelial 
carcinoma. The physician reviewer found that as noted in the medical records, this patient 
presents with metastatic lung cancer with metastases to brain, liver, and bone. The patient has 
been treated with Tagrisso plus Balversa therapy with improvement of her condition. The 
provider has recommended continuation of this therapeutic regimen. As noted in the medical 
literature, patients with EGFR mutations with initial responses to osimertinib have been able to 
overcome resistance with the addition of Balversa both in vitro and in small case reports. This 
patient  is  not  listed  as  having  positive  PDL1  or  other  markers  to  indicate  benefit  from 
immunotherapy. The patient was noted to have pneumonitis increasing the risk of recurrence 
with immunotherapy. There are limited options for treatment after recurrence on osimertinib. 
Given this support, the requested Balversa 4 mg tablets (two tablets per day) is likely to be more 
beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 50-year-old female enrollee has requested authorization and coverage for Balversa 4 mg 
tablets (two tablets per day). The Health Insurer has denied this request indicating that the 
requested medication is considered investigational for treatment of the insureds urothelial 
carcinoma. The physician reviewer found that the use of next-generation sequencing (NGS) panel 
testing as a means to select anticancer therapies in the treatment of patients with advanced 
cancer has been advancing over the past few years. Once identified, a specific therapy can be 
given to the patient directly treating their tumor. In this patient, NGS based molecular testing 
demonstrated  EGFR  exon  19  mutation  and  FGFR2  amplification.  The  U.S.  Food  and  Drug 
Administration (FDA) approved Balversa for use in the setting of FGFR2/3 alteration metastatic 
bladder/urothelial cancer. This patient has been treated with multiple lines of therapies including 
EGFR targeted agents and chemotherapy. She has also been treated with liver directed therapies. 
The patient was recently started on combination therapy with Tagrisso and Balversa. The 
provider noted that the patient has responded well to this combination treatment reflected with 
a decreasing tumor marker (CEA). A phase II clinical study also demonstrated the benefits of 
Balversa in the treatment of patients with metastatic solid tumors with EGFR 2/3 alterations 
(Loriot, et al.). As such, the requested Balversa 4 mg tablets (two tablets per day) is not likely to 
be more beneficial for treatment of the patients medical condition than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A 50-year-old female enrollee has requested authorization and coverage for Balversa 4 mg 
tablets (two tablets per day). The Health Insurer has denied this request indicating that the 
requested medication is considered investigational for treatment of the insureds urothelial 
carcinoma. The physician reviewer found that molecular testing in patients with metastatic non-
small cell lung cancer has helped develop significant advances in therapy options for patients 
with improved patient health outcomes. Medical therapies such as Tagrisso are FDA approved 
for the treatment of patients with EGFR mutations. At this time, no FGFR inhibitor, such as 
Balversa, is approved for non-small cell lung cancer, but trials are ongoing. In addition, there is a 
lack of support from societal guidelines to include FGFR directed therapy in the management of 
non-small cell lung cancer. The patients recent improvement in CEA may be the result of Y90 
therapy, which was completed in 2022. The patients recent CT scan showed mixed response with 
some new growth in the lungs. Therefore, the requested Balversa 4 mg tablets (two tablets per 
day) is 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 1 
 
A 54-year-old female enrollee has requested reimbursement for advanced lipoprotein testing 
performed on 4/15/22. 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 in this case, the American College of Cardiology calculated ten-year coronary 
artery disease risk score is in the low-risk range for this patient. Patients with high-sensitivity C-
reactive protein (hs-CRP) levels less than two do not have an increased risk of disease associated 
with elevated lipoprotein(a). There is a lack of data in current medical literature demonstrating 
that  the  lowering  of  lipoprotein(a)  in  patients  other  than  in  those  at  high  traditional 
cardiovascular risk is beneficial. While lipoprotein(a) testing may be reasonable in adults to aid 
in the clinician-patient discussion about whether to prescribe a statin in those aged 40 to 75 with 
borderline ten-year atherosclerotic cardiovascular disease risk, to identify a possible cause for a 
less-than-anticipated low-density lipoprotein cholesterol lowering, to use in cascade screening 
of family members with severe hypercholesterolemia, and to identify those at risk for progressive 
atherosclerotic cardiovascular disease, the submitted records did not demonstrate that this 
patient met any of these risk factors. The patient does not have a documented family history of 
premature coronary artery disease and has normal lipoprotein levels. Therefore, advanced 
lipoprotein testing performed on 4/15/22 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 54-year-old female enrollee has requested reimbursement for advanced lipoprotein testing 
performed on 4/15/22. 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 in this case, the patient has increased coronary risk.  The American College 
of Cardiology (ACC) and American Heart Association (AHA) guidelines for the management of 
cardiac risk and dyslipidemia do not recommend routine performance of specialized tests in the 
context of assessing coronary risk including coronary calcium quantification, coronary computed 
tomography (CT) scanning, advanced lipoprotein analysis, genetic testing, and homocysteine. 
Treatment changes or additions based on the results of screening with these specialized tests 
have not been shown to improve cardiac outcomes over those achievable by treatment based 
on standard risk factor profiling and basic lipid analysis. While results from some of these 
specialized tests may be abnormal and considered independent risk markers for coronary 
disease, there is a lack of data in controlled trials demonstrating outcome benefits from treating 
routinely obtained abnormal results. Therefore, advanced lipoprotein testing performed on 
4/15/22 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 3 
 
A 54-year-old female enrollee has requested reimbursement for advanced lipoprotein testing 
performed on 4/15/22. 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 current medical literature does not demonstrate that advanced lipoprotein 
testing adds significant actionable information to what is already known from a basic fasting lipid 
profile.  There  is  a  lack  of  randomized  trials  showing  that  therapies  to  correct  any  novel 
lipoprotein abnormalities, such as lipoprotein(a), have any effect on cardiovascular outcomes 
such as myocardial infarction, stroke, or death. In this clinical setting, there is insufficient 
evidence to support the use of the service at issue. Therefore, advanced lipoprotein testing 
performed on 4/15/22 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 Overturned

Summary Reviewer  
 
The patient is a 45-year-old female with attention deficit/hyperactivity disorder (ADHD). The 
patient has requested authorization and coverage for brand name Adderall 20 mg tablets. The 
physician reviewer found that the submitted documentation supports the medical necessity of 
the requested medication. This patient was diagnosed with ADHD previously and has benefited 
from treatment with Adderall. Given the patients lack of misuse of the stimulant and benefit in 
her ADHD symptoms from this medication, there is support for the requested medication. 
Additionally, the patient has tried generic Adderall and had numerous adverse effects from that 
formulation, which she did not experience from brand name Adderall. This was reported in 
medical records. Therefore, brand name Adderall 20 mg tablets are medically necessary for the 
treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 63-year-old female enrollee has requested reimbursement for Guardant360 testing performed 
on 2/04/21. 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 National Comprehensive Cancer Network guidelines recommend biopsy 
of recurrence of disease. This patient has not been confirmed to have recurrent disease, just 
suspected.  Comprehensive  somatic  profiling  is  typically  reserved  for  confirmed  disease 
recurrence. It is not used to monitor for disease recurrence. Should she have confirmed disease 
recurrence, then several prior lines of therapy would be available prior to turning to therapies 
that may be revealed in targeted testing. Therefore, Guardant360 testing performed on 2/04/21 
was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 63-year-old female enrollee has requested reimbursement for Guardant360 testing 
performed on 2/04/21. 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 this patient had lymphadenopathy that was suspicious for breast 
cancer recurrence. The priority should have been resection or biopsy of the lymph node 
followed by mutation analysis. Instead, the patient had a peripheral blood analysis of oncogenic 
mutations. Guardant360 testing cannot be used to diagnose metastatic disease. The 
Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70 
genes. Von Hoff and colleagues performed a clinical study directly compared the use of 
targeted agents with conventional chemotherapy approaches. The study involved 86 patients, 
and the progression-free survival on regimen selected by molecular profiling was compared to 
the progression-free survival on the last chemotherapy regimen. The regimen selected by 
molecular profiling offered a 27% survival advantage. This trial has very significant results for 
patients with stage IV tumors. Under normal circumstances with the diagnosis of metastatic 
disease, a comprehensive mutational analysis is indicated to better hone therapeutic options. 
However, in this case, the test was being used for diagnostic purposes, to diagnose the 
presence of stage four disease. There is a lack of support for the services at issue in this setting. 
Therefore, Guardant360 testing performed on 2/04/21 was not likely to have been more 
beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3   
A 63-year-old female enrollee has requested reimbursement for Guardant360 testing performed 
on 2/04/21. 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 molecular testing is an important part of testing in breast cancer and can 
help direct treatment options. In this case, although the patient has a history of breast cancer, 
she appears to be in remission as her last documented therapy (2004) was 17 years prior to the 
Guardant360 test.  Although the recent imaging studies are concerning for recurrence, there is 
no  histologic  confirmation  of  her  disease.    National  Comprehensive  Cancer  Network  and 
American Society of Clinical Oncology guidelines for metastatic breast cancer recommend a 
tissue  biopsy  to  confirm  the  diagnosis  prior  to  treatment  planning.    Previous  notes  had 
mentioned BRCA1 positive disease, and so this positive finding on the Guardant360 testing would 
not confirm disease recurrence at the present time. Without prior confirmation of recurrent 
disease,  the  Guardant360  test  is  not  more  beneficial  than  standard  therapy.  Therefore, 
Guardant360 testing performed on 2/04/21 was not likely to have been more beneficial than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 54-year-old female with a history of left hip pain. The patient underwent an MRI 
of the left hip on 12/22/22. The physician reviewer found that at issue is whether the left hip MRI 
provided on 12/12/22 was medically necessary for this patient. Guidelines from the American 
College of Radiology (ACR) have established that MRI is highly sensitive and specific for detecting 
many abnormalities involving the surrounding soft tissues and should, in general, be the first 
imaging technique used after radiographs. The guidelines add that, MRI is useful for examining 
surrounding  soft  tissue  entities  such  as  iliopsoas  or  subiliacus  bursitis,  athletic  pubalgia, 
trochanteric bursitis, abductor tendinosis or tears, calcific tendonitis, and hamstring injuries and 
for sources of referred pain from spine or knee. Other causes of a chronically painful hip for which 
MRI has been used with considerable success include acute and chronic soft tissue injuries. In 
this case, the patients symptoms were present for more than a year. The patient underwent 
routine radiographs. It is unlikely that any imaging modality other than an MRI would provide the 
important information to evaluate the patient. Therefore, the left hip MRI provided on 12/12/22 
was medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 73-year-old male who presented to his provider on 5/11/23. The records noted that 
the patient initially presented with an elevated prostate-specific antigen of 6.5 ng/mL in 2019. The 
patient has requested authorization and coverage for PBRT. The Health Insurer has denied this 
request and reported that the requested service is not medically necessary for the treatment of this 
patient. This denial is the subject of this appeal and determination. The physician reviewer found 
that the submitted documentation does not support the medical necessity of the requested service 
Proton beam has unique properties compared to standard photon or x-ray beam in its ability to 
deposit radiation doses. The use of proton beams potentially results in fewer areas of low scattered 
radiation dose as fewer proton beams may be used to achieve a dose distribution similar to standard 
photon beams. Proton therapy is currently utilized and strongly indicated in settings where severe 
toxicities would result if normal tissue constraints cannot be met by photon beam. However, in the 
setting of localized prostate cancer, there has not been a demonstrable clinically significant 
improvement in either quality of life or reduction of high-grade toxicities. Studies in current 
medical literature have not demonstrated a significant difference in overall survival nor normal 
tissue toxicities over photon beam in the treatment of prostate cancer. These data question the 
utility of proton beam radiation particularly for patients with localized disease. There are ongoing 
prospective trials investigating the potential benefits in disease outcomes and toxicities, however, 
no definite benefit has been demonstrated for proton beam at this time. While proton therapy may 
be medically indicated in some cases of unusual anatomy or in cases of re-irradiation of adjacent 
tissues, this is not the case for this particular patient. In this clinical setting, given this patients 
medical history and the nature of his prostate cancer diagnosis, the requested service is not 
medically indicated. Therefore, PBRT is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 63-year-old female enrollee has requested reimbursement of liquid CDx laboratory testing by 
FoundationOne on 4/29/22. The Health Insurer has denied this request and reported that the service 
at issue was investigational for the evaluation of the enrollees lung cancer. At issue is whether 
CDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for 
evaluation of the enrollee's condition than any available standard therapy. The physician reviewer 
found that the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of 
non-small cell lung cancer (NSCLC) note that there is growing recognition of the molecular 
mechanisms of resistance to therapy. Retesting a sample from a tumor that is actively progressing 
while exposed to targeted therapy can shed light on appropriate next therapeutic steps. Broad 
genomic profiling may be the most informative approach to examining potential mechanisms of 
resistance, which may require more than one instance of such profiling over the course of an 
individual patients therapy. While liquid biopsy should not be used in lieu of tissue-based testing, 
Rolfo  and  colleagues  note  that  isolation  and  analysis  of  circulating  cell-free  tumor 
deoxyribonucleic acid (DNA) in plasma is a powerful tool with considerable potential to improve 
clinical outcomes across multiple cancer types, including NSCLC. Cell-free tumor DNA testing 
generally has very high specificity. While it may also have significantly compromised sensitivity, 
with up to a 30% false-negative rate, current medical literature supports complementary testing to 
reduce turnaround time and increase the yield of targetable alteration detection. This is especially 
true with procedures that typically have a low yield of tissue such as endobronchial ultrasound 
(EBUS). Therefore, the service at issue was likely to have been more beneficial for treatment of 
the patients medical condition than standard therapy with tissue-based testing alone. Therefore, 
CDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for 
evaluation of the patients condition than any available standard therapy.