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

Summary Reviewer 2 
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 in this clinical setting, the NCCN guidelines for the treatment of NSCLC note that next 
generation sequencing (NGS) is appropriate to detect actionable mutations for targeted treatment. 
In this case, the patient developed local recurrence along with metastatic disease to the brain. Based 
on the patients KRAS G12C mutation identified by the service at issue, a targeted treatment, 
specifically sotorasib, was identified. In a study including 928 patients with stage IV NSCLC, of 
which 295 patients underwent NGS, Al-Ahmadi and colleagues report, Patients undergoing NGS 
testing had significantly longer survival of 25.3 months versus those who did not undergo 
sequencing with a median survival of 14.6 months irrespective if they received targeted therapy or 
not. that patients In this clinical setting, the service at issue was likely to have been more 
beneficial for treatment of this patient than not utilizing NGS. In this case, while notes dated 
7/27/22 reported that the patient underwent EBUS with tissue biopsy, the records do not document  an NGS result from the tissue biopsy.  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.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
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 Metastatic adenocarcinoma of the lung is an incurable disease, but many advances have 
been made with targeted therapies to help extend survival. Multiple guidelines including by the 
NCCN,  College  of  American  Pathologists  (CAP),  American  Society  of  Clinical  Oncology 
(ASCO), and European Society for Medical Oncology (ESMO), recommend testing for mutations 
such as epidermal growth factor receptor (EGFR), KRAS, anaplastic lymphoma kinase (ALK), 
and c-ros oncogene (ROS1) on tumor samples to help direct therapy options. If patients are not fit 
for biopsy, or if the tissue sample is insufficient for testing, then cell-free testing may help identify 
mutations.  Cell-free tests, such as the FoundationOne CDx liquid test at issue, are very specific 
but not as sensitive as tissue testing for mutations and are not a substitute when appropriate tissue 
can be obtained. In this case, notes dated 7/27/22 reported that the patient underwent a repeat 
biopsy on 4/12/22 by EBUS to confirm recurrent disease. Molecular testing and FoundationOne 
CDx liquid testing were requested from this sample at the same time. In this clinical setting, given 
that the tissue sample is considered more sensitive/specific than liquid biopsy and is the standard 
for diagnostic management, the service at issue was not likely to have been more beneficial than 
the standard management. Therefore, CDx laboratory testing by FoundationOne on 4/29/22 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  
The patient is a 38-year-old female. The patient has requested authorization and coverage for 
nasal/sinus  endoscopy  with  maxillary  antrostomy  and  total  ethmoidectomy.  The  physician 
reviewer found that at issue is whether nasal/sinus endoscopy with maxillary antrostomy and 
total ethmoidectomy is medically necessary for the treatment of this patient. The submitted 
documentation supports the medical necessity of the requested service. The American Academy 
of Otolaryngology notes that the clinical indicators for endoscopic sinus surgery include chronic 
rhinosinusitis without nasal polyps with persistent symptoms and objective evidence of disease 
by endoscopic and/or CT imaging that is refractory to optimal medical treatment. In this case, 
the records document that the patient has chronic sinusitis and has failed optimal medical 
therapy with abnormalities seen on CT of the sinus. In this clinical setting, the requested surgical 
intervention is medically indicated. Therefore, nasal/sinus endoscopy with maxillary antrostomy 
and total ethmoidectomy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 22-year-old female who was diagnosed with narcolepsy type 1. The patient has 
requested authorization and coverage for Wakix tablets 17.8 mg. The physician reviewer found 
that the submitted documentation supports the medical necessity of the requested medication. 
This patient was diagnosed with narcolepsy following adequate tests. The patients response to 
previous treatment is well documented. Wakix has been approved by the U.S. Food and Drug 
Administration (FDA) for the treatment of narcolepsy. Given the failure of other medications, the 
requested medication is medically indicated. Therefore, Wakix tablets 17.8 mg are medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 44-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral on 7/6/21. The Health Insurer has denied 
this request and reported that the service at issue was investigational for the treatment of the 
enrollees bilateral chronic eustachian tube dysfunction. The physician reviewer found that the Anand 
and colleagues report that balloon eustachian tuboplasty shows efficacy at a follow-up of one year 
with  the  combination  of  balloon  dilation  and  medical  management  resulting  in  improved 
eustachian tube dysfunction symptoms versus medical management alone. In this case, the patient 
had a history of ear pressure and had undergone bilateral myringotomy with tube placement 
without improvement. A balloon eustachian tuboplasty resolved his symptoms. In this clinical 
setting, the balloon eustachian tuboplasty, which provides long-term relief, was likely to have been 
more  beneficial  than  standard  therapies  that  only  provide  short-term  relief.  Therefore, 
nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e. balloon dilation); bilateral on 
7/6/21 was likely to have been more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 44-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral on 7/6/21. The Health Insurer has denied 
this request and reported that the service at issue was investigational for the treatment of the 
enrollees bilateral chronic eustachian tube dysfunction. The physician reviewer found that the 
standard medical therapies for the treatment of eustachian tube dysfunction include a trial of 
intranasal steroid therapy and/or oral glucocorticoids. The most widely accepted standard surgical 
treatment for eustachian tube dysfunction is myringotomy, with or without tube insertion, regarded 
as relatively safe and effective. While Poe and colleagues along with Meyer and colleagues appear 
to demonstrate a statistically significant benefit of balloon dilation of the eustachian tube over 
intranasal steroids and/or oral glucocorticoids, these studies were both limited by small patient 
pools, lack of blinding, loss to follow up, and a large enough degree of crossover of patients from 
the control arm to the treatment arm midway through the studies that neither study was able to 
compare the treatment and control groups at the final follow up. In a study of outcomes through 
52 weeks, Anand and colleagues suggested that the beneficial effects of balloon dilation of the 
eustachian tube and medical management on tympanogram normalization and symptoms of 
subjects  with  refractory  obstructive  eustachian  tube  dysfunction  demonstrated  significant 
durability. There is less data available comparing balloon dilation of the eustachian tube with 
myringotomy, with or without tube insertion. In a cohort study comparing balloon dilation of the 
eustachian tube to balloon dilation of the eustachian tube along with adjunctive myringotomy with 
tube insertion, Chen and colleagues noted a statistically significant difference in post-operative 
hearing loss between the two groups, favoring balloon dilation of the eustachian tube along with 
tube placement, but did not identify a statistically significant difference in regards to overall cure 
rate or effectiveness. Thus, while current medical literature suggests that balloon dilation of the 
eustachian tube is more efficacious than the standard medical therapies of intranasal steroids and 
oral glucocorticoids in the management of eustachian tube dysfunction, there is a lack of similar  data to suggest that it is a more effective treatment than myringotomy with or without tube 
placement. Therefore, nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e. balloon 
dilation); bilateral on 7/6/21 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 Overturned

Summary Reviewer 3 
A 44-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral on 7/6/21. The Health Insurer has denied 
this request and reported that the service at issue was investigational for the treatment of the 
enrollees bilateral chronic eustachian tube dysfunction. The physician reviewer found that the current 
medical literature supports the use of eustachian tube balloon dilation in the setting of chronic 
otitis media and eustachian tube dysfunction. The symptoms of obstructive eustachian tube 
dysfunction include aural fullness, pressure, hearing loss, and otalgia. Eustachian tube dysfunction 
is typically transient. For persistent eustachian tube dysfunction, nonsurgical medical management 
consisting of nasal steroid spray or oral steroid, nasal sprays, or pressure equalization maneuvers 
may suffice. Surgical management may consist of the placement of ear tubes in select cases, along 
with eustachian tube dilation when needed. Once extrinsic causes of eustachian tube dysfunction 
have been ruled out, and other common causes such as allergies, sinusitis, and laryngopharyngeal 
reflux have been managed, eustachian tube dilation may be of significant benefit. In a systematic 
review of eustachian tube balloon dilation for the treatment of eustachian tube dysfunction, 
Froehlich and colleagues reported clinically significant improvement in both subjective and 
objective criteria. In a study to assess balloon dilation of the eustachian tube with eustachian tube 
balloon catheter in conjunction with medical management, Poe and colleagues concluded that the 
study demonstrated the superiority of balloon dilation of the eustachian tube with balloon catheter 
in addition to medical management over medical management alone with nasal and oral steroids 
in the treatment of eustachian tube dilatory dysfunction in adults. Wang and colleagues report that 
balloon dilation results in significant improvement of eustachian tube dysfunction over newer 
techniques such as laser tuboplasty. In this case, notes dated 9/11/20 reported that the patient 
underwent medical management with a nasal steroid spray and an oral antihistamine. When 
medical management failed, the patient underwent the more conservative procedure of placement 
of ear tubes. However, the patient continued to have symptoms and underwent eustachian tube 
dilation. In this clinical setting, the service at issue was likely to have been more beneficial than 
standard  medical  management,  ear  tube  placements,  and  laser  tuboplasty.  Therefore, 
nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e. balloon dilation); bilateral on 
7/6/21 was 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 Reviewer  
 
The patient is a 42-year-old male with a history of relapsing-remitting multiple sclerosis (RRMS) 
and optic atrophy. The provider has recommended treatment with Vumerity because it has the 
same mechanism of action as dimethyl fumarate, but with fewer gastrointestinal side effects. 
The  Health  Insurer  has  denied  the  requested  medication  as  not  medically  necessary  for 
treatment of the patients medical condition. The physician reviewer found that for patients with 
relapsing forms of multiple sclerosis (MS), disease-modifying therapies (DMTs) have shown 
benefit in terms of reducing relapses. However, adherence to a DMT may be affected by adverse 
effects (Rae-Grant, et al.). The U.S. Food and Drug Administration (FDA) has approved Vumerity 
as a DMT for patients with relapsing forms of MS, including RRMS). Vumerity undergoes the same 
mechanism of action as the delayed-release dimethyl fumarate (Naismith, et al.). The authors 
found that Vumerity demonstrated an improved gastrointestinal tolerability compared with 
dimethyl fumarate. This patient has RRMS and is currently asymptomatic but has cervical spine 
lesions on MRI. The records document that the patient has experienced good response with 
dimethyl fumarate treatment but with adverse effects. Given the similarity of Vumerity to 
dimethyl  fumarate  with  fewer  reported  gastrointestinal  side  effects,  this  medication  is 
appropriate for this patient. Therefore, the requested Vumerity 231 mg capsule is medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene test 
(CPT 81529) performed on 5/27/21. 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 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 (SLNB), requires further prospective investigation in large, contemporary data 
sets of unselected patients. Prognostic GEP testing to differentiate melanomas at low-risk versus 
high-risk for metastasis should not replace pathologic staging procedures. Moreover, since there 
is a low probability of metastasis in melanoma in stage I and a higher proportion of false-positive 
results, GEP testing should not guide clinical decision-making in this subgroup. Therefore, the 
DecisionDx-Melanoma gene test (CPT 81529) performed on 5/27/21 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 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene test 
(CPT 81529) performed on 5/27/21. 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 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 a high depth of invasion, from 0.76 mm to 1.0 mm. Metastases to regional 
lymph nodes may be amenable to excision but suggest a high risk for the development of 
metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. 
While Gerami and colleagues report that GEP signature accurately predicted metastasis risk in a 
multicenter cohort of primary cutaneous melanoma tumors, the patients analyzed were part of 
a high-risk cohort, and there appears to be some lack of consistency between various genes being 
used as biomarkers. The use of data from DecisionDx-Melanoma is not part of routine analysis 
following SLNB. The service at issue is novel, and it unclear how its results would be incorporated 
it into the treatment algorithm beyond standard staging techniques recommended by the 
National Comprehensive Cancer Network (NCCN). Therefore, the DecisionDx-Melanoma gene 
test  (CPT  81529)  performed  on  5/27/21  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 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene test 
(CPT 81529) performed on 5/27/21. 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 in this case, a pathology report dated 4/30/21 reported stage 
IA cutaneous melanoma arising in a junctional dysplastic nevus. GEP testing is an evolving 
modality and may assist in differentiating precancerous from malignant lesions. While some 
studies show its efficacy in risk stratification in melanoma, it is unclear if GEP performs better 
than standard methods such as histopathologic risk factors and SLNB. In this clinical setting, the 
NCCN  guidelines  for  cutaneous  melanoma  recommend  only  wide  excision  and  do  not 
recommend GEP. Therefore, the DecisionDx-Melanoma gene test (CPT 81529) performed on 
5/27/21 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 Reviewer  
 
The patient is a 53-year-old male who presented for a spine surgery evaluation on 6/8/22. The 
patient has requested authorization and coverage for inpatient surgery  disk replacement, 
cervical. The physician reviewer found that the submitted documentation does not support the 
medical necessity of the requested service. In this case, the records do not demonstrate that the 
patient is an appropriate candidate for the proposed cervical arthroplasty as an inpatient surgery 
as he not completed nonoperative therapies like physical therapy, injections, or chiropractic care. 
Such nonoperative therapies should be attempted before any surgical intervention as they would 
affect whether the proposed procedure should be an inpatient or outpatient surgery or whether 
the surgical recommendation should be an arthroplasty or fusion. While the patient reports 
weakness, which may be a reason to proceed with surgery at some point in the near future, the 
patients surgeon does not report that the weakness is profound or worrisome enough to 
represent an emergency or to cause permanent morbidity. Rather, the patients surgeon has 
recommended that the patient take the time to complete a cardiac evaluation and optimize his 
pulmonary function, during which time it would be appropriate for the patient to attempt 
nonoperative  therapies  for  his  chronic  symptoms.  Therefore,  inpatient  surgery    disk 
replacement, cervical, is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 34-year-old male. X-rays of the lumbar spine dated 4/22/22 reported findings of 
mild upper lumbar scoliosis centered at L2 and convex to the left, with otherwise normal alignment 
and no malalignment provoked by flexion or extension. The patient has requested authorization 
and coverage for single-level lumbar fusion. 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. Bydon 
and colleagues note, A trial of conservative therapy may be considered for patients with low-
grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options 
may include physical therapy, epidural steroid injection, and pain medications. If unresolved, 
surgical options may include decompression alone or decompression and fusion. Chan and 
colleagues report, Patients with symptomatic lumbar spondylolisthesis may first be treated with 
conservative management strategies including, but not limited to, non-narcotic and narcotic pain 
medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-
selected  patients  who  fail  conservative  management  strategies,  surgical  management  is 
appropriate. Resnick and colleagues explain, As a result of the decompression, the inherent 
instability associated with the spondylolisthesis may progress and lead to further misalignment 
that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar 
fusion is considered appropriate to stabilize the spine and prevent delayed deterioration. In this 
case,  the  patient  is  a  34-year-old  male  with  back  pain,  lumbar  radiculopathy,  and  lumbar 
spondylosis. The patient reported ongoing low back pain that is interfering with his ability to return 
to work that he rated at a five as of 2/24/23. An examination revealed moderate tenderness to 
palpation over the lumbar spine. The records noted that the patient was neurologically intact. 
However, the submitted records did not include detailed documentation regarding a trial and 
failure  of  recent,  reasonable,  comprehensive,  less  invasive  conservative  care  measures,  as 
recommended prior to surgery in current medical literature. Dynamic flexion/extension films did 
not corroborate instability at the requested surgical level of L5-S1, and there was no detailed 
documentation regarding potential impending/inevitable temporary intra-operative instability. 
Therefore, single-level lumbar fusion is not medically necessary for the treatment of this patient.