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

Summary  
The patient is a 49-year-old male with a history of hypogonadism based on low testosterone levels. The 
records available for review indicate that the patient has been undergoing treatment with testosterone 
replacement therapy since 2015 with good clinical response. The physician reviewer found that at issue 
is whether the requested testosterone 1.62% transdermal gel is medically necessary for the treatment 
of this patient. Low testosterone can lead to complications such as reduced libido, erectile dysfunction, 
reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood, and fatigue 
(Marcelli and Mediwala). Numerous formulations have been approved for the treatment of patients 
with hypogonadism, including testosterone injections and transdermal gels (Lo, et al.). Transdermal gel 
provides a relatively steady level of serum testosterone as compared to testosterone injections, which 
may cause instabilities in symptoms due to fluctuations in serum testosterone levels (Surampudi, et al.). 
In this case, the patient presents with a history of hypogonadism based on low testosterone levels. The 
records indicate that the patient has been undergoing successful treatment with testosterone 
replacement therapy for several years, with his total testosterone levels improving from 240 ng/dL to 
the 400-500 ng/dL range. Moreover, the medical literature has established the efficacy of transdermal 
gel for the treatment of patients with hypogonadism. For these reasons, the requested testosterone 
1.62% transdermal gel is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 66-year-old male who presented with lower urinary tract symptoms. The 
patient has requested reimbursement for MRI of pelvis performed on 11/08/21. The physician 
reviewer found that the submitted documentation fails to demonstrate the medical necessity 
of the services at issue. This case was previously reviewed, and the patient submitted additional 
documentation for reconsideration. According to the American Urological Association Standard 
Operating Procedure referenced below, there is level 1 data to support the recommendation of 
multiparametric MRI prior to biopsy for all men without a previous history of biopsy who are 
under consideration for prostate biopsy. Per the AUA, Multiparametric MRI-targeted prostate 
biopsy in men at suspicion of prostate cancer, with no previous history of prostate cancer, 
detects more clinically significant prostate cancer when combined with systematic biopsy, and 
less clinically insignificant prostate cancer, than systematic biopsy alone. However, in this case, 
the patient had an elevated PSA level in the setting of a urinary tract infection. This had 
normalized after antibiotic treatment. Additionally, digit rectal examination was normal. There 
was no suspicion about prostate cancer. Performing an MRI would not be considered a clinically 
appropriate and generally accepted standard for management of this patients medical 
condition. There are indications for performing MRIs based on the risk of prostate cancer. If a 
patient has an elevated PSA and/or abnormal digital rectal examination, an MRI may be 
indicated. As noted above, this patients PSA had normalized to 3.69 by 10/20/21, and his 
digital rectal examination was normal. The additional documentation provided for 
reconsideration did not alter the original determination. Therefore, MRI of pelvis performed on 
11/08/21 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 41-year-old male. Notes dated 10/27/21 reported that the patient presented to the 
hospital on 9/18/21 with acute hypoxemic respiratory failure and sepsis in the setting of COVID-
19  pneumonia. The patient has requested reimbursement for LTACH days from 11/11/21 through 
11/13/21. The Health Insurer has denied this request and reported the services at issue were not 
medically necessary for the treatment of this patient. This denial is the subject of this appeal and 
determination. The physician reviewer found that the submitted documentation supports the 
medical necessity of the services at issue. In this case, the patient remained at a very high aspiration 
risk, highlighted by his witnessed  aspiration event  on 11/11/21. It is not uncommon for patients 
to fail tracheostomy decannulation in the LTACH setting, as they are at high risk for mucous 
impaction and aspiration in the days following decannulation. The LTACH screened the patient 
for transfer to a lower level of service, the skilled nursing facility (SNF) setting. Regardless of the 
timing of when the patient was accepted to the SNF versus when he was transferred to SNF, the 
patient continued to receive medically necessary LTACH care, including aggressive mucous 
clearance and pulmonary hygiene. By 11/13/21, the patients providers had observed him for three 
days following tracheostomy  tube removal and felt more comfortable transferring the patient to 
the SNF, where less aggressive respiratory support would be available to the patient. Therefore, 
LTACH days from 11/11/21 through 11/13/21 were medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 29-year-old female who presented to the emergency department on 6/6/22 with clinical 
and radiographic appendicitis. An operative report dated 6/7/22 reported a diagnosis of acute 
appendicitis. The physician reviewer found that at issue is whether inpatient hospital charges from 
6/6/22 through 6/7/22 were medically necessary for the treatment of this patient. The submitted 
documentation supports the medical necessity of the services at issue. Moris and colleagues note that 
the clinical diagnosis of acute appendicitis is based on history and physical, laboratory evaluation, and 
imaging, and that appendectomy remains first-line therapy for acute appendicitis, but treatment with 
antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis. In 
this case, the patient had clinical and radiographic appendicitis, and an appendectomy, the preferred 
treatment, was appropriately recommended and performed. A pathology report confirmed appendicitis. 
In this clinical setting, given the patients acute illness with unplanned surgery for acute appendicitis, the 
service at issue was medically indicated. Therefore, inpatient hospital charges from 6/6/22 through 
6/7/22 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 48-year-old male enrollee has requested reimbursement for laboratory testing on 12/2/22. The Health 
Insurer has denied this request and reported that services at issue were investigational for the 
evaluation of the enrollees premature coronary artery disease and hyperlipidemia. The physician 
reviewer found that the current guidelines for the management of cardiac risk and dyslipidemia do not 
recommend the routine performance of specialized tests, including screening lipoprotein(a) levels, in 
the context of assessing coronary risk. Treatment changes or additions based on the results of 
lipoprotein testing has not been shown to improve cardiac outcomes over those achievable through 
treatment based on standard risk factor profiling and a basic lipid analysis. In this patients case, a high 
dose-statin medication is recommended regardless of lipid levels or of lipoprotein(a) levels based on the 
patients known coronary disease. There is a lack of evidence from clinical trials testing the hypothesis 
that lipoprotein(a) reduction reduces the incidence of future cardiovascular events over those 
achievable with standard therapy. Therefore, laboratory testing on 12/2/22 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 1 
 
A 36-year-old female insured has requested reimbursement for laser hair removal performed on 
10/25/22. A review of the record indicates that the insured was diagnosed with hidradenitis 
suppurativa at the axillae and groin two years ago, which worsened with pregnancy. The Health 
Insurer indicates the services at issue were considered investigational for the treatment of the 
insured's medical condition. Therefore, the Health Insurer has denied reimbursement for the 
services at issue. This denial is the subject of this appeal and determination. The physician reviewer 
found that there are several options for the treatment of patients with hidradenitis suppurativa, 
including pharmacological, surgical, and other modalities. For moderate-to-severe hidradenitis 
suppurativa, adalimumab is U.S. Food and Drug Administration (FDA) approved for treatment 
(Kimball, et al.; Jemec, et al.). While laser hair removal has emerged as a potential treatment 
option, there is a lack of quality evidence for specific laser modalities. Minimal evidence supports 
the use of alexandrite laser treatment for the treatment of patients with hidradenitis suppurativa. 
One small study exploring the use of alexandrite laser treatment for the treatment of patients with 
hidradenitis suppurativa showed some potential therapeutic benefit (Molinelli, et al.). Another 
larger  randomized  trial  of  laser  hair  removal  for  the  treatment  of  hidradenitis  suppurativa 
demonstrated efficacy in the reduction of inflammatory lesions but did not report an effect on 
disease flares (Naouri, et al.). In this case, the patient has a history of chronic hidradenitis 
suppurativa. The patient underwent alexandrite laser hair removal, which the medical literature 
has not established as an effective treatment option for the reduction of disease flares in patients 
with hidradenitis suppurativa. Given these findings, the laser hair removal performed on 10/25/22 
was not likely to be more beneficial for the treatment of the patients condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
A 36-year-old female insured has requested reimbursement for laser hair removal performed on 
10/25/22. A review of the record indicates that the insured was diagnosed with hidradenitis 
suppurativa at the axillae and groin two years ago, which worsened with pregnancy. The Health 
Insurer indicates the services at issue were considered investigational for the treatment of the 
insured's medical condition. Therefore, the Health Insurer has denied reimbursement for the 
services at issue. This denial is the subject of this appeal and determination. The physician reviewer 
found that there are several options are available for the treatment of patients with hidradenitis 
suppurativa, including medical and surgical modalities. However, there is a paucity of studies 
comparing medical treatments to surgical treatments. According to the United States and Canadian 
Hidradenitis  Suppurativa  Foundations,  oral  antibiotics  such  as  clindamycin,  rifampicin,  and 
ertapenem, other medical treatments such as infliximab and adalimumab, and surgical treatments 
such as laser therapy and surgical excision, are all considered standard therapies for the treatment 
of patients with hidradenitis suppurativa (Alikhan, et al.; Goldburg, et al.). In this case, the patient 
has a history of hidradenitis suppurativa that was treated with laser hair removal. While laser hair 
removal is a treatment option, the current medical literature has not established its benefits over 
other standard therapies, including oral antibiotics. There is a lack of documentation indicating 
that the patient tried oral antibiotics such as clindamycin, rifampicin, and ertapenem. For these  reasons, the laser hair removal performed on 10/25/22 was not likely to be more beneficial for the 
treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
A 36-year-old female insured has requested reimbursement for laser hair removal performed on 
10/25/22. A review of the record indicates that the insured was diagnosed with hidradenitis 
suppurativa at the axillae and groin two years ago, which worsened with pregnancy. The Health 
Insurer indicates the services at issue were considered investigational for the treatment of the 
insured's medical condition. Therefore, the Health Insurer has denied reimbursement for the 
services at issue. This denial is the subject of this appeal and determination. The physician reviewer 
found that as noted in the current peer-reviewed medical literature, laser hair removal is not 
supported as a first-line treatment for patients with hidradenitis suppurativa. According to Alikhan 
and  colleagues,  several  treatment  options  are  indicated  for  the  treatment  of  patients  with 
hidradenitis suppurativa including antibiotic combinations with metformin, adalimumab, and 
surgery. Specifically, adalimumab is FDA-approved and likely to be more effective for the 
treatment of patients with hidradenitis suppurativa than laser hair removal. The records provided 
for review indicate that this patient underwent laser hair removal for the treatment of his chronic 
hidradenitis suppurativa. However, the medical literature has established adalimumab as a more 
effective treatment option. Therefore, the laser hair removal performed on 10/25/22 was not likely 
to be more beneficial for the treatment of the patients condition than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 21-year-old female with chronic urticarial eruption and severe atopic dermatitis. The 
patient has requested authorization and coverage for Dupixent. 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. The U.S. Food and 
Drug Administration (FDA) approves the use of Dupixent for the treatment of severe atopic dermatitis. In 
this case, the patient has failed numerous medications, including topical and systemic medications, and is 
currently being treated with Dupixent. In this clinical setting, the requested medication is medically 
indicated.  Therefore,  Dupixent  is  medically  necessary  for  the  treatment  of  this  patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The  patient  is  a  14-year-old  male  who  was  diagnosed  with  eosinophilic  esophagitis  after 
presenting  with  intermittent  episodes  of  food  impaction  and  vomiting.  The  provider  has 
recommended treatment with Dupixent. The physician reviewer found that on review of the 
available records, this patient presents with a diagnosis of eosinophilic esophagitis. The patients 
provider has recommended treatment with Dupixent. The U.S. Food and Drug Administration 
(FDA) has approved Dupixent for the treatment of for adolescents and adults with refractory 
eosinophilic esophagitis. Gutierrez-Junquera and colleagues reported on a prospective study 
evaluating proton pump inhibitor (PPI) treatment in young patients with eosinophilic esophagitis. 
The authors found that PPI therapy led to histologic remission in approximately 50% of the young 
patients studied. Oliva and colleagues performed a recent registry-based longitudinal study that 
found a 30% response rate in children age 10 years and older. There is evidence that patients 
with fibrostenotic disease or more severe endoscopic findings are less likely to respond to PPI 
than those with an inflammatory phenotype or milder endoscopic findings. The correspondence 
from  this  patients  provider  described  a  concern  for  a  fibrostenotic  phenotype.  However, 
approxiatemly  30%  of  patients  with  fibrostenotic  phenotype  have  been  found  to  achieve 
remission with PPI therapy. Overall, the patient has a 30-50% likelihood of histologic response to 
oral treatment with PPI. Thus, trial of a PPI is indicated prior to consideration for treatment with 
Dupixent. With regard to the providers concern about the patients growth, a review of the 
enclosed growth chart does not include a height-for-age or body mass index (BMI)-for-age chart 
to further assess this situation. Accordingly, the requested Dupixent Injection 300/3 mL is not 
medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 15-year-old male with a history of chronic migraine. The patient has undergone 
evaluation magnetic resonance imaging (MRI) of the head with and without contrast, which was 
interpreted as normal. The patient has reportedly experienced excellent results with abortive 
therapy in the form of intranasal ketorolac tromethamine solution 15.75 mg/spray. The provider 
has recommended continued treatment with ketorolac tromethamine solution spray. The Health 
Insurer has denied the requested medication as not medically necessary. This denial is the subject 
of  this  appeal and  determination.   The  physician reviewer  found  that  the  patients records 
document a history of chronic migraines. As reported by the provider, the patient has been treated 
with  Migrelief,  acupuncture,  Advil,  and  nortriptyline  without  substantial  improvement  in 
symptoms. The patients provider has recommended treatment with ketorolac tromethamine 
solution spray. As noted in the medical literature, ketorolac tromethamine solution spray has been 
demonstrated to be effective in the management of patients with chronic migraine who have not 
responded to, or are in intolerant to treatment with, other currently available mediations for 
migraine. In one study, Rao and colleagues concluded that, This study supports that ketorolac 
nasal spray is superior to placebo and that it is non-inferior to sumatriptan nasal spray for the acute 
abortive treatment of migraine. Considering this patients documented success with intranasal 
abortive therapy with ketorolac tromethamine solution at a dose of 15.75 mg/spray, continued 
treatment with this medication is appropriate. Moreover, treatment with ketorolac tromethamine 
solution is indicated to help avoid emergency department services should the patients headache 
progress to persistent migraine. All told, the requested ketorolac tromethamine solution 15.75 
mg/spray is medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 34-year-old female who presented to the emergency department from urgent care 
via ambulance with complaints of right lower back pain radiating to the left lower back with 
headache,  dizziness,  vomiting,  and  fever.  The  patient  has  requested  reimbursement  for  the 
inpatient hospital stay from 6/26/22 through 6/29/22. The Health Insurer has denied the services 
at issue as not medically necessary. This denial is the subject of this appeal and determination. The 
physician reviewer found that inpatient care is indicated when a patients signs, symptoms, and 
general medical condition can only be managed safely in an acute inpatient setting, when the 
patient requires diagnostic studies in an inpatient setting, or if there is another clinical indication, 
such as sepsis, for the patient to remain in the acute inpatient setting.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating 
that the requested services are considered investigational for treatment of the insureds chronic 
low  back  pain.  The  physician  reviewer  found  that  according  to  the  U.S.  Food  and  Drug 
Administration (FDA), intraosseous nerve ablation is intended to be used in conjunction with 
radiofrequency for the ablation of basivertebral nerves for the relief of chronic low back pain of 
at least six months duration that has not responded to at least six months of conservative care 
and is also accompanied by features such as disruption and fissuring of the endplate. This 
patients MRI of the lumbar spine demonstrated fibrotic type endplate change at L4-5 that would 
make the patient a good candidate for ablation of basivertebral nerves. However, the patients 
MRI also showed mild central and moderate left paracentral disc protrusion, moderate left lateral 
recess stenosis, mild right and moderate left foraminal narrowing secondary to disc protrusion 
and mild central canal stenosis. Thus, there are multiple plausible pathologic sources of low back 
pain and finding the source of chronic lower back pain is clinically challenging (Tieppo Francio 
and Sayed). A small minority low back pain diagnoses can be attributed to an anatomical source. 
Overall, the medical evidence is insufficient to support a finding of spinal vertebral bodies as 
being the overwhelming primary generators of the patients chronic low back pain. Therefore, 
the requested intraosseous basivertebral nerve ablation (CPT code 64628) is not likely to be more 
beneficial than any other available standard treatments for the patients medical condition.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating 
that the requested services are considered investigational for treatment of the insureds chronic 
low back pain. The physician reviewer found that pain from degenerated or damaged vertebral 
endplates can trigger inflammation and result in chronic low back pain. Basivertebral nerve 
ablation is a minimally invasive treatment for the relief of chronic low back pain (Fischgrund, et 
al.).  The  authors  concluded  that  patients  with  chronic  low  back  pain  who  underwent 
basivertebral  nerve  ablation  have  exhibited  significantly  greater  improvement  after  three 
months than patients who continued with non-operative care.  This patients MRI showed 
degenerative endplate changes in the L4 and L5 vertebral bodies. Earlier records indicate the 
possibility of lumbar radiculopathy, but the current assessment does not include the diagnosis. 
The records indicate that the patients low back pain has significantly inhibited bending, lifting, 
and sitting. Additionally, this patient has exhausted conservative treatment such as physical 
therapy and home exercise. The patient has been treated with Gabapentin, Meloxicam and 
methocarbamol without relief.  Given these findings, the requested intraosseous basivertebral 
nerve ablation (CPT code 64628) is likely to be more beneficial than any other available standard 
treatments for the patients medical condition.