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

Summary Reviewer 3 
A 59-year-old male enrollee has requested authorization and coverage for deep brain stimulation. 
The Health Insurer has denied this request and reported that the requested service is investigational 
for the treatment of the enrollees Parkinsons disease. The physician reviewer found that the 
standard therapies available for patients with Parkinsons disease depend on a number of factors 
including whether the patient has been newly diagnosed, whether the patient has tried standard 
medication therapies such as carbidopa/levodopa, what type of responses the patient demonstrates 
to oral medication therapies, and the duration of treatment with medications. In this case the patient 
is not newly diagnosed, has tried standard oral medication therapies with  considerable and 
intolerable side-effects, had less favorable and escalating medication dosages leading to unwanted 
side-effects following initial good response to medications, and has been on a medication regimen 
for ten years. In this clinical setting, DBS represents the only standard therapy option for this 
patient following the trial and failure of standard oral medication therapies. Therefore, deep brain 
stimulation is likely to be more beneficial for treatment of the patients condition than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is an 18-year-old male with a longstanding history of abdominal pain and diarrhea 
with night waking and slow weight gain. The patients parent has requested authorization and 
coverage for treatment with Sucraid 8500 mL solution. The Health Insurer has denied the 
requested medication as not medically necessary since the patients records do not support a 
diagnosis of sucrase isomaltase deficiency. The physician reviewer found that the U.S. Food and 
Drug Administration (FDA) has approved Sucraid for the treatment of patients with congenital 
sucrase-isomaltase deficiency (CSID). Although dietary management of CSID is possible, it is 
highly restrictive and would not be recommended for this adolescent patient with a history of 
poor weight gain. However, this patients records do not support a diagnosis of CSID to support 
an indication for treatment with Sucraid. The patients symptoms may also be consistent with IBS 
(Shah and Pimentel). The patient reportedly underwent C13 breath testing, which reflected low 
sucrase-isomaltase activity. This coupled with the providers report of the patients symptomatic 
improvement with use of Sucraid is suggestive of CSID but is insufficient to support this diagnosis 
without genetic testing. C13 breath testing is unable to distinguish between low sucrase activity 
due to primary enzyme deficiency versus low activity due to mucosal damage. The European 
Society for Pediatric Gastroenterology, Hepatology, and Nutrition recommends using genetic 
testing for to confirm a diagnosis of CSID (Broekaert, et al.). In the absence of testing reporting a 
diagnosis of CSID, this patient does not meet the requirements for treatment with Sucraid. 
Therefore, the requested Sucraid 8500 mL solution is not medically necessary for treatment of 
this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 64-year-old male with a history of left hip and leg symptoms. The patient has 
requested reimbursement for left lateral femoral nerve surgery performed on 11/15/18. The 
physician reviewer found that California law defines an emergency medical condition as a 
medical condition manifesting itself by acute symptoms of sufficient severity (including severe 
pain) such that the absence of immediate medical attention could reasonably be expected to 
result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious 
impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Meralgia 
paresthetica is a pain syndrome that results from compression or entrapment of the lateral 
femoral cutaneous nerve. Patients can complain of pain and/or numbness in the region of the 
lateral  femoral  cutaneous  nerve.  A  number  of  treatment  options  are  available,  including 
medications, injections, pulse radiofrequency neuromodulation, neurostimulation, neurolysis 
and neurectomy. Surgery in the form of neurolysis or neurectomy is typically reserved for 
patients who have failed non-surgical strategies. Based on the available literature and the 
understanding of the pathology as an entrapment syndrome of a purely sensory nerve, it is 
difficult to characterize meralgia paresthetica as a medical emergency. Based on the records, the 
definition of emergency medical condition as a medical condition manifesting itself by acute 
symptoms does not apply in this case. The patients symptoms were present for greater than six 
years. This was not an acute problem. After careful evaluation of this case, a prudent layperson, 
who possesses an average knowledge of health and medicine, would not reasonably expect the 
absence of immediate medical attention to result in the following in this case: (i) placing the 
health of the individual in serious jeopardy, (ii) serious impairment to bodily functions, or 
(iii) serious dysfunction of any bodily organ or part. Therefore, left lateral femoral nerve surgery 
performed on 11/15/18 was not emergent in nature.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 13-year-old male with a history of idiopathic isolated growth hormone (GH) 
deficiency. The provider has recommended continued treatment with GH therapy. The Health 
Insurer has denied the requested treatment 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 Skytrofa is U.S. Food and Drug Administration (FDA) approved for 
the treatment of pediatric patients with GH deficiency. According to Maniatis and colleagues, 
pediatric patients treated with once-weekly Skytrofa showed continued improvement of height 
SDs through the second year of therapy without excess advancement of bone age. The failure of 
two standard GH provocative tests, combined with a small pituitary gland, is consistent with a 
diagnosis of pediatric GH deficiency (Ibba and Loche). In this case, the patient failed to respond 
to glucagon and clonidine stimulating testing. An MRI of the patients brain revealed a relatively 
small pituitary gland for the patients age. Furthermore, based on this patients standing height and 
contemporary bone age, the patients predicted adult height before initiating treatment with 
Skytrofa was 65.9 inches, which is more than two SDs below his estimated MPTH of 72 inches. 
Therefore, prior to initiating treatment with Skytrofa, this patient met generally accepted and FDA-
approved diagnostic criteria for pediatric GH deficiency. Moreover, the records provided for 
review indicate that the patient has been tolerating and responding well clinically to Skytrofa, as 
demonstrated by the increase in the patients growth velocity. For these reasons, the requested 
Skytrofa is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 31-year-old female has requested reimbursement for lab tests that measure the levels of 
medication, adalimumab (ADA) performed on 8/1/22. The Health Insurer has denied this request 
indicating that the testing at issue was considered investigational for evaluation of the insureds 
ulcerative colitis. The physician reviewer found that the use of testing for the assessment of this 
patients adalimumab (ADA) drug level and anti-ADA antibody level is supported by the current 
guidelines from the American Gastroenterological Association (AGA) and American College of 
Gastroenterology (ACG) (Feuerstein, et al.; Rubin, et al.). The records indicate that this patient 
was on ADA for the treatment of ulcerative colitis. The patient reportedly demonstrated ongoing 
symptoms of active ulcerative colitis, and showed a markedly elevated C-reactive protein, which 
are accepted markers for uncontrolled ulcerative colitis (Rubin, et al.). Given the patients elevated 
C-reactive protein and ongoing symptoms, which are consistent with active or uncontrolled 
ulcerative colitis, the patient was at risk for complications of ulcerative colitis. According to the 
AGA, In adults with active inflammatory bowel disease treated with anti-tumor necrosis factor 
agents, the AGA suggests reactive therapeutic drug monitoring to guide treatment changes 
(Feuerstein, et al.). According to the AGA guidelines, drug concentration and anti-drug antibody 
levels should be checked if there is a loss of response to an anti-tumor necrosis factor (TNF) 
medication, such as ADA, with a subsequent change in management. Per the ACG guidelines, 
The patient with nonresponse or loss of response to therapy should be assessed with therapeutic 
drug monitoring to identify the reason for lack of response and whether to optimize the existing 
therapy or to select an alternate therapy (Rubin, et al.; Roda, et al.; Irving and Gesce.). Assessment 
of whether the patients ADA dose should have been increased or changed to an alternative therapy 
was appropriate per the ACG and AGA guidelines. For these reasons, the lab tests that measure 
the levels of medication, adalimumab (ADA) performed on 8/1/22 were likely to be more 
beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 31-year-old female has requested reimbursement for lab tests that measure the levels of 
medication, adalimumab (ADA) performed on 8/1/22. The Health Insurer has denied this request 
indicating that the testing at issue was considered investigational for evaluation of the insureds 
ulcerative colitis. The physician reviewer found that on review of the current medical literature, 
there is insufficient clinical data provided to support the ADA drug levels and antibody testing 
performed in this patients evaluation and treatment. The records do not demonstrate that the ADA 
testing was recommended to evaluate the patient to confirm dosing or due to suspected failure of 
medication. In the setting of suspected drug failure, additional testing such as stool cultures should 
also be performed to rule-out other potential causes of the patients disease flare. A recent meta-
analysis  concluded  that,  Routine  proactive  therapeutic  drug  monitoring  to  target  biologic 
concentration to specific thresholds, regardless of disease activity, did not offer clinical benefit in 
patients with inflammatory bowel disease treated with TNF-alpha antagonists in randomized 
controlled trials conducted to date (Nguyen, et al.). All told, the lab tests that measure the levels 
of medication, ADA performed on 8/1/22 were not likely to be more beneficial for evaluation of 
the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
A 31-year-old female has requested reimbursement for lab tests that measure the levels of 
medication, adalimumab (ADA) performed on 8/1/22. The Health Insurer has denied this request 
indicating that the testing at issue was considered investigational for evaluation of the insureds 
ulcerative colitis. The physician reviewer found that on review of the current peer-reviewed 
medical literature, the drug assay testing for ADA performed on 8/1/22 was likely to be more 
beneficial for the evaluation of this patient than any available standard therapy. The drug testing 
performed was reactive drug monitoring since the test was recommended in response to the 
patients symptoms of ulcerative colitis. The most recent national guideline from the AGA 
specifically  endorses  reactive  drug  monitoring  in  this  clinical  setting  when  the  patient  has 
symptoms while on anti-TNF agents such as ADA (Feuerstein, et al.). The AGA guidelines cite 
data that has shown that reactive drug monitoring is more beneficial than standard therapy 
including  change of  drug therapy without the drug  assay  and  is  supported with  consensus 
agreement among experts (Feuerstein, et al.; Papamichael, et al.). Thus, the lab tests that measure 
the levels of adalimumab performed on 8/1/22 was likely more beneficial for evaluation of the 
patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 73-year-old female who presented to her provider on 7/19/22. The records noted 
statin intolerance, coronary artery disease, and an abnormal electron beam computed tomography 
(EBCT) result. The patient has requested authorization and coverage for Repatha Sureclick 
solution auto-injector 140 mg/mL. 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. In this case, the records 
document that the patient has coronary artery disease, has been unable to tolerate multiple statins, 
has a high LDL level, and an abnormal EBCT result. In addition, according to Nissen and 
colleagues, this medication has been successfully used in statin intolerant patients. In this clinical 
setting, current medical literature supports the use of the requested medication. Therefore, Repatha 
Sureclick solution auto-injector 140 mg/mL is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 56-year-old female who presented in 2012 with breast 
cancer. The patient has requested authorization and coverage for 
stereotactic body radiation therapy. The physician reviewer found the 
submitted documentation fails to demonstrate the medical necessity of the 
requested services. The use of stereotactic body radiotherapy in 
metastatic breast cancer is not standard of care. Stereotactic body 
radiotherapy allows for the use of a high dose of radiation to a small 
volume and is generally utilized in the curative setting. This patient 
requires palliative radiotherapy, and the standard technique is typically 
with 3D conformal radiotherapy. There is a lack of meaningful clinical 
data to support the routine use of stereotactic body radiotherapy in 
patients with widespread metastases. Furthermore, there is a lack of 
published randomized trials that support the use of stereotactic body 
radiotherapy over standard treatment. The current National Comprehensive 
Cancer Network guidelines also do not support the routine use of 
stereotactic body radiotherapy in treatment of breast cancer. In this 
case, the provider noted the plan to use stereotactic body radiotherapy 
to target a single lung metastasis that is not responding to systemic 
therapy. In this setting, there is no proven benefit of stereotactic body 
radiation therapy to the one progressive lesion. Therefore, the requested 
stereotactic body radiation therapy is not medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 44-year-old female. In a letter dated 2/10/22, the provider reported that the 
patient has a medical history of sarcoidosis of the lung, liver disease, and fibromyalgia. The 
patient has requested authorization and coverage for Humira 40 mg/0.4 mL injectable every two 
weeks. The physician reviewer found that the submitted documentation supports the medical 
necessity  of  the  requested  medication.  Infliximab  is  a  chimeric  human-murine  antihuman 
antibody that specifically blocks the effect of tumor necrosis factor-alpha (TNF-alpha). Current 
medical literature suggests that infliximab may be useful in selected patients with pulmonary and 
extrapulmonary sarcoidosis refractory to glucocorticoid therapy, and includes positive trials of 
Humira, which has a similar mechanism of action to infliximab, in the treatment of pulmonary 
and cutaneous sarcoidosis and sarcoid arthritis. Crommelin and colleagues report, Adalimumab 
is an effective alternative for patients intolerant to infliximab. The switch to adalimumab 
achieved clinical improvement in 39% and stabilization in 33% of patients intolerant to infliximab. 
Further research is needed to develop guidelines on how to use adalimumab for sarcoidosis in 
terms of dosing regimen. In a small, open-label study, Sweiss and colleagues reported that 
adalimumab improved refractory pulmonary sarcoidosis and was well tolerated. Pariser and 
colleagues reported that adalimumab is likely to be an effective and relatively safe suppressive 
treatment for cutaneous sarcoidosis. In this case, given the patients risks for side effects with 
the long-term use of prednisone, the requested medication is medically indicated. Therefore, 
Humira 40 mg/0.4 mL injectable every two weeks is medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 61-year-old male. In a letter dated 12/8/22, the provider reported that the patient 
presented with a variety of neurological symptoms and was initially evaluated in Japan in August 
2018 with a diagnostic angiogram that showed a lesion. The patient has requested authorization 
and coverage for the PET with CT scan. The Health Insurer has denied this request and reported 
that the requested services are not medically necessary for the evaluation 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 services. PET-CT scans are 
invaluable in determining whether a skull base lesion is of neoplastic origin or vascular origin. The 
surgical approach and treatment of these two possibilities are vastly differently so as to profoundly 
increase the importance of accurate, pre-intervention diagnosis. Chang and colleagues note that 
combined with high specificity and patient convenience, dotatate PET/CT should be considered 
the ideal first line investigation for imaging neuroendocrine tumors. In this clinical setting, given 
that current medical literature supports the use of dotatate PET/CT in a standard work-up of this 
patient, the requested services are medically indicated. Therefore, the PET with CT scan is 
medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 60-year-old male. An echocardiography report dated 10/13/21 reported severe 
apical  hypertrophy,  reduced  strain,  and  an  apical  aneurysm.  The  patient  has  requested 
reimbursement  for  a  S-ICD  subcutaneous  cardioverter  defibrillator  from  12/9/21  through 
12/10/21. The Health Insurer has denied this request and reported the service at issue was not 
medically necessary for the evaluation 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.  In  the  setting  of  primary  prevention  implantable 
cardioverter defibrillator (ICD) placement, the usual indications for a subcutaneous defibrillator 
over a transvenous defibrillator include inadequate vascular access, anticipated multiple venous 
access procedures (for example, in the case of a patient with young age), previous cardiac infection, 
increased risk of infection, and existence of right-sided artificial heart valves that preclude 
transvenous lead placement. In this case, none of these indications are documented in the records 
provided and there is report of ventricular tachycardia that would not be able to be terminated by 
tachypacing, if needed, if a subcutaneous device were placed. Therefore, S-ICD subcutaneous 
cardioverter defibrillator from 12/9/21 through 12/10/21 was not medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 66-year-old male who has a history of hyperlipidemia and moderate coronary 
disease. The patient has requested authorization and coverage for Vascepa (icosapent ethyl 
capsule 1 gm). The patients parent has requested authorization and coverage for Norditropin 
(somatropin) 10 mg in 1.5 ml. The physician reviewer found that in the REDUCE-IT trial, Vascepa 
was  shown  to  be  superior  to  placebo  in  reducing  triglycerides,  cardiovascular events  and 
cardiovascular death among patients with high triglycerides and either known cardiovascular 
disease or patients with diabetes plus significant cardiovascular risk factors. This patient has 
significant cardiovascular disease with documented coronary atherosclerosis. The submitted 
documentation  included  laboratory  testing  from  2003,  2007  and  2008.  These  records 
documented  elevated  triglyceride  levels.  Vascepa  is  indicated  for  elevated  triglycerides  in 
patients  with  cardiovascular  disease  or  diabetics  with  cardiovascular  risk  factors.  There  is 
sufficient support for the requested medication in this clinical setting.  Therefore, Vascepa 
(icosapent ethyl capsule 1 gm) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is an 18-year-old female who presented to her provider on 10/22/21. The patient has 
requested authorization and coverage for sinus surgery (31267 x 2, 31259 x 2, 31276 x 2, 61782 
and 30140 x 2). The physician reviewer found that while sinus surgery can be an appropriate 
therapeutic option for patients with chronic sinusitis and recurrent acute sinusitis, the criteria 
have not been met in this patient. The American Academy of Otolaryngology Head and Neck 
Surgery (AAOHNS) defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by 
inflammation of the mucosa of the nose and paranasal sinuses with associated signs and 
symptoms of 12-week consecutive duration. CRS is characterized by two or more symptoms, one 
of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal 
drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic 
evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or 
air fluid levels in the sinuses. The AAOHNS defines recurrent acute sinusitis as four or more 
recurrent episodes of acute rhinosinusitis with complete clearing of symptoms between episodes 
over a one-year period. In this patients case, chronic rhinosinusitis was not documented in this 
patient. There was no documentation of 12 weeks of consecutive disease. Recurrent acute 
sinusitis was not documented in this patient. There was no documentation of four or more 
recurrent episodes over a one-year period. There was no documentation of chronology of 
disease, symptoms or treatment. There was no documentation that  she was treated with 
maximal medical therapy prior to the CT scan. On review of the scan, only a retention cyst in the 
maxillary sinus was present. There was minimal mucosal disease on the CT scan. Therefore, sinus 
surgery is not medically necessary in this patients case. Additionally, there was no report of nasal 
obstruction secondary to turbinate hypertrophy, refractory to medical management. Therefore, 
turbinate reduction surgery is not medically necessary. All told, the requested sinus surgery 
(31267 x 2, 31259 x 2, 31276 x 2, 61782 and 30140 x 2) is not medically necessary for the 
treatment of this patient.