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

Summary Reviewer  
The patient is a 70-year-old male who was being treated for other spondylosis, lumbosacral 
region; other intervertebral disc displacement, lumbar region; spinal stenosis, lumbosacral 
region; other forms of scoliosis, lumbosacral region; and lumbar radiculopathy. The patient has 
requested authorization and coverage for spinal surgery (CPT codes 22612, 22853, 63044, 
22848, 63042, 22614, 22842, 22558, 63048, 22585, 63047, 22800 and two inpatient days). The 
physician reviewer found that Bydon and colleagues noted, 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 noted, 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 noted, 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. This patient was being 
treated for other spondylosis, lumbosacral region; other intervertebral disc displacement, 
lumbar region; spinal stenosis, lumbosacral region; other forms of scoliosis, lumbosacral region; 
and lumbar radiculopathy. He presented with increased back pain. He has had intermittent loss 
of bowel and bladder control. He also has noticed some weakness, particularly in the left lower 
extremity. His pain has increased significantly. Examination reveals weakness in the left 
iliopsoas at 3+/5, left glut and hamstrings at 4/5. These are new findings since September 2021, 
when he was neurologically intact. He has had previous L2-5 laminectomies on 9/29/20. 
Provided documentation demonstrates subjective and objective deficits that are corroborated 
by imaging studies. Trial and failure of conservative treatment modalities has been 
documented. There is potential impending/inevitable temporary intraoperative instability 
evident. Therefore, spinal surgery (CPT codes 22612, 22853, 63044, 22848, 63042, 22614, 
22842, 22558, 63048, 22585, 63047, 22800 and two inpatient days) is medically necessary for 
the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 65-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) 
testing on 8/10/21. The Health Insurer has denied this request and reported that the service at 
issue was investigational for the evaluation of the enrollees severe diarrhea. The physician 
reviewer found that The Infectious Diseases Society of America guidelines for acute diarrhea note 
that  certain  pathogens  that  can  cause  protracted  diarrhea,  and  cannot  be  detected  with 
commonly used tests, may be found with nucleic acid amplification tests (NAATs). The American 
College of Gastroenterology guidelines for the management of acute diarrhea states, Traditional 
methods  of  diagnosis  (bacterial  culture,  microscopy  with  and  without  special  stains  and 
immunofluorescence, and antigen testing) fail to reveal the etiology of the majority of cases of 
acute diarrheal infection. If available, the use of U.S. Food and Drug Administration (FDA) 
approved culture-independent methods of diagnosis can be recommended at least as an adjunct 
to traditional methods. PCR testing may be far more sensitive in clinical testing for the detection 
of certain pathogens due to a high sensitivity. Beal and colleagues note that a gastrointestinal 
PCR  test  may  more  accurately  diagnose  patients  with  diarrhea,  resulting  in  improved 
management. In this case, the patient had persistent diarrhea for weeks. A provider letter dated 
9/20/22 reported that the testing at issue showed enteropathogenic Escherichia coli (E.coli).  In 
this clinical setting, initial gastrointestinal PCR pathogen panel testing was likely to have been 
more beneficial for evaluation of the patients diarrhea than any available standard therapy. 
Therefore, PCR testing on 8/10/21 was likely to have been more beneficial for the evaluation of 
the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 65-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) 
testing on 8/10/21. The Health Insurer has denied this request and reported that the service at 
issue was investigational for the evaluation of the enrollees severe diarrhea. The physician 
reviewer found that in the setting of acute diarrhea in a non-toxic, healthy patient, standard 
therapy consists of supportive care. Many of the organisms tested for, such as norovirus, cause 
self-limited disease and have no treatment. Others cause self-limited disease and can be treated 
with antibiotics, although antibiotics tend to delay clearance of the organism and may cause 
immune-mediated side effects such as hemolytic uremic syndrome. Additionally, many of the 
organisms tested for, such as entamoeba histolytica, are incredibly rare in North Americans 
eating a normal diet such that testing for them does not make sense. In this clinical setting, the 
PCR testing at issue, which involved testing for numerous gastrointestinal pathogens, was not 
likely to be more beneficial than standard testing using routine cultures for pathogens including 
E. coli subtype, or a PCR or enzyme immunoassay (EIA) test limited to determine the presence of 
Clostridioides difficile. Therefore, PCR testing on 8/10/21 was not likely to have been more 
beneficial for the evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 65-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) 
testing on 8/10/21. The Health Insurer has denied this request and reported that the service at 
issue was investigational for the evaluation of the enrollees severe diarrhea. The physician 
reviewer found that while PCR stool testing is indicated for patients who have severe illness or 
high-risk comorbidities, it is not indicated for patients whose diarrhea symptoms have resolved. 
In  this  clinical  setting,  standard  diagnostic  testing  involves  performing  stool  cultures  for 
microbiologic stool testing, which can identify the most common bacterial causes of diarrhea. 
PCR testing is not likely to be more beneficial than standard diagnostic testing as any specimens 
that test positive on a PCR test would need to be submitted for confirmatory stool culture for 
susceptibility testing. Therefore, PCR testing on 8/10/21 was not likely to have been more 
beneficial for the evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 28-year-old female enrollee has requested reimbursement and prospective authorization and 
coverage for ketamine infusions from 9/07/21 forward. The Health Insurer has denied this 
request and reported that the services at issue were and are investigational for the treatment of 
the enrollees medical condition. The physician reviewer found that there is sufficient support for 
the services at issue in this clinical setting. The patient has been diagnosed with major depressive 
disorder. Based on her failing at least two antidepressants plus psychotherapy, she qualifies for 
a  diagnosis  of  treatment-resistant  depression.  The  patient  has  tried  numerous  somatic 
treatments, such as transcranial magnetic stimulation and neurofeedback, still without remission 
of her depressive symptoms. In the course of her recent ketamine infusions, the patients 
depression lifted, as did her suicidality. Intravenous ketamine has been found to have a rapid and 
significant effect on depression and suicidality. Therefore, ketamine infusions from 9/07/21 
forward were and are likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 28-year-old female enrollee has requested reimbursement and prospective authorization and 
coverage for ketamine infusions from 9/07/21 forward. The Health Insurer has denied this 
request and reported that the services at issue were and are investigational for the treatment of 
the enrollees medical condition. The physician reviewer found that the patient has a history of 
major  depressive  disorder  that  has  not  responded  to  multiple  antidepressants,  dialectical 
behavior therapy, eye movement desensitization and reprocessing, and transcranial magnetic 
stimulation. Her provider recommended intravenous ketamine infusions for treatment-resistant 
depression. Per the psychiatrist, the ketamine infusions have improved the patients quality of 
life and suicidal ideations. Currently, there is insufficient data on the long-term efficacy, safety, 
and tolerability of intravenous ketamine for patients with treatment-resistant depression. The 
U.S.  Food  and  Drug  Administration  has  approved  Spravato  (esketamine)  nasal  spray,  in 
conjunction with an oral antidepressant, for the treatment of depression in adults who have tried 
other antidepressant medicines but have not benefited from them. Like intravenous ketamine, 
esketamine nasal spray appears to have a robust and moderate effect on reducing symptoms of 
depression. To date, there is a lack of high quality data comparing the efficacy of intranasal to 
intravenous ketamine. Given this support, dosing with intravenous ketamine is not likely to be 
more beneficial than standard of care. Therefore, ketamine infusions from 9/07/21 forward were 
not and are not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3   
A 28-year-old female enrollee has requested reimbursement and prospective authorization and 
coverage for ketamine infusions from 9/07/21 forward. The Health Insurer has denied this 
request and reported that the services at issue were and are investigational for the treatment of 
the enrollees medical condition. The physician reviewer found that the records note multiple 
failed  trials  of  antidepressants,  augmentation  agents,  psychotherapies,  and  transcranial 
magnetic stimulation. The patient needed a residential level of care prior to ketamine infusion. 
After ketamine treatment, she was able to be discharged to the outpatient level of care and has 
had symptomatic and functional improvement. For patients with severe, treatment-resistant, 
unipolar, major depression without psychotic features who decline electroconvulsive therapy, 
ketamine is a reasonable alternative to antidepressants. Ketamine may be particularly helpful for 
patients with refractory, active suicidal ideation. Evidence supporting short-term use of ketamine 
for severe, treatment-resistant, unipolar, major depression without psychotic features includes 
multiple analyses of randomized trials that consistently demonstrate ketamine can rapidly 
improve depression for a relatively short period of time, and that the drug is relatively well-
tolerated. Thase and Connolly noted, Randomized trials have demonstrated that intravenous 
ketamine and intranasal esketamine can each rapidly improve treatment-resistant depression, 
including symptoms of suicidal ideation. Per the authors, For unipolar major depression, the 
efficacy of esketamine and ketamine appear to be comparable. However, no head-to-head trials 
comparing the two drugs have been published. Given that this patient has responded to her 
current treatment regimen of ketamine, it is appropriate to continue with this treatment rather 
than subjecting her to a trial of esketamine as an alternative. The medical evidence supports the 
services at issue in this clinical setting. Therefore, ketamine infusions from 9/07/21 forward were 
and are likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
This patient is 63-year-old male who presented to the emergency room on 7/22/22. The patient 
reported a posterior headache associated with dizziness and lightheadedness. The patient has 
requested reimbursement for an emergency room claim for 7/22/22 through 7/23/22. The Health 
Insurer has denied this request and reported that the services at issue were not medically necessary 
for the treatment of this patient. This denial is the subject of this appeal and determination. 
The physician reviewer found that the submitted documentation  does  not  support  the medical 
necessity of the services at issue. Cerebellar, or posterior infarcts, are notoriously difficult to 
diagnose without obtaining a brain MRI. In this case, the patient reported dizziness and had 
abnormal heel-to-toe tandem walking. As a hemorrhagic stroke was ruled out, a brain MRI was 
necessary. Given that a brain MRI could have been obtained from the emergency department or at 
a lower level of care, such as observation level of service, the service at issue was not medically 
indicated. Therefore, the emergency room claim for 7/22/22 through 7/23/22 was not medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 46-year-old male enrollee has requested authorization and coverage for Acthar Gel. The Health 
Insurer has denied this request indicating that the requested medication is investigational for the 
treatment of the enrollees sarcoidosis. The physician reviewer found that while the U.S. Food 
and Drug Administration (FDA) approves the use of Acthar Gel for the treatment of sarcoidosis, 
the  European  Respiratory  Society  (ERS)  clinical  practice  guidelines  note  that  the  initial 
pharmacological treatment for symptomatic pulmonary sarcoid with concern for adverse clinical 
outcomes  is  a  corticosteroid,  such  as  prednisone.  In  patients  unable  to  tolerate  steroids, 
experiencing  disease  relapse  with  steroid  taper,  or  with  disease  that  has  not  been  fully 
controlled, methotrexate may be utilized as a second-line treatment agent. Other second-line 
agents  following  the  use  of  methotrexate  include  azathioprine,  mycophenolate  mofetil, 
hydroxychloroquine, or leflunomide, if needed. Third-line agents include biologic drugs such as 
infliximab or adalimumab. The use of Acthar Gel may be considered after the trial and failure of 
these second and third-line treatment options. In this case, the records note that the patient has 
tried methotrexate and azathioprine. However, the records do not document that the patient 
has tried and failed treatment with second-line and third-line agents such as mycophenolate 
mofetil, leflunomide, infliximab or adalimumab as is typically expected prior to the use of Acthar 
gel. In this clinical setting, the requested medication is not likely to be more beneficial for the 
treatment of sarcoid than second-line and third-line agents therapies including mycophenolate 
mofetil, leflunomide, infliximab or adalimumab as recommended by clinical practice guidelines. 
Therefore, Acthar Gel is not likely to be more beneficial for treatment of the patients condition 
than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 46-year-old male enrollee has requested authorization and coverage for Acthar Gel. The Health 
Insurer has denied this request indicating that the requested medication is investigational for the 
treatment of the enrollees sarcoidosis. The physician reviewer found that Gerke explains that 
treatment  of  sarcoidosis  involves  the  use  of  corticosteroids  and  conventional 
immunosuppression with medications such as methotrexate, azathioprine, leflunomide, and 
mycophenolate. Baughman and colleagues note, The biologic agents, especially monoclonal 
anti-tumor necrosis factor (anti-TNF) antibodies, have proved effective in patients who have 
failed other treatments. While Acthar Gel is FDA-approved for the treatment of symptomatic 
sarcoidosis, in this clinical setting, current medical literature does not support its use as superior 
to multiple other treatment options that have been proven to be effective for the treatment of 
sarcoidosis. Therefore, Acthar Gel is not likely to be more beneficial for treatment of the patients 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 46-year-old male enrollee has requested authorization and coverage for Acthar Gel. The Health 
Insurer has denied this request indicating that the requested medication is investigational for the 
treatment of the enrollees sarcoidosis. The physician reviewer found that while there is a lack of 
organizational guidelines on the treatment of sarcoidosis, based on case reports and small 
studies, sarcoidosis refractory to prednisone is frequently treated with disease modifying anti-
rheumatic drugs (DMARDs) such as methotrexate, Plaquenil, leflunomide, and infliximab. The 
FDA approves the use of Acthar Gel for the treatment of sarcoidosis. Baughman, and colleagues 
note an improvement in symptoms of fatigue, pulmonary function testing, chest imaging, and 
quality of life, along with decreasing prednisone doses with the use of repository corticotropin. 
Chopra and colleagues report that the use of repository corticotropin resulted in improvement 
in patients with advanced symptomatic sarcoidosis. In this clinical setting, given the side effects 
that may accompany standard therapies, the requested medication is likely to be more beneficial 
for the treatment of this patients sarcoidosis than available standard therapy. Therefore, Acthar 
Gel is likely to be 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 38-year-old transgender male. In a letter dated 8/23/22, the provider reported that 
the patient had a diagnosis of gender dysphoria and recommended masculinizing body contouring 
procedures. The patient has requested authorization and coverage for 15839-22 excision, excessive 
skin and subcutaneous tissue (includes lipectomy), other area, and 15877 x 12 suction assisted 
lipectomy, trunk. 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 supports the 
medical necessity of the requested services. The World Professional Association for Transgender 
Health (WPATH) notes that medically necessary gender-affirming include but are not limited to 
hysterectomy  with  or  without  bilateral  salpingo-oophorectomy;  bilateral  mastectomy,  chest 
reconstruction or feminizing mammoplasty, nipple resizing or placement of breast prostheses; 
genital reconstruction, for example, phalloplasty and metoidioplasty, scrotoplasty, and penile and 
testicular prostheses, penectomy, orchiectomy, vaginoplasty, and vulvoplasty; hair removal from 
the face, body, and genital areas for gender affirmation or as part of a preoperative preparation 
process; and gender-affirming facial surgery and body contouring. The WPATH further notes that 
non-genital procedures are routinely performed for the treatment of gender dysphoria and that 
these surgical interventions are often of greater practical significance in the patients life than 
reconstruction of the genitals. Given that current medical literature supports the use of body 
contouring, lipectomy, and skin removal as treatments for gender dysphoria, the requested services 
are medically indicated. Therefore, 15839-22 excision, excessive skin and subcutaneous tissue 
(includes lipectomy), other area, and 15877 x 12 suction assisted lipectomy, trunk are medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 52-year-old male insured has requested authorization and coverage for Panzyga (immune globulin 
(Human)-ifas). The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insureds small fiber neuropathy and paresthesia of 
the feet. The physician reviewer found that there is a paucity of medical literature suggesting that IVIG 
therapy is efficacious for the treatment of patients with small fiber neuropathy (Zeidman, et al.; Devigili, 
et al.). In one study by Gibbons and colleagues, the authors demonstrated a lack of benefit from 
treatment with IVIG in patients with small fiber neuropathy. The records provided for review indicate 
that this patient presents with a history of small fiber neuropathy and significant paresthesia of the feet. 
Per the provider, the patient has tried and failed numerous medications, including Effexor, Elavil, Lyrica, 
Cymbalta, gabapentin, meloxicam, mexiletine, and topical lidocaine. Overall, there is a lack of medical 
evidence suggesting that IVIG is a superior treatment option to the medications already tried and failed 
by the patient. Therefore, the requested Panzyga (immune globulin (Human)-ifas) is not likely to be 
more beneficial for the treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 52-year-old male insured has requested authorization and coverage for Panzyga (immune globulin 
(Human)-ifas). The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insureds small fiber neuropathy and paresthesia of 
the feet. The physician reviewer found that the records reflect that this patient has a history of small 
fiber neuropathy with symptoms including progressive paresthesia in his lower extremities and feet. 
Antibody testing was obtained, and the patient tested positive for TS-HDS. Per the provider, the patient 
has tried and failed medications such as Effexor, Elavil, Lyrica, Cymbalta, gabapentin, meloxicam, 
mexiletine, and topical lidocaine. These medications are considered first-line or standard therapies for 
patients with small fiber neuropathy. The current medical literature has shown that IVIG is beneficial for 
patients with small fiber neuropathy who test positive for the TS-HDS antibody (Zeidman and Kubicki). 
While there is a lack of direct comparative studies analyzing the efficacy of IVIG versus standard 
therapies for the treatment of patients with small fiber neuropathy, Panzyga is an established next step 
in therapy that has shown to be efficacious for such patients. Additionally, the records reflect that this 
patient has previously tried and received benefit from IVIG. For these reasons, the requested Panzyga 
(immune globulin (Human)-ifas) is likely to be more beneficial for the treatment of the patients 
condition than any available standard therapy.