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

Summary  
The patient is a 10-year-old male with a diagnosis of autism. The patients parent states that the 
patients therapy was terminated due to non-coverage, so no additional records are available. The 
patients parent has requested reimbursement and prospective authorization and coverage for 
occupational therapy. 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 on review of the medical records and current medical literature occupational therapy 
services provided from 2/22/23 through 2/28/24 were and are medically necessary for treatment 
of this patient. The use of occupational therapy services will help address the patients ADLs, 
sensory  integration,  and  coordination,  as  well  as  gross  and  fine  motor  skills.  Continued 
occupational therapy services can help establish new performance baselines for this patient while 
the developing central nervous system still has neuroplasticity. In this case, the patient started 
occupational therapy for the habilitative treatment of deficiencies associated with an autism 
spectrum disorder. Specifically, the patient has motor coordination problems and deficits in ADLs, 
which are planned to be addressed with the requested occupational therapy. Occupational therapy 
is the most appropriate treatment modality to address the patients deficits (Campi, et al.). Given 
these findings, the occupational therapy (CPT codes 99214, 97530, 97535, 97166, and 97112) 
from 2/22/23 through 2/28/24 was and is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 38-year-old female enrollee has requested reimbursement for Guardant360 CDx panel performed on 
4/01/21. 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 
understanding the molecular drivers of cancer progression and metastases is an area of ongoing 
and active research, predominantly driven by the goal of identifying specific genomic aberrations 
that may ultimately result in individualized cancer treatment. In addition to likely providing 
prognostic information, the value of next generation sequencing (NGS) to predict candidates for 
specific mutation-driven treatment holds promise. Patients with inflammatory and metastatic 
breast cancers benefit from NGS to identify markers that may indicate benefit from targeted 
treatment or clinical trials. For hormone receptor-positive/HER2-negative breast cancer, testing 
for PIK3CA mutations with tumor or liquid biopsy to identify candidates for alpelisib plus 
fulvestrant should be performed. Therefore, Guardant360 CDx panel performed on 4/01/21 was 
likely to have been 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 38-year-old female enrollee has requested reimbursement for Guardant360 CDx panel 
performed on 4/01/21. 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 Guardant360 test is a liquid biopsy that analyzes patient plasma 
for mutations in a panel of 70 genes. Von Hoff and colleagues performed a clinical study which 
directly compared the use of targeted agents with conventional chemotherapy approaches. The 
progression-free survival on the regimen selected by molecular profiling was compared to 
progression-free survival on the last chemotherapy regimen. The regimen selected by 
molecular profiling offered a 27% survival advantage. This trial has significant results for 
patients with stage IV tumors. Additionally, current National Comprehensive Cancer Network 
(NCCN) guidelines recommend mutational testing for metastatic tumors that may suggest some 
targeted therapies. PIK3CA is one such example. In most instances of visceral disease or lymph 
node involvement, testing can be performed on the excised tissue but in certain cases such as 
bone metastases, the decalcification process makes the material unsuitable for gene 
sequencing. Thus, liquid biopsy is specifically mentioned in the NCCN guidelines. The requisition 
for a sample from 3/25/21 is included in the case file. The requisition indicated that the patient 
did not have any other accessible disease for biopsy and mutational analysis. In this patients 
case, the results from molecular profiling may offer a rational selection of the next regimen.  Therefore, Guardant360 CDx panel performed on 4/01/21 was likely to have been 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  38-year-old  female  enrollee  has  requested  reimbursement  for  Guardant360  CDx  panel 
performed on 4/01/21. 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 Guardant Assay is an assay done on the patients blood, looking for DNA 
presumably of the cancer cells origin. It is generally approved in situations where tissue biopsy 
is approved, wherein tissue biopsy is not safe or feasible. Overall, the percentage of patients who 
benefit using such assays to choose a therapeutic agent appears to be small. The overall use of 
this assay to pick a treatment is not likely to be beneficial. There is at least one mutation (PIK3CA) 
that does have therapeutic indication if the patient has an estrogen receptor positive cancer that 
is no longer responding to hormonal therapy with CDK4/6 inhibition. However, there is a lack of 
support for the whole general panel. Therefore, Guardant360 CDx panel performed on 4/01/21 
was not likely to have been more beneficial for evaluation of the patients medical condition than 
any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 23-year-old female enrollee has requested reimbursement for intraoperative monitoring on 
7/25/22. The Health Insurer has denied this request and reported that the service at issue was 
investigational for the treatment of the enrollees spastic quadriparesis secondary to cerebral palsy 
and spastic dislocation of the right hip. The physician reviewer found that the complex hip and 
femur surgery performed in this case involves not only bone and muscle tissue but proximity to 
major nerves that provide critical function to the lower extremities. These include the sciatic and 
femoral nerves. Damage to these nerves can result in paralysis, weakness, numbness, and chronic 
pain. Therefore, it is critical that the surgeon monitor the functioning of these nerves during this 
type of surgery. The alternative standard is to perform surgery without monitoring. In this clinical 
setting, performing complex hip and femoral surgery such as that done during varus deformity 
with neuromonitoring is more beneficial than not using neuromonitoring. Therefore, intraoperative 
monitoring on 7/25/22 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 23-year-old female enrollee has requested reimbursement for intraoperative monitoring on 
7/25/22. The Health Insurer has denied this request and reported that the service at issue was 
investigational for the treatment of the enrollees spastic quadriparesis secondary to cerebral palsy 
and spastic dislocation of the right hip. The physician reviewer found that in a review of the 
intraoperative monitoring records of 40 hip periacetabular osteotomies, Novais and colleagues 
found that abnormal recording alerts notified the surgeon in six cases, allowing the surgeon to alter 
the surgical plan and take steps to avert serious permanent sciatic nerve injury. In a case series of 
10 patients, Overzet and colleagues identified changes in 36% of the cases, due to leg lengthening 
procedures, that allowed the surgeon to take corrective procedures to avoid permanent injury. In a 
systematic review, Murena and colleagues concluded, There is general agreement in recognizing 
a role for intraoperative nerve monitoring to define the critical maneuvers, positions or pathologies 
that could lead to sciatic nerve intraoperative damage. In this clinical setting, given the complex 
nature of this patients severe hip deformity and osteotomy, the service at issue was likely to have 
provided more benefit for this patient than standard care.  Therefore, intraoperative monitoring on 
7/25/22 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 3 
A 23-year-old female enrollee has requested reimbursement for intraoperative monitoring on 
7/25/22. The Health Insurer has denied this request and reported that the service at issue was 
investigational for the treatment of the enrollees spastic quadriparesis secondary to cerebral palsy 
and spastic dislocation of the right hip. The physician reviewer found that in this case, the patient  is  a  23-year-old  female  with  spastic  quadriparesis  secondary  to  cerebral  palsy  and  spastic 
dislocation  of  right  hip.  Cerebral  palsy  is  a  group  of  permanent  disorders  that  affect  the 
development of movement, causing a limitation of activity. Spastic quadriparesis secondary to 
cerebral palsy occurs when a patient has spasticity and motor difficulties affecting all four 
extremities. There are many complications that can occur in a patient with cerebral palsy, including 
orthopedic disorders such as hip subluxation, dislocation, foot deformities, and scoliosis. In this 
case, the patient had spastic dislocation of the right hip and was treated by orthopedic surgery. 
Surgical  procedures  included  varus  derotational  osteotomy  of  the  right  proximal  femur, 
periacetabular osteotomy, lengthening of the hip adductors and iliopsoas, intraoperative nerve 
monitoring, and peripheral nerve block. Intraoperative nerve monitoring is a technique applied 
during a surgical procedure to continuously evaluate nerve signals to use as an early warning sign 
of nerve injury. There are several types of intraoperative nerve monitoring, including motor evoked 
potentials,  somatosensory  evoked  potentials,  electromyography,  and  anterior  root  muscle 
response. The evidence supporting the use of intraoperative nerve monitoring during surgical 
procedures varies in the medical literature depending on type of surgery. For surgeries that pertain 
to the hip, there is evidence that intraoperative nerve monitoring is effective at helping prevent 
nerve damage, especially in high-risk cases. In this case, given the patients history of cerebral 
palsy and spastic quadriparesis, she is at high-risk for severe deformities. In addition, evidence 
demonstrates the benefit of intraoperative nerve monitoring for surgical procedures of the hip. In 
this clinical setting of a patient is diagnosed with spastic quadriparesis secondary to cerebral palsy 
and spastic dislocation of right hip, intraoperative nerve monitoring is considered standard care. 
Therefore, intraoperative monitoring on 7/25/22 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  
 
This patient is a 55-year-old female with a history of morbid obesity and several weight related 
medical problems including prediabetes, gastroesophageal reflux disease (GERD), and mixed 
hyperlipidemia. On 11/30/22, the patient completed her preoperative psychological evaluation, 
and the provider noted that the patient was an appropriate candidate for surgery. The Health 
Insurer has denied the requested services not medically necessary. The physician reviewer found 
that new updated bariatric guidelines from the American Society for Metabolic and Bariatric 
Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders 
(IFSO) published in 2022, provide medical evidence to support the safety and efficacy of bariatric 
surgery in patients with a BMI of at least 35 kg/m2, with or without the presence of severe obesity 
related comorbid conditions (Eisenberg, et al.). The current BMI eligibility guidelines were 
published to replace and update the older existing National Institutes of Health (NIH) consensus 
guidelines. The ASMBS and IFSO guidelines state that bariatric surgery may be considered in any 
patient  with  BMI  of  at  least  35  kg/m2  or  greater  with  or  without  other  severe  obesity 
considerations and in patients with a BMI of at least 30 kg/m2 with comorbid metabolic disorders 
such as diabetes. The records document that this patient has a BMI of 36 kg/m2. In addition, the 
patient has completed a comprehensive multidisciplinary evaluation and meets criteria with a 
BMI of 35 kg/m2. Given this support, the requested bariatric surgery and inpatient stay are 
medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 63-year-old female who presented to her provider on 4/26/23. The patient has 
requested authorization and coverage for dexlansoprazole (Dexilant) 60 mg DR capsule. The 
Health Insurer has denied this request and reported that the requested medication is not 
medically necessary for the treatment of this patient. The physician reviewer found that the 
submitted documentation does not support the medical necessity of the requested medication. 
The  records  do  not  document  any  physiologic  reason  why  generic  dexlansoprazole  or 
lansoprazole would not provide the equivalent beneficial effect as Dexilant. Grady and colleagues 
explain that dexlansoprazole is the R(+)-enantiomer of lansoprazole. Current medical literature 
does not show that dexlansoprazole is more effective than the double enantiomer parent 
molecule, lansoprazole. Dexlansoprazole/Dexilant is the R-enantiomer of lansoprazole packaged 
in a special delivery system to work 24 hours per day at a dose of 60 mg. Lansoprazole, at 30 mg 
twice daily, would provide full acid inhibition for 24 hours per day and would be as good or better 
than dexlansoprazole 60 mg. Therefore, dexlansoprazole (Dexilant) 60 mg DR capsule is not 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 75-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 5/26/21. 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  cancer  Committee  (AJCC)  melanoma  stage  requires  further  prospective 
investigation in large, contemporary datasets of unselected patients. Prognostic GEP testing to 
differentiate melanomas at low versus high risk for metastasis should not replace pathologic 
staging procedures. Moreover, since there is a low probability of metastasis in early stage 
melanoma and a higher proportion of false-positive results, GEP testing should not guide clinical 
decision-making in this subgroup. It remains unclear where these GEP platforms provide clinically 
actionable prognostic information when used in addition to or in comparison with known 
clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor 
location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel lymph 
node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up 
schedules has not been established. Therefore, DecisionDx-Melanoma testing performed on 
5/26/21 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 75-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 5/26/21. 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 high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be 
amenable to excision but this suggests a high risk for the development of metastatic disease in 
the future. Such patients may be observed or treated with interferon-alpha. The data on 
DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node 
biopsy. There has also been some lack of consistency between various genes being used as 
biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the 
treatment algorithm beyond standard staging techniques. This is also the consensus opinion of 
the  National  Comprehensive  Cancer  Network  guidelines.  Therefore,  DecisionDx-Melanoma 
testing performed on 5/26/21 was not likely to have been more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
A 75-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 5/26/21. 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 per the National Comprehensive Cancer Network guidelines, the 
recommended therapy for stage IB cutaneous melanoma is history and physical and only 
imaging to evaluate certain signs and symptoms. The recommended primary category 1A 
treatment is wide excision of the melanoma and to discuss and offer sentinel lymph node 
biopsy. Furthermore, the guidelines state, For stage IB (pT2a) melanoma, the probability of a 
positive sentinel lymph node is greater than 10%. There is no indication for a gene expression 
assay to determine the primary course of treatment as sentinel lymph node biopsy should be 
offered with the above case. Marchetti and colleagues concluded, The prognostic ability of 
GEP tests among patients with localized melanoma varied by AJCC stage and appeared to be 
poor at correctly identifying recurrence in patients with stage I disease, suggesting limited 
potential for clinical utility in these patients. Therefore, DecisionDx-Melanoma testing 
performed on 5/26/21 was not likely to have been more beneficial than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 56-year-old male with a history of elevated prostate specific antigen (PSA) of 7.4 
ng/mL  and  prostate  cancer.  The  patient  was  evaluated  by  a  radiation  oncologist  who 
recommended combined short-term androgen deprivation therapy with proton beam radiation 
treatment. The Health Insurer has denied this request and reported that the services at issue are 
not medically necessary for the treatment of this patient. The physician reviewer found that the 
patients provider recommended a course of radiation therapy for the patients early stage 
prostate  cancer.  Per  the  National  Comprehensive  Cancer  Network  (NCCN)  guidelines,  the 
utilization of proton beam radiation therapy as a treatment modality is not supported for the 
routine treatment of patients with prostate cancer. Proton beam radiation therapy has unique 
properties compared to standard photon beam radiation therapy or x-ray beam radiation 
therapy in its ability to deposit radiation dose. However, there is a lack of data demonstrating 
that the use of proton beam radiation therapy will result in any significant improvement in clinical 
outcome (Royce and Efstathiou). Thus, proton beam radiation therapy is strongly indicated in 
settings where severe toxicities would result if normal tissue constraints cannot be met by 
photon beam. Additional studies have not demonstrated clinically significant improvements in 
survival or normal tissue toxicities over photon beam when treating prostate cancer (Royce, et 
al.). In addition, proton beam radiation therapy may be appropriate in cases of unusual anatomy 
or in cases of re-irradiation of adjacent tissues. On review of this patients records, there is a lack 
of documentation of unusual anatomy or previous radiation in the target area. Given these 
findings, the requested proton beam radiation therapy is not medically necessary for treatment 
of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 10-year-old female with a history of Pitt-Hopkins syndrome and associated motor 
planning difficulties, possible weakness in the oral area, and receptive and expressive language 
delays. The provider has recommended that the patient continue to receive individual speech 
and language therapy sessions twice a week for 60-minute sessions. The Health Insurer has 
denied the requested services as not medically necessary for treatment of the patients medical 
condition. The physician reviewer found that Pitt-Hopkins Syndrome is a genetic condition that 
presents as a neurodevelopmental disorder caused by monoallelic mutation or deletion in the 
transcription factor 4 (TCF4) gene (Kim, et al.). The patients underlying genetic defect does not 
preclude neuroplasticity while the brain is still undergoing neurodevelopment during the first 
two decades of life. In this developmental timeframe, speech therapy has been shown to impact 
ongoing  neurodevelopment.  Given  this  patients  motor  planning  disabilities,  oromotor 
weakness, and receptive and expressive language delays, the patients treatment will continue 
to consist of oral motor exercises, tactile-kinesthetic associative mapping of speech sounds in 
syllables and words, and a program of building receptive and expressive language. Furthermore, 
the patients previous speech and language therapy sessions twice a week for 60-minute sessions 
have produced positive results for the patient. For these reasons, the requested speech therapy 
sessions are medically necessary for treatment of this patient.