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

Summary Reviewer 1 
 
A 47-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 8/26/21. 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 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 stage I melanoma and a higher 
proportion of false-positive result, GEP testing should not guide clinical decision making in this 
group. Commercially available GEPs, such as DecisionDx-Melanoma testing, are marketed as 
being able to classify cutaneous melanoma into separate categories based on risk of metastasis. 
However, 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. Various (mostly retrospective) studies of prognostic GEP testing suggest its role 
as an independent predictor of worse outcome, although not superior to Breslow thickness or 
sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of 
outcome across the risk spectrum of melanoma. Prospective validation studies are required to 
more  accurately  define  the  clinical  utility  of  molecular  testing  prior  to  widespread 
implementation  of  GEP  for  prognostication  of  cutaneous  melanoma,  and  in  particular  to 
determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant 
treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 8/26/21 was not 
likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 47-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 8/26/21. 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. Therefore, DecisionDx-Melanoma  testing performed on 8/26/21 was not likely to have been more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 47-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 8/26/21. 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  current  guidelines  recommend  using  histopathologic  features  of  the 
melanoma  and  consideration  of  sentinel  lymph  node  biopsy  to  accurately  stage  and 
prognosticate localized cutaneous melanoma.  Gene expression profile (GEP) testing and other 
molecular testing platforms are being tested in melanoma for risk stratification, but no high level 
evidence has shown they are superior to established standards, and some data suggests they 
perform poorly in stage I disease.  Furthermore, GEP testing does not inform on treatment of 
localized, early stage disease. Therefore, DecisionDx-Melanoma testing performed on 8/26/21 
was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 58-year-old female who fell from a horse while in Mexico on 7/27/22. The patient 
sustained bilateral rib fractures and bilateral pneumothoraces. The patient was transferred by air 
ambulance from Mexico to a facility in San Francisco, California. The Health Insurer has denied 
the air ambulance services as not medically necessary for treatment of the patients medical 
condition. This denial is the subject of this appeal and determination. The physician reviewer found 
that the air medical transport is considered medically necessary when the patients condition is life-
threatening such that any form of transportation other than ambulance would be medically 
contraindicated, the time needed to transport by ground poses a threat to the patients survival, and 
the patient is transported to the nearest hospital with appropriate facilities for treatment. When 
transporting from one hospital to another, the air medical transport criteria must be met, and the 
initial hospital must not have the required services and facilities available to treat the patient. In 
this case, the patient had been admitted in the initial hospital in Mexico for seven days. The records 
do not document that the patient had a flail chest or required emergent rib fixation. The initial 
hospital had already managed the left pigtail catheter for seven days, and the patients pain was 
controlled. For these reasons, the air ambulance  services were not medically necessary for 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 49-year-old male who presented to his provider on 4/05/22. The records noted 
erectile dysfunction and Peyronies disease. Digital rectal examination revealed a 30 g anodular 
prostate. On 4/06/22, the records noted that the patients medications included finasteride. The 
patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the 
pelvis. The physician reviewer found that the submitted documentation supports the medical 
necessity of the requested services in this clinical setting. In this patients case, MRI is indicated 
based on the elevated PSA, age of the patient, and previous history of finasteride. Increasingly, 
as supported by National Comprehensive Cancer Network (NCCN) guidelines, multiparametric 
prostate MRI and serum biomarker testing are being used to assist in this initial assessment of an 
elevated PSA as an alternative to routine initial transrectal ultrasound-guided biopsy. Prostate 
MRI with MRI-directed biopsy is increasingly regarded as a valuable tool for refining risk status 
for clinically meaningful prostate cancer. Multiparametric MRI-directed biopsy is more sensitive 
than  systematic  transrectal  ultrasound-guided  techniques  when  used  alone  for  detecting 
clinically significant prostate cancers and, importantly, for reducing the number of insignificant 
cancers diagnosed. Therefore, the requested MRI of the pelvis is medically necessary for the 
evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 10-year-old male with a history of short stature and suspected pediatric growth 
hormone  (GH)  deficiency  related  to  optic  nerve  hypoplasia  (ONH).  The  provider  has 
recommended treatment with GH therapy. The Health Insurer has denied the requested treatment 
as not medically necessary for treatment of the patients medical condition. This denial is the 
subject of this appeal and determination. The physician reviewer found that this patients records 
document a history of short stature with a previous diagnosis of ONH, which is a congenital 
disorder of midbrain development that can be associated with hypopituitarism. However, this 
patients records lack documentation confirming a diagnosis of ONH by MRI, genetic testing, 
and/or dilated ophthalmic examination. There is also a lack of evidence of anterior pituitary 
hormone deficiencies or intracranial lesions. As noted in the medical literature and current 
guidelines, the essential diagnostic criterion for idiopathic short stature is a height z-score -2.25 
standard deviations below the mean (Grimberg, et al.). The available records indicate that this 
patient has not met this essential diagnostic criterion, because his height has been within normal 
range with a z-score between -2.0 and +2.0. Based on the patients normal bone age, normal recent 
height, and chronological age, the patients predicted adult height was reported as 174.9 cm, 
estimated within 3.1 cm. This predicted adult height is within the normal range for age and gender 
and within two standard deviations of the patients estimated MPTH of 72.5 inches. There is a lack 
of documentation indicating the patient underwent GH provocative tests to support the diagnosis 
of pediatric GH deficiency. Moreover, direct height measurements of both biological parents are 
preferred to evaluate suspected growth disorders in pediatric endocrine care, as self-reported 
parental heights can be unreliable. Overall, the patient does not meet the U.S. Food and Drug 
Administration (FDA) requirements for any approved indications for GH therapy. For these 
reasons, the requested Norditropin 10 mg/1.5 mL pen injector is not medically necessary for 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 27-year-old female. Notes dated 7/20/22 reported that biopsies and clinical 
presentation were consistent with moderate-severe Crohns disease, with inadequate response to 
budesonide. The physician reviewer found that the submitted documentation supports the medical 
necessity of the requested medication. Large, high-quality, randomized controlled trials have 
demonstrated the safety and efficacy for induction and maintenance of remission in patients with 
moderate-severe Crohn's disease using Skyrizi. D'Haens and colleagues note that risankizumab is 
effective and well tolerated as induction therapy in patients with moderately to severely active 
Crohn's  disease.  Ferrante  and  colleagues  report  that  long-term  maintenance  treatment  with 
subcutaneous risankizumab is well tolerated by patients with Crohn's disease, with no new safety 
signals. With Skyrizi, patients achieve high rates of clinical and endoscopic remission.  The 
American College of Gastroenterology (ACG) guidelines do not recommend alternatives such as 
budesonide, which this patient has tried and failed, as chronic therapy. In this case, the records 
document that the patient has had improvement with Skyrizi, and a discontinuation may result in 
recurrent symptoms and complications such as disease flare, hospitalization, need for surgery, 
fistula, and stricture. Continuation of therapy after intravenous induction doses would warrant 
subcutaneous dosing. Given that current medical literature supports the use of Skyrizi in this 
clinical setting, the requested medication is medically indicated. Therefore, Skyrizi 150 mg is 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 26-year-old female with a history of major depressive disorder. The patient has 
requested  authorization  and  coverage  for  six  additional  sessions  of  adult  mental  health 
transcranial magnetic stimulation. The physician reviewer found that per the literature, TMS is 
indicated for severe, recurrent major depressive disorder that has not responded to traditional 
medication and psychotherapy treatment. This patient qualifies for the diagnosis of treatment 
refractory depression given that she has failed more than three antidepressant trials in addition 
to psychotherapy. Additionally, she was evaluated by a psychiatrist who recommended TMS. The 
patient made significant gains with the beginning of TMS treatment, and it would be ill advised 
to discontinue this treatment before she has completed a full treatment cycle, as defined by the 
TMS psychiatrist. The medical evidence supports the use of TMS at this point in the decision-
making algorithm for treatment-refractory depression. TMS is the appropriate next step in the 
treatment of this patient and should be completed until the patient has achieved maximal effect 
from this treatment. Therefore,  six additional sessions of  adult mental health transcranial 
magnetic stimulation are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 63-year-old male who presented to his provider on 10/17/22. The records noted 
that a fusion magnetic resonance imaging (MRI) and biopsy of the prostate revealed intermediate 
risk Gleason score 3+4 cancer in five out of 15. 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 service. HIFU is an 
established  alternative  to  cryotherapy  for  local  nonmetastatic  disease  that  is  established  as 
effective,  particularly  in  cases  of  radiation  failure.  Given  this  patients  potentially  locally 
controllable disease and the potential for good results with minimal side effects, the requested 
service is medically indicated. Therefore, HIFU is medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 12-year-old male with 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 authorization and coverage for occupational therapy. The Health Insurer has denied 
the requested services as not medically necessary. This denial is the subject of this appeal and 
determination. The physician reviewer found that the current peer-reviewed medical literature 
supports the use of occupational therapy in the routine management of pediatric patients with 
autism (Houtrow, et al.). In addition, occupational therapy is known to be effective in improving 
functional outcomes for patients with autism with deficits as documented in this patients case 
(Schoen, et al.; Schaaf, et al.). Kashefimehr and colleagues noted that their findings support the 
effectiveness  of  occupational  therapy  with  a  sensory-integrated  approach  in  improving 
occupational  performance  in  pediatric  patients  with  autism  spectrum  disorders.  Moreover, 
occupational therapy is the most appropriate treatment modality to address the patients deficits. 
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 IADLs and ADLs, which are planned to be addressed with the requested 
occupational therapy. Therefore, the requested occupational therapy is medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 63-year-old male with a history of high-risk prostate cancer. A hydrogel spacer 
was recommended as well. The Health Insurer has denied the requested services as not medically 
necessary for treatment of the insureds medical condition. The physician reviewer found that, 
overall, the utilization of proton beam therapy is not recommended for routine use in the 
treatment  of  patients  with  prostate  cancer.  Proton  beam  therapy  has  unique  properties 
compared to standard photon beam therapy in its ability to deposit radiation dose and can 
potentially result in fewer areas of low scattered radiation dose. Proton beam therapy is currently 
utilized and most strongly indicated in settings where severe toxicities would result if normal 
tissue constraints cannot be met by photon beam. However, in the treatment of patients with 
prostate cancer, studies have failed to show that the use of proton beam therapy results in a 
demonstrable, clinically significant difference in overall survival, quality of life, or reduction of 
high-grade toxicities over photon beam therapy (Royce and Efstathiou). Proton beam therapy 
may be efficacious in the treatment of patients with prostate cancer in cases of unusual anatomy 
or in cases of re-irradiation of adjacent tissues. Volumetric modulated arc therapy (VMAT) is a 
standard photon therapy radiation technique that is frequently utilized to achieve clinically 
equivalent normal organ dose constraints as proton beam therapy (Schroeck, et al.; Nogueira, et 
al.). Excellent dose toxicity outcomes have been demonstrated for standard VMAT in locally 
advanced prostate cancer. In this case, the records provided for review indicate that this patient 
has high-risk prostate cancer, but there is a lack of documentation indicating that the patient had 
unusual anatomy or re-irradiation of adjacent tissues. Therefore, the requested proton beam 
therapy is not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 27-year-old female with a history of severe adolescent idiopathic scoliosis with 
trunk rotation asymmetry, trunk shift, and associated pain. The patient was diagnosed with 
scoliosis at 13 years of age. The provider has recommended treatment with surgical correction of 
the patients scoliosis. The Health Insurer has denied the requested surgery 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 the records provided for review 
indicate that the patient has a history of severe adolescent idiopathic scoliosis. According to Kuznia 
and colleagues, Patients with severe scoliosis (Cobb angle of 40 degrees or more) may have 
physical pain, cosmetic deformity, psychosocial distress, or, rarely, pulmonary disorders. The 
authors note that surgical correction of scoliosis should be reserved for severe cases, while 
conservative treatment may be effective for mild to moderate scoliosis. Per Yang and colleagues, 
Surgical  management  of  adolescent  idiopathic  scoliosis  can  be  performed  using  standard 
posterior spinal fusion or with a posterior minimally invasive approach. The benefits of the 
requested surgical procedure are further corroborated by Nishida and colleagues, who concluded 
that, Posterior correction and fusion surgery have improved preoperative asymmetric global 
rotational kinematics of trunk and pelvis in transverse plane to symmetric postoperatively in 
adolescent idiopathic scoliosis patients with thoracic single major curve. In this case, the patient 
has a history of severe scoliosis with a Cobb angle of 66 degrees as measured from the superior 
endplate at T8 to the inferior endplate at L2. There is a lack of additional imaging demonstrating 
any other significant spinal deficits that could be contributing to the patients pain. The patient has 
undergone physical therapy without adequate benefit. The peer-reviewed literature supports that 
conservative treatment is not as effective as surgical correction in severe cases of scoliosis. 
Without surgical correction, the patients severe curve is likely to progress and further affect her 
pulmonary function. Moreover, an initial perioperative hospital stay is indicated and supported for 
lumbar fusion procedures as recommended for this patient. For these reasons, the requested 
arthrodesis, anterior, for spinal deformity with or without cast, and anterior instrumentation with 
an inpatient stay are medically necessary for the treatment of the patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 26-year-old male who sustained a traumatic spinal cord injury in a motor vehicle 
accident. On 7/14/22, the patient was transported by air ambulance from the hospital in San Diego 
to a specialized rehabilitation hospital in Englewood, Colorado. The Health Insurer has denied the 
services at issue 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 Air 
medical  transport  is  considered  medically  necessary  when  the  patients  condition  is  life-
threatening such that any form of transportation other than an ambulance would be medically 
contraindicated, the time needed to transport by ground poses a threat to the patients survival, and 
the patient is transported to the nearest hospital with appropriate facilities for treatment. When 
transferring a patient from one hospital to another, the air medical transport criteria must be met, 
and the initial hospital must not have the required services and facilities available to treat the 
patient. In this case, the patient sustained a traumatic spinal cord injury following a motor vehicle 
accident and reported no sensation or motor function in his bilateral lower extremities. After the 
initial hospital in San Diego, California provided all the care it could, the patient was transported 
by air ambulance to the nearest specialized rehabilitation hospital in Englewood, Colorado. 
Overall, the patient met the criteria for air ambulance transportation. The transferring hospital was 
not capable of providing specialized inpatient spinal cord rehabilitation services, and the receiving 
hospital was over 1,000 miles away. Given these findings, the air ambulance services performed 
on 7/14/22 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 45-year-old female with a family history of breast cancer in her mother. The patient 
presented on 12/16/22 for magnetic resonance imaging (MRI) of the breast as a screening for 
suspected malignant neoplasm of the breast. The Health Insurer has denied the services at issue as 
not medically necessary for the evaluation of the patients medical condition. This denial is the 
subject of this appeal and determination. The physician reviewer found that according to American 
College of Radiology (ACR) guidelines, annual breast MRI screening is indicated for high-risk 
patients with a lifetime risk of breast cancer of 20% or greater. The records available for review 
indicate that this patient has a family history of breast cancer and was calculated to have above a 
20% lifetime risk of breast cancer. The patient appropriately underwent a breast MRI to screen for 
suspected malignant neoplasm of the breast. Given these findings, the breast MRI performed on 
12/16/22 was medically necessary for the evaluation of this patient.