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

Summary Reviewer 1 
 
A 60-year-old male enrollee has requested reimbursement for CPT 81529, which is an oncology 
(cutaneous melanoma, mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 
content and three housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm 
reported as recurrence risk including likelihood of sentinel lymph node metastasis, on 3/8/22. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  service  at  issue  was 
investigational for the evaluation of the enrollees melanoma. The physician reviewer found that 
the service at issue is not approved by the U.S. Food and Drug Administration (FDA) for the 
staging or treatment of melanoma. Current medical literature does not demonstrate the clinical 
utility, appropriate use, or improved outcomes for melanoma patients with the use of the service 
at issue, and there is insufficient evidence to confirm its reliability or improved outcomes in the 
staging  or  treatment  of  melanoma.  Traditional  pathologic  factors  remain  the  strongest 
independent predictors of recurrence risk. In the setting of a thin melanoma, standard therapy is 
a  wide  local  excision  followed  by  periodic  skin  examination.  The  service  at  issue  is  not 
recommended under the National Comprehensive Cancer Network (NCCN) guidelines in this 
clinical setting, and the results from the testing would not change the outcome or treatment. The 
NCCN further notes that it remains unclear whether gene expression profiling (GEP) platforms 
provide clinically actionable prognostic information. The American Academy of Dermatology 
guidelines do not report any practical benefit from the use of the service at issue in this clinical 
setting.  Therefore,  CPT  81529,  which  is  an  oncology  (cutaneous  melanoma,  mRNA,  gene 
expression profiling by real-time RT-PCR of 31 genes (28 content and three housekeeping), 
utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk including 
likelihood of sentinel lymph node metastasis, on 3/8/22, was not likely to have been more 
beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
A 60-year-old male enrollee has requested reimbursement for CPT 81529, which is an oncology 
(cutaneous melanoma, mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 
content and three housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm 
reported as recurrence risk including likelihood of sentinel lymph node metastasis, on 3/8/22. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  service  at  issue  was 
investigational for the evaluation of the enrollees melanoma. The physician reviewer found that 
the American Academy of Dermatologys clinical guidelines for melanoma note that routine 
molecular testing, including GEP, for prognostication is discouraged until better use criteria are 
defined. The guidelines further note that the application of molecular information for clinical 
management, such as informing on sentinel lymph node eligibility, follow-up, and/or therapeutic 
choices,  is  not recommended  outside  of a  clinical  study or trial.  The NCCN  guidelines on 
cutaneous melanoma note that the use of GEP testing according to specific American Joint 
Committee on Cancer (AJCC)-8 melanoma staging, before or after sentinel lymph node biopsy, 
requires  further  prospective  investigation  in  large,  contemporary  data  sets  of  unselected 
patients, and that prognostic GEP testing to differentiate melanomas at low versus high risk for 
metastasis should not replace pathologic staging procedures. The NCCN further notes that there 
is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive 
results,  and  that  GEP  testing  should  not  guide  clinical  decision-making  in  this  subgroup.  Therefore, CPT 81529, which is an oncology (cutaneous melanoma, mRNA, gene expression 
profiling by real-time RT-PCR of 31 genes (28 content and three housekeeping), utilizing formalin-
fixed paraffin-embedded tissue, algorithm reported as recurrence risk including likelihood of 
sentinel lymph node metastasis, on 3/8/22, was not likely to have been more beneficial for 
evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 28-year-old female with a history of a prior emergency hysterectomy due to 
placenta  accreta  and  postpartum  hemorrhage.  The  patient  is  requesting  coverage  for  IVF, 
intracytoplasmic sperm injection (ICSI), and assisted hatching. 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 this 
patient has requested coverage for IVF, ICSI, and assisted hatching. The records reflect that the 
patient underwent a hysterectomy. As the patient does not have a uterus, she will require IVF and 
a gestational surrogate in order to have biological children. Regarding ICSI, according to the 
American Society for Reproductive Medicine (ASRM) guidelines, in the absence of a male-factor, 
ICSI has not been shown to improve live birth outcomes. On the contrary, ICSI may lead to a 
decrease in live birth rates. Regarding assisted hatching, one medical study concluded that despite 
significantly improved odds of clinical pregnancy, there is insufficient evidence to determine 
whether assisted hatching has any effect on live birth rates (Zeng, et al.). The ASRM guidelines 
similarly state that laser-assisted hatching should not be routinely recommended for all patients 
undergoing IVF. Overall, the patient will require IVF and a gestational surrogate in order to have 
biological children. However, there is a lack of documentation indicating that this patient has a 
history of male-factor infertility. Therefore, ICSI is not indicated for this patient. Finally, the 
current medical literature and guidelines have not shown that assisted hatching is indicated for this 
patient. All told, the requested IVF is medically necessary for the treatment of this patient, but the 
requested ICSI and assisted hatching are not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 19-year-old female enrollee has requested reimbursement for a Papanicolaou (Pap) smear 
performed on 1/03/22. 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 cervical cancer screening with Pap smear testing is a preventative measure 
included in a routine well-women examination. Per current medical care and American College 
of Obstetricians and Gynecologists (ACOG) guidelines, screening is typically initiated at age 21. In 
this clinical scenario, the patient was 19 years old on the date of service in dispute. Per the 
standard of care, it would have been appropriate for the provider to defer screening until age 21, 
as per the guidelines. Therefore, the Pap smear performed on 1/03/22 was not likely to have 
been more beneficial for evaluation of the patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 19-year-old female enrollee has requested reimbursement for a Papanicolaou (Pap) smear 
performed on 1/03/22. 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 current medical evidence does not supports the services at issue in this 
clinical setting. This patient was seen by her provider at 19 years of age, and a Pap smear was 
performed. Pap smear in women under the age of 21 for routine screening is not indicated per 
multiple professional organizational opinions. It is not more beneficial for this patient to have a 
Pap smear than the standard treatment of waiting to screen for cervical cancer at age 21. 
Therefore, the Pap smear performed on 1/03/22 was not likely to have been more beneficial for 
evaluation of the patient than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 19-year-old female enrollee has requested reimbursement for a Papanicolaou (Pap) smear 
performed on 1/03/22. 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 submitted documentation fails to demonstrate the superior efficacy of 
the services at issue. Currently, the recommendation is to begin cervical cancer screening at age 
21 in otherwise healthy women. The records do not demonstrate that a Pap smear was indicated 
in this patient at age 19. A pelvic examination is also not required in an asymptomatic patient for 
sexually transmitted disease screening or renewal of contraception. Therefore, the Pap smear 
performed on 1/03/22 was not likely to have been more beneficial for evaluation of the patient 
than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 28-year-old female with a medical history including fibromyalgia, migraines and 
chronic fatigue. She is requesting naltrexone HCl for the treatment of fibromyalgia and migraine 
pain. The physician reviewer found that Fibromyalgia is a chronic pain disorder with treatment 
directed at reducing the major symptoms including pain, fatigue, insomnia and cognitive 
dysfunction. Treatment is approached in a stepwise pattern, starting with education and 
treatment of any mood or sleep disturbances. Initiation of low-dose tricyclic antidepressants or 
selected antidepressants or anticonvulsants are tried when individuals do not respond to 
education alone. Key aspects of treatment include an exercise program, physical therapy, 
psychological interventions and multidisciplinary programs.  Combination therapy is also 
recommended. During flares of pain, acetaminophen, tramadol and nonsteroidal anti-
inflammatory drugs are recommended. There is limited data to support the use of naltrexone in 
the treatment of fibromyalgia. Low-dose naltrexone has been associated with improved general 
satisfaction with life and with improved mood but not associated with improved fatigue or 
sleep. In this case, the documentation does not support that the patient has tried and failed all 
recommended treatment for fibromyalgia with associated chronic fatigue. There is limited data 
to support the use of low-dose naltrexone for the treatment of fibromyalgia. The data that is 
available does not show an improvement in chronic fatigue, which is one of the patients 
prominent symptoms. Therefore, naltrexone HCL 50 mg used to compound to the final 
outcome strength of 4.5 mg provided from 6/07/21 to October 2021 was not medically 
necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a four-year-old female with a history of lamellar ichthyosis. The records provided 
for review indicate that the patient was previously treated with tazarotene cream with great efficacy 
and improvement in her skin condition. The provider has recommended treatment with tazarotene 
cream. 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 currently, there is a lack of U.S. Food and Drug 
Administration (FDA) approved treatments for patients with lamellar ichthyosis. According to the 
Pediatric Dermatology Research Alliance (PeDRA) guidelines, topical retinoids are preferred over 
systemic retinoids for the treatment of pediatric patients with lamellar ichthyosis, as topical 
retinoids have been demonstrated to have a higher level of tolerability and a greater reduction of 
side effects (Hanson, et al.; Zaenglein, et al.). In this case, the patient has a history of lamellar 
ichthyosis which has been successfully treated with tazarotene cream. The records provided for 
review indicate that the discontinuation of topical tazarotene resulted in worsening of the patients 
scales and symptoms. Furthermore, the medical literature suggests that topical retinoids are the 
preferred treatment option over systemic retinoids for pediatric patients with lamellar ichthyosis. 
For these reasons, the requested tazarotene cream 0.1% is medically necessary for the treatment of 
this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 40-year-old female enrollee has requested authorization and coverage for thermal destruction 
of intraosseous basivertebral nerve. The Health Insurer has denied this request indicating that 
the requested services are considered investigational for treatment of the insureds spondylosis 
without myelopathy or radiculopathy, lumbar region. The physician reviewer found that with 
regard to the request for thermal destruction of intraosseous basivertebral nerve, there is 
medical evidence supporting this treatment modality for the treatment of chronic low back pain. 
Per  Fischgrund  and  colleagues,  patients  treated  with  radiofrequency  ablation  of  the 
basivertebral nerve for chronic low back pain exhibited sustained clinical benefits in Oswestry 
Disability Index (ODI) and Visual Analog Scale (VAS) and maintained high responder rates at two 
years following treatment.  The authors concluded that, Basivertebral nerve ablation appears 
to be a durable, minimally invasive treatment for the relief of chronic low back pain. Similarly, 
Khalil and colleagues found that, minimally invasive radiofrequency ablation of the basivertebral 
nerve led to significant improvement of pain and function at 3-months in patients with chronic 
vertebrogenic related low back pain. Furthermore, Sayed and colleagues reported that, Current 
evidence supports long-term improvement in pain and function in properly selected patients for 
basivertebral nerve ablation. Within the records available for review, there is documentation of 
chronic low back pain and the patient has been diagnosed with spondylosis without myelopathy 
or radiculopathy of the lumbar region, and intervertebral disc degeneration of the lumbar region. 
The treating provider has recommended thermal destruction of intraosseous basivertebral 
nerve. The medical records indicate that the patient has exhausted conservative treatment 
including physical therapy, medication management, transforaminal epidural steroid injections, 
and  chiropractic  care.  Therefore,  the  requested  thermal  destruction  of  intraosseous 
basivertebral nerve is likely to be more beneficial for treatment of the patients medical condition 
than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 40-year-old female enrollee has requested authorization and coverage for thermal destruction 
of intraosseous basivertebral nerve. The Health Insurer has denied this request indicating that 
the requested services are considered investigational for treatment of the insureds spondylosis 
without myelopathy or radiculopathy, lumbar region. The physician reviewer found that when 
Modic changes are present in the disc spaces, the vertebrogenic source is considered an etiology 
of a patients chronic back pain. To address this issue, ablation of the basivertebral nerve has 
been demonstrated to be a safe and effective procedure that is evidence-based for appropriately 
selected candidates. One study noted that based on the U.S. Preventative Task Force (USPSTF) 
criteria for grading evidence, basivertebral nerve ablation has Level A grade evidence with high 
certainty that the net benefit is substantial in appropriately selected individuals (Sayed, et al.). 
Furthermore, a prospective, randomized, multicenter study by Khalil and colleagues highlighted 
that basivertebral nerve ablation led to significant improvement of pain and function at three- months in patients with chronic vertebrogenic related low back pain. In terms of long-term 
results, Fischgrund and colleagues demonstrated basivertebral nerve ablation was associated 
with sustained clinical improvements in pain and improvement in function at a mean of 6.4 years 
following treatment. Standard therapies in this instance would be conservative care with physical 
therapy,  medications,  and  procedural  interventions  such  as  lumbar  medial  branch 
radiofrequency ablation. On review of this patients records, she has failed to improve despite 
adequate attempts at conservative therapies. Given these findings, the requested thermal 
destruction of intraosseous basivertebral nerve is likely to be more beneficial for treatment of 
the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
A 40-year-old female enrollee has requested authorization and coverage for thermal destruction 
of intraosseous basivertebral nerve. The Health Insurer has denied this request indicating that 
the requested services are considered investigational for treatment of the insureds spondylosis 
without myelopathy or radiculopathy, lumbar region. The physician reviewer found that this 
patient has a longstanding history of low back pain that is purported to be vertebrogenic. The 
records indicate the pain occurs in the patients low back with prolonged sitting, standing, 
bending. and lifting that is improved with rest and walking. The records suggest that this patients 
pain is primarily axial in nature. The patient experienced six months of pain relief with lumbar 
epidural steroid injections in the past. Recent epidural steroid injections provided 30% relief. The 
patients pain could be vertebrogenic or facetogenic based on the movements that provoke her 
pain in the clinic notes. Radiofrequency ablation of medial branch nerves is a standard therapy 
often used to treat facet mediated pain. Based on the available documentation, it has not been 
determined  whether  the  patient  has  facet  mediated  pain  and  if  she  might  benefit  from 
radiofrequency ablation. Also, there is a lack of comparative studies of basivertebral nerve versus 
radiofrequency ablation of facets for the treatment of patients with chronic low back pain. It 
cannot be determined that basivertebral nerve would be superior to radiofrequency ablation of 
medial branch nerves in this case. In sum, the requested thermal destruction of intraosseous 
basivertebral nerve is not likely to be more beneficial for treatment of the patients medical 
condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 61-year-old male with persistent, symptomatic atrial fibrillation with multiple 
hospital visits for chemical cardioversion. The patient has requested authorization and coverage 
for hybrid convergent ablation treatment of atrial fibrillation (CPT 33266). The physician reviewer 
found  that  the  hybrid  convergent  procedure  has  superior  effectiveness  compared  with 
endocardial-only ablation in patients with advanced atrial fibrillation. This was demonstrated in 
the CONVERGE trial, a multicenter, randomized clinical trial which also showed a significantly 
higher number of patients in the hybrid convergent arm remaining free from cardioversion at 18 
months follow-up. This was also associated with an acceptable safety profile. The cumulative 
experience with the convergent procedure is now greater than 10,000 patients to date and has 
an established position in managing atrial fibrillation. Therefore, hybrid convergent ablation 
treatment of atrial fibrillation (CPT 33266) is medically necessary for treatment of the patients 
medical condition.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 31-year-old female who presented to her provider on 7/15/22 with a flare of truncal 
and facial acne vulgaris. The patient has requested authorization and coverage for Azelex 20% 
cream. 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. There are limited treatments available to control 
acne vulgaris during pregnancy or in patients trying to conceive. Most common topical treatments 
are either contraindicated in pregnancy, such as retinoids, or do not have data to support their safe 
usage in pregnancy. Kong and Tey recommend the use of topical medications as  first-line 
treatment for acne vulgaris in pregnant and lactating women, including antibiotics, such as 
erythromycin and clindamycin, and azelaic acid. Prescription azelaic acid is available in different 
concentrations such as a 15% gel or a 20% cream. There is a lack of head-to-head trials showing 
a clear superiority of using a higher concentration of azelaic acid in a 20% cream versus a 15% gel 
or vice versa. Given that either formulation is a safe and effective treatment in this specific subset 
of patients, the requested medication is reasonable. Therefore, Azelex 20% cream is medically 
necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 61-year-old female with prior instrumented lumbar fusion. The patient has 
requested authorization and coverage for percutaneous or minimally invasive sacroiliac joint 
arthrodesis. The physician reviewer found the current medical evidence supports the requested 
services in this clinical setting. Sturesson and colleagues noted significant improvement with 
surgical treatment for chronic sacroiliac joint mediated pain with minimally invasive fusion over 
continued conservative management. Martin and colleagues noted, Minimally invasive 
sacroiliac joint fusion provides clinically significant improvement in pain scores and disability in 
most patients, across multiple studies and implant manufacturers. In addition, Martin and 
colleagues noted, The authors of this manuscript recommend that in order to be candidates 
for an MIS SI joint fusion, patients have at least 3 of 5 positive provocative exam maneuvers, 
report pain consistent with that coming from the SI joint with a positive Fortin finger sign, and 
have a positive response to diagnostic SI joint injections. In this case, the patient has clear 
degenerative changes of the sacroiliac joint with positive temporary response to injection, pain 
noted by a Fortin sign, and 5/5 provocative SI joint tests on exam. The requested services are 
likely to decrease pain and increase function. Therefore, the requested percutaneous or 
minimally invasive sacroiliac joint arthrodesis is medically necessary for the treatment of this 
patient.