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

Summary Reviewer 1 
 
A  63-year-old  female  enrollee  has  requested  reimbursement  for  FoundationOne  CDx  TM 
comprehensive genomic profiling test performed on 1/26/21. 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 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 to predict candidates for specific mutation-driven 
treatment holds promise. Patients with inflammatory and metastatic breast cancers benefit from 
next  generation  sequencing  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.  In  addition, molecular  markers  can indicate response  to 
immunotherapy. The medical evidence supports the services at issue in this setting. Therefore, 
FoundationOne CDx TM comprehensive genomic profiling test performed on 1/26/21 was likely 
to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 63-year-old female enrollee has requested reimbursement for FoundationOne CDx TM 
comprehensive genomic profiling test performed on 1/26/21. 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 there is sufficient support 
for the services at issue in this setting. Many patients with metastatic breast cancer encounter 
off-label therapies that may be supported by medical evidence. Von Hoff and colleagues 
performed a study of 86 patients. The progression-free survival on regimen selected by 
molecular profiling was compared to progression-free survival on the last chemotherapy 
regimen. The authors noted that the regimen selected by molecular profiling offered a 27% 
survival advantage. This trial has very significant results for patients with stage IV tumors. This 
patient may be offered something off-label or a phase I/II clinical trial. The results from 
molecular profiling offer a rational selection of the next regimen. More recent data on breast 
cancer also supports the use of FoundationOne testing. The National Comprehensive Cancer 
Network guidelines also support a role for mutational analysis. Therefore, FoundationOne CDx 
TM comprehensive genomic profiling test performed on 1/26/21 was likely to have been more 
beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A  63-year-old  female  enrollee  has  requested  reimbursement  for  FoundationOne  CDx  TM 
comprehensive genomic profiling test performed on 1/26/21. 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 there is a lack of support for the 
services at issue in this clinical setting. The hope is that the FoundationOne assay will identify a 
target that would indicate a useful treatment drug. At this time, there is a lack of evidence that 
therapy guided by such assays is likely to be superior to therapy guided by the literature and 
experience. A randomized study by Le Tourneau and colleagues did not indicate that genome 
driven therapy was superior to conventional therapy. Marquart and colleagues indicated that the 
percentage of patients who benefit from assay directed therapy is actually quite low. The use of 
the  FoundationOne  assay  was  not  likely  to  have  been  of  clinical  benefit.  Therefore, 
FoundationOne CDx TM comprehensive genomic profiling test performed on 1/26/21 was not 
likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 20-year-old female who presented to her provider on 3/2/21 with chronic sacral 
and coccygeal pain for the past seven months. The patient has requested reimbursement for MRI 
CPT 72195 on 12/29/21. The Health Insurer has denied this request and reported that the service 
at issue was not medically necessary for the evaluation of this patient. This denial is the subject of 
this appeal and determination. The physician reviewer found that the submitted documentation 
supports the medical necessity of the service at issue. Current medical literature regarding the use 
of MRI for the evaluation of low back pain note that MRI may be indicated in some clinical 
presentations to rule out infectious or tumor processes. In this case, the patient had failed maximal 
conservative care and had ongoing severe pain and functional limitations. Given that this patient 
had failed six weeks of conservative care in a comprehensive manner, the use of MRI was 
supported to rule out infectious or neoplastic causes for the pain. Therefore, MRI CPT 72195 on 
12/29/21 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 42-year-old male who has requested authorization and coverage for Oxbryta 500 
mg. The patient has requested authorization and coverage for Oxbryta 500 mg. The physician 
reviewer found that the submitted documentation supports the requested medication in this 
clinical setting. Voxelotor (Oxbryta) has been approved by the U.S. Food and Drug Administration 
for the treatment of sickle cell disease in adults and pediatric patients who are four years of age 
or older. Adakveo and Endari are used to decrease the incidence of vaso-occlusive events. This 
patients main issue is fatigue. Voxelotor may be considered in patients whose morbidity is from 
severe anemia (hemoglobin less than or equal to 6.5 g/dL), excessive fatigue, poor quality of life, 
and decreased Clinical Global Impression of Change (CGI-C) score. The other drugs are not used 
for fatigue. The use of the requested medication is supported by phase III clinical trials. Therefore, 
Oxbryta 500 mg is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 47-year-old female who presented to her provider on 11/29/22. The records noted 
a diagnosis of Susac syndrome, currently treated with intravenous immunoglobulin (IVIG) and 
rituximab. The patient has requested authorization and coverage for Panzyga SOL 5 gm/50 mL. 
The Health Insurer has denied this request and reported that the requested medication is not 
medically necessary for the treatment of this patient. This denial is the subject of this appeal and 
determination. The physician reviewer found that the submitted documentation supports the 
medical necessity of the requested medication. Marrodan and colleagues describe Susac syndrome 
as an autoimmune disease affecting the endothelial cells, leading to symptoms of encephalopathy, 
visual disturbances, and sensorineural hearing impairment. Susac syndrome is commonly treated 
with immunosuppressive therapies such as corticosteroids, IVIG, Cellcept, rituximab, and/or 
cyclophosphamide. As patients treated with corticosteroids alone may initially respond well but 
later  relapse  spontaneously  or  following  a  decrease  in  corticosteroids,  IVIG  therapy  is 
recommended for all patients with Susac syndrome. In this case, the patient has a diagnosis of 
Susac syndrome and has demonstrated symptom improvement with IVIG treatments. The records 
indicate that the patient has tried and failed treatment with Cellcept and has derived minimal 
benefit with corticosteroid infusion and rituximab. Given that current medical literature supports 
the use of IVIG in the treatment of Susac syndrome, the requested medication is medically 
indicated. Therefore, Panzyga SOL 5 gm/50 mL is medically necessary for the treatment of this 
patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 37-year-old male enrollee has requested reimbursement for laboratory testing performed on 
6/05/20. 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 according to National Comprehensive Cancer Network (NCCN) guidelines, assessment 
of peripheral blood involvement optimally by flow cytometry is important for staging and is also 
useful to differentiate cutaneous T-cell lymphoma with peripheral blood involvement from other 
forms of leukemic T-cell lymphomas. Flow cytometry allows for the assessment of a population 
of  expanded  CD4+  cells  with  abnormal  immunophenotype.  Since  this  is  a  rare  disease, 
investigation into the tissue and blood needs to be performed to be able to direct optimal 
treatment. If there is clonality in the peripheral smear, then the treatment will be directed 
systemically, not just to the skin. There is no other test that will be more beneficial at the current 
time to help stage the systemic component of mycosis fungoides. Therefore, laboratory testing 
performed on 6/05/20 was likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 37-year-old male enrollee has requested reimbursement for laboratory testing performed on 
6/05/20. 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 Cutaneous T-cell lymphoma affects the skin and tends to transform and spread. 
Oncogenic microRNAs are stable epigenetic inhibitors often deregulated in the tumor and 
detectable  as  biomarkers  in  non-cellular  fractions  of  peripheral  blood.  The  tumor-specific 
expression of miR-155, miR-203, and miR-205 was shown to correctly diagnose cutaneous T-cell 
lymphoma. The studies demonstrate that these microRNAs can be used as plasma biomarkers 
for clinical cutaneous T-cell lymphoma monitoring. Quantitation of the selected microRNAs in 
plasma of the patient was a specific and straightforward approach for evaluating his cutaneous 
T-cell lymphoma activity. Therefore, laboratory testing performed on 6/05/20 was likely to have 
been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
  A 37-year-old male enrollee has requested reimbursement for laboratory testing performed on 
6/05/20. 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 for primary cutaneous lymphoma (including mycosis fungoides), the most recent 
NCCN guidelines state that T-cell receptor analysis is useful to support the diagnosis of mycosis 
fungoides  and  to  distinguish  mycosis  fungoides  from  other  inflammatory  dermatoses.  In 
addition, demonstration of identical clones in the skin, blood, and/or lymph nodes may be helpful 
both for diagnosis and differentiating mycosis fungoides and Sezary syndrome from benign 
inflammatory skin diseases, and blood testing is useful to identify blood involvement, which is 
critical for staging purposes. The patient had noticed a skin lesion in 2018 and was diagnosed 
with mycosis fungoides stage IB in 2018 at UC Irvine; he was originally diagnosed with mycosis 
fungoides at age 22 in China. On the examination of 4/16/20, he was noted to have patchy 
erythema by his provider, who was unsure if this represented underlying cutaneous lymphoma 
versus other process. As he had lost insurance, biopsy was deferred. On subsequent examination 
on 6/04/20, he again had patchy erythema and had biopsies taken and blood taken for ClonoSeq 
ID (T-cell receptor analysis). Biopsy results from 6/04/20 were consistent with mycosis fungoides 
of the skin. T-cell clonality studies from the skin showed dominant TCR beta and TCR gamma 
sequences, providing support for a clonal process.  NCCN guidelines for mycosis fungoides 
highlight the importance of identifying TCR clones in skin and blood for staging purposes (in this 
case to ensure that the staging had remained the same versus changed for the patient with 
known history of mycosis fungoides). Therefore, laboratory testing performed on 6/05/20 was 
likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 30-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg tablet. 
The Health Insurer has denied this request and reported that the requested medication is 
investigational for the treatment of the enrollees medical condition. The physician reviewer 
found that there are no FDA approved medications for the treatment of alopecia areata. 
Commonly used treatments have included off-label use of steroids and steroid sparing drugs like 
methotrexate as well as topical agents and topical immunotherapy with squaric acid (which 
cannot be use for practical reasons on the eyelids). There are many Janus kinase inhibitors 
currently in phase 3 trials and many more patients that are using this treatment off-label with 
good success for this disease.  There is sufficient support for the requested medication in this 
clinical setting. Therefore, Xeljanz 5 mg tablet is likely to be more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 30-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg tablet. 
The Health Insurer has denied this request and reported that the requested medication is 
investigational for the treatment of the enrollees medical condition. The physician reviewer 
found that there is no currently FDA approved treatment for alopecia areata, totalis, and similar 
alopecias.  Thus,  there  is  no  standard  approved  treatment.  Baricitinib  (Janus  kinase  (JAK) 
inhibitor) has done well in phase 2 clinical trials and may be soon approved. This patients 
provider is requesting another JAK inhibitor, tofacitinib. In addition, per clinical notes from the 
patients dermatologist, the patient has tried and failed other treatments, including topical 
steroids and oral minoxidil. Notably, the patient has done well on Xeljanz since March 2021, with 
near total regrowth of hair. There are several large case series reports in the literature of 
improvement of alopecia with tofacitinib. Thus, there is a large body of growing evidence that 
JAK inhibitors, in particular tofacitinib, is efficacious for alopecia areata/totalis. Therefore, Xeljanz 
5 mg tablet is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A 30-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg tablet. 
The Health Insurer has denied this request and reported that the requested medication is 
investigational for the treatment of the enrollees medical condition. The physician reviewer 
found that available treatment options for alopecia areata are quite limited. This is especially 
true for diffuse/multifocal involvement, where standard therapies such as topical steroids, 
intralesional kenalog, contact immunotherapy and conventional immunosuppressants are often 
less than satisfactory and associated with side effects. There is substantial clinical evidence to  support the use of oral Janus kinase inhibitors such as tofacitinib for alopecia areata (including 
from clinical trials). In one open label pilot study by Jabbari and colleagues, eight of 12 patients 
demonstrated greater than 50% hair regrowth as measured by Severity in Alopecia Tool (SALT) 
scoring. Liu and colleagues performed a retrospective study which consisted of patients age 18 
years or older with alopecia areata with at least 40% scalp hair loss treated with tofacitinib. The 
authors found that 77% achieved a clinical response. There have been minimal adverse effects 
reported to date. Moreover, these results are better than what has been reported for contact 
immunotherapy and systemic steroids (which have considerable short-term and long-term side 
effects). Therefore, Xeljanz 5 mg tablet is likely to be more beneficial than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 55-year-old female who has been diagnosed with cervical dystonia. The patient 
has requested authorization and coverage for J0585, Botox 200 unit vial and service code 64615 
x  4  chemodenervation.  The  physician  reviewer  found  that  the  submitted  documentation 
supports the medical necessity of the requested services. Cervical dystonia is one of the most 
common adult-onset focal dystonias. It is a movement disorder with symptoms of neck posturing, 
tremor, and/or pain. Although mostly considered benign, cervical dystonia can lead to significant 
disability. The treatment of choice for cervical dystonia is botulinum toxin injections, which are 
administered into neck muscles to cause denervation and relaxation of the abnormal neck 
posture. There is sufficient support for the requested services in this setting. Therefore, J0585, 
Botox 200 unit vial and service code 64615 x 4 chemodenervation are medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 15-year-old male who has been diagnosed with growth hormone deficiency. 
The patients parent has requested authorization and coverage for Norditropin Flexpro 15 
mg/1.5 ml pen injector. The physician reviewer found that Somatotropin therapy, such as 
Norditropin Flexpro 15 mg/1.5 ml pen injector, is medically necessary for the treatment of 
growth hormone deficiency in children. On 5/26/21, this patient met the auxologic criterion for 
growth hormone deficiency of one-year height velocity Z-score below -2 for chronological age. 
On 7/07/21, he met the diagnostic criteria for growth hormone deficiency by failing two 
standard growth hormone provocative tests with L-arginine and clonidine. Standard of care for 
evaluation of pediatric short stature includes direct measurements of parental heights. 
Nevertheless, his predicted adult height by the Bayley-Pinneau method based on the height 
observed on 5/26/21 was significantly lower than (more than one standard deviation below) 
the mid-parental target height. Therefore, Norditropin Flexpro 15 mg/1.5 ml pen injector is 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 59-year-old male enrollee has requested authorization and coverage for deep brain stimulation. 
The Health Insurer has denied this request and reported that the requested service is investigational 
for the treatment of the enrollees Parkinsons disease. The physician reviewer found that Deep 
brain stimulation (DBS) treatment for advanced, medically refractory Parkinson's disease has been 
extensively studied. In particular, targeting of the subthalamic nucleus (STN) has been evaluated 
with no less than six randomized controlled trials, generally tested against medical management. 
The  European  Academy  of  Neurology/Movement  Disorder  Societys  guidelines  on  the 
management of Parkinson's disease with invasive treatments conclude that based on the published 
literature  on  patients  with  advanced  disease  with  medically  unresponsive  fluctuations  or 
unresponsive  tremor,  STN-DBS  likely  results  in  large  improvements  in  quality  of  life, 
performance of activities of daily living, motor fluctuations, and dyskinesias. The authors further 
note that a number of longer-term, non-randomized studies suggest that results are durable over 
many years and across several domains such as improvement in motor complications and stable 
reductions in dopaminergic medications. The authors indicate that STN-DBS may be offered to 
patients  with  advanced  Parkinsons  disease  if  fluctuations  or  tremors  are  not  satisfactorily 
controlled with medication. While there is less data available on globus pallidus internus (GPi) 
targeting, with studies concentrating on comparing the outcomes of GPi and STN targeting, the 
authors recommend GPi-DBS as effective in select patients. The primary difference in the two 
targets is the greater reduction in dopaminergic medications with STN-DBS. Other invasive 
treatment strategies, including pump therapy and lesional techniques, may be appropriate only for 
very select patients who are not eligible for DBS. Rughani and colleagues note that as related to 
STN or GPi targeting, STN targeting is more effective at allowing reductions in dopaminergic 
medications. In this case, the Health Insurer appears to rely on the Unified Parkinsons Disease 
Rating Scale (UPDRS) score in  determining  coverage for DBS. However, the  number one 
predictor of efficacy of DBS in the treatment of Parkinson's disease is an excellent response to 
dopaminergic medications, which this patient demonstrates. In this case, the patient has advanced 
Parkinson's  disease  with  medically  refractory  motor  fluctuations  and  dyskinesias,  and  has 
attempted a number of medications at varying doses. In this clinical setting, the requested service 
is likely to be more beneficial for the treatment of this patient than standard medical therapy. 
Therefore, deep brain stimulation is likely to be more beneficial for treatment of the patients 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 59-year-old male enrollee has requested authorization and coverage for deep brain stimulation. 
The Health Insurer has denied this request and reported that the requested service is investigational 
for the treatment of the enrollees Parkinsons disease. The physician reviewer found that DBS is 
indicated in cases of Parkinson's Disease in which motor fluctuations and dyskinesias are present. 
DBS is approved by the U.S. Food and Drug Administration (FDA) for the treatment of Parkinson's 
Disease. In this case, the patient has motor fluctuations and dyskinesias despite best medical 
management,  which  is  standard  management  for  Parkinsons  Disease.  The  patient  is  now  experiencing the known limitations and side effects of standard medication management. In this 
clinical setting, the requested service is likely to be more beneficial than standard medical therapy 
as DBS reduces motor fluctuations secondary to medications. Therefore, deep brain stimulation is 
likely to be more beneficial for treatment of the patients condition than any available standard 
therapy.