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

Summary  
The patient is a 52-year-old female with a history of cervical dystonia and secondary cervicogenic 
headaches. The patient received Xeomin injections on 12/23/22. The Health Insurer denied the 
treatment 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 
according to the recent American Academy of Neurology (AAN) practice guidelines, botulinum 
toxin is accepted as first-line treatment for patients with cervical dystonia. Xeomin is a preparation 
of botulinum toxin approved by the U.S. Food and Drug Administration (FDA). Per the AAN 
guidelines, Xeomin is likely safe and effective for the treatment of patients with cervical dystonia. 
In this case, the patient had a history of cervical dystonia with secondary cervicogenic headaches. 
The patient had tried several treatment options, including include indomethacin, oxycodone, 
Zanaflex, Advil, Nurtec, left C3-5 facet injections, dry needling, and trigger point injections. 
Xeomin is accepted as a first-line treatment option for this patients condition. Therefore, the 
Xeomin injections received on 12/23/22 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 52-year-old female who presented to her provider on 3/17/22. The patient reported 
pain in her left knee that she rated at an eight out of a scale of ten. The patient has requested 
reimbursement for Synvisc from 6/15/22 through 6/29/22. The Health Insurer has denied this 
request and reported that the services at issue were not medically necessary. This denial is the 
subject  of  this  appeal  and  determination.  The  physician  reviewer  found  that  the  submitted 
documentation supports the medical necessity of the services at issue. Per the medical literature, 
although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is 
not known as to which individuals will benefit. The current evidence is limited, and guidelines 
from organizations such as the American Academy of Orthopedic Surgeons indicate that the 
evidence  is  not  conclusive.  In  light  of  the  foregoing,  viscosupplementation  can  only  be 
recommended in individuals with a history of lasting benefit from prior injections, and in carefully 
selected cases where everything else has been tried, and the options are limited. In this case, the 
patient reported pain at a level of eight out of ten that did not respond to a corticosteroid injection 
on 3/17/22. The patient had tried and failed other conservative treatments. Given the patients 
limited options and based on the current medical literature, the services at issue were medically 
indicated. Therefore, Synvisc from 6/15/22 through 6/29/22 was medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 59-year-old male with a diagnosis of benign prostatic hyperplasia (BPH) with 
lower urinary tract symptoms (LUTS) and atrial fibrillation. The provider has recommended a 
prostatic artery embolization (PAE) to treat the patients medical condition. The Health Insurer 
has denied this request and reported that the services at issue are not medically necessary for the 
treatment of this patient. This denial is the subject of this appeal and determination. The physician 
reviewer found that according to the European Association of Urology (EAU), management for 
BPH  includes  medical  treatments,  such  as  alpha  blockers,  5  alpha  reductase  inhibitors, 
phosphodiesterase inhibitors and anticholinergic medication (Grazke, et al.). For patients with 
BPH who do not respond to medical therapy, the recommended treatment is transurethral resection 
of the prostate (TURP). The EAU guidelines state that in patients with highly enlarged prostates, 
such  as  this  patient,  a  holmium  laser  enucleation  of  the  prostate  (HoLEP)  procedure  or 
prostatectomy would be also effective treatment for BPH. Current medical literature is limited for 
the effectiveness of PAE over procedures such as HoLEP, TURP or prostatectomy. The American 
Urological Association (AUA) guidelines on BPH, state that PAE is not recommended for the 
treatment of LUTS attributed to BPH outside the context of a clinical trial (Foster, et al.). Given 
this patients BPH with enlarged prostate and LUTS, the appropriate treatment would be HoLEP, 
TURP or prostatectomy based on the medical literature. Therefore, the requested PAE is not 
medically necessary for treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 60-year-old female enrollee has requested authorization and coverage for percutaneous or 
endoscopic spinal surgery. The Health Insurer has denied this request and reported that the 
requested services are investigational  for the treatment  of the  enrollees medical condition. 
The physician reviewer found that this patient has been treated for spinal stenosis, lumbar region with 
neurogenic claudication; chronic pain syndrome; complex regional pain syndrome I of left lower 
limb; and post- laminectomy syndrome. She presented with worsening low back pain. There is 
current evidence-based medical literature support for the use of this procedure for the treatment of 
spinal stenosis, as compared to lumbar epidural steroid injection. However, in this case, there are 
no clinical examination findings documented and no clear  discussion to  support minimally 
invasive surgery over standard lumbar decompression in the setting of thickening of the ligament 
flavum,  bilateral  foraminal  protrusions,  cross-sectional  area  of  the  central  canal  measuring 
approximately 50 square mm, severe canal stenosis and bilateral lateral recess stenosis, which 
cannot typically be fully addressed with minimally invasive surgery. Therefore, percutaneous or 
endoscopic spinal surgery is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 60-year-old female enrollee has requested authorization and coverage for percutaneous or 
endoscopic spinal surgery. The Health Insurer has denied this request and reported that the 
requested services are investigational  for the treatment  of the  enrollees medical condition. 
The physician reviewer found that this patient has had prior posterior decompression and fusion. Her 
complaints of pain and fatigue are consistent with symptomatic spinal stenosis. The patient has 
failed multiple lumbar treatments. The articles cited below note that the endoscopic decompression 
planned is as effective as open decompression surgery for lumbar stenosis as seen on the patients 
CT  scan  of  3/31/21.  These  benefits  are  achieved  at  a  much  lower  risk  and  require  less 
hospitalization.  Therefore,  percutaneous  or  endoscopic  spinal  surgery  is  likely  to  be  more 
beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A 60-year-old female enrollee has requested authorization and coverage for percutaneous or 
endoscopic spinal surgery. The Health Insurer has denied this request and reported that the 
requested services are investigational  for the treatment  of the  enrollees medical condition. 
The physician reviewer found that a clear majority of current quality studies support MILD in 
appropriately indicated patients. Jain and colleagues performed a review of 13 clinical studies, 
including  two  randomized  controlled  trials.  The  authors  noted  statistically  significant 
improvement in pain and mobility, and superiority of MILD versus epidural steroid injections. In  the multicenter study by Chopko, patients demonstrated a statistically significant reduction of pain 
and statistically significant improvement in physical function and mobility from baseline through 
two years. A randomized controlled clinical study by Staats and colleagues showed excellent 
durability of the MILD procedure out to two years. All efficacy outcomes achieved significant 
improvement from baseline to all follow-up intervals through two years. There was no evidence 
of spinal instability at two years after the MILD procedure. According to the authors, MILD 
demonstrated lower re-operation rates, less morbidity and greater safety when compared to the 
broad range of lumbar spine interventions, including spacers, surgical decompression, and spinal 
fusion. In a retrospective study by Mekhail, and colleagues, subjects experienced statistically 
significant pain relief and reduction of opioid medications utilization at 3, 6, and 12 months 
compared to baseline. MILD was also shown to be durable with only 9 out of 75 patients requiring 
lumbar surgical decompression during the five-year follow-up period. MILD has been shown to 
be a safe and effective procedure. There is sufficient support for the requested services in this 
clinical  setting.  Therefore,  percutaneous  or  endoscopic  spinal  surgery  is  likely  to  be  more 
beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
The parent of a one-year-old female enrollee has requested authorization and coverage for a whole 
genome test. The Health Insurer has denied this request and reported that the requested service is 
investigational for the enrollees of the enrollees ataxia. The Health Insurer indicated that the 
requested  service  is  investigational  for  the  evaluation  of  the  enrollees  medical  condition. 
Therefore, the Health Insurer has denied coverage for the requested service. At issue is whether a 
whole genome test is likely to be more beneficial for evaluation of the enrollee's condition than 
any available standard therapy. The physician reviewer found that the American College of Medical 
Genetics and Genomics (ACMG) evidence-based clinical practice guideline, for the use of exome 
and genome sequencing (ES/GS) in the care of pediatric patients with one or more congenital 
anomalies with onset prior to age one year or developmental delay or intellectual disability with 
onset prior to age 18 years, strongly recommends that ES/GS be considered as a first- or second-
tier test for such patients. While this child has ataxia, this practice guideline shows the benefits of 
genome sequencing. Ngo and colleagues report an approximately 50% diagnostic rate for current 
whole-exome sequencing (WES) based methods when evaluating patients with ataxia, suggesting 
that genome sequencing will likely have significant added benefit in identifying genetic etiologies 
for ataxias and other neurodegenerative diseases. Given this child's young age and rapid onset and 
progression of disease, the requested service is warranted to identify a specific diagnosis as quickly 
as possible. Therefore, a whole genome test is likely to be more beneficial for evaluation of the 
patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
The parent of a one-year-old female enrollee has requested authorization and coverage for a whole 
genome test. The Health Insurer has denied this request and reported that the requested service is 
investigational for the enrollees of the enrollees ataxia. The Health Insurer indicated that the 
requested  service  is  investigational  for  the  evaluation  of  the  enrollees  medical  condition. 
Therefore, the Health Insurer has denied coverage for the requested service. At issue is whether a 
whole genome test is likely to be more beneficial for evaluation of the enrollee's condition than 
any available standard therapy. The physician reviewer found that while whole genome sequencing 
may be effective at finding a diagnosis in complex patients in whom other genetic tests are 
negative, there are alternative, simpler tests addressing ataxia telangiectasia. In this clinical setting, 
ATM gene testing would have a 90% yield. In this case, the requested service is too big of a test 
and does not justify the risk of unknown variants. The records did not note the rationale behind the 
urgency of the requested rapid whole genome sequencing test and how this may affect the patients 
management. Therefore, a whole genome test is not likely to be more beneficial for evaluation of 
the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
The parent of a one-year-old female enrollee has requested authorization and coverage for a whole 
genome test. The Health Insurer has denied this request and reported that the requested service is 
investigational for the enrollees of the enrollees ataxia. The Health Insurer indicated that the 
requested  service  is  investigational  for  the  evaluation  of  the  enrollees  medical  condition. 
Therefore, the Health Insurer has denied coverage for the requested service. At issue is whether a 
whole genome test is likely to be more beneficial for evaluation of the enrollee's condition than 
any available standard therapy. The physician reviewer found that Renaud and colleagues explain, 
AFP is a biomarker of several autosomal recessive cerebellar ataxias (ARCAs), especially ataxia 
telangiectasia (AT) and ataxia with oculomotor apraxia (AOA) type 2 (AOA2). AT typically 
presents with progressive gait and truncal ataxia with onset between the ages one and four years. 
Nystagmus,  dysphagia,  and  elevations  in  serum  concentrations  of  AFP  are  also  commonly 
observed in AT. Sequencing and deletion/duplication analysis of the causative gene in AT, ATM, 
is available. Alternatively, multigene hereditary ataxia panels that include AT, AOA2, and other 
hereditary ataxias are also available. In this case, the patient had an onset of symptoms after turning 
one, presenting with progressive ataxia, nystagmus, dysphagia, and an elevated AFP level. The 
records noted that AT was the primary consideration by the clinical geneticist at an evaluation of 
the patient. The records do not reflect that single gene or multigene panel testing for the hereditary 
ataxias were undertaken. In this case, whole genome sequencing is not likely to be more beneficial 
than the available standard targeted gene testing of ATM or a multigene hereditary ataxia panel. 
Therefore, a whole genome test is not likely to be more beneficial for evaluation of the patients 
condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 56-year-old male who presented to his provider on 1/6/22. The patient has 
requested authorization and coverage for aprepitant 80 mg. The physician reviewer found that 
at issue is whether aprepitant 80 mg is medically necessary for the treatment of this patient. The 
submitted documentation supports the medical necessity of the requested medication. Pruritus 
occurs in the majority of patients with polycythemia vera and is often exacerbated by bathing,  
especially with hot water, which results in aquagenic pruritus. Symptom management begins 
with simple measures such as avoidance of precipitating exposures such as paying attention to 
the temperature of the environment and the water used for bathing, adding laundry starch to 
bath water, drying the skin by patting rather than rubbing, and using moisturizing creams and 
antihistamines.  Low-dose  aspirin  is  generally  effective  for  alleviating  pruritus  and  other 
symptoms associated with polycythemia vera. Among cytoreductive agents, the most effective 
agent for pruritus associated with polycythemia vera is ruxolitinib, which this patient is already 
on. He and colleagues report that aprepitant has demonstrated effectiveness in several case 
series  and  open  label  trials  in  relieving  pruritus  for  patients  who  are  refractory  to  other 
treatments. Current medical literature supports the benefits of aprepitant in the setting of 
pruritus related to hematologic malignancies including T-cell lymphomas, polycythemia vera, and 
other malignancies. In this clinical setting, given that the patient has tried and failed several 
measures and medications for the treatment of debilitating aquagenic pruritus, and reports 
benefits from aprepitant 80 mg, the requested medication is medically indicated. Therefore, 
aprepitant 80 mg is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 36-year-old female. The patient has requested authorization and coverage for 
NuvaRing. The physician reviewer found that at issue is whether NuvaRing is medically necessary 
for the treatment of this patient. The submitted documentation supports the medical necessity 
of the requested medication. The American College of Obstetricians and Gynecologists (ACOG) 
states, All U.S. Food and Drug Administration (FDA) approved contraceptive methods should be 
available to all insured women without cost sharing and without the need to fail certain 
methods first. In the absence of contraindications, patient choice and efficacy should be the 
principal factors in choosing one method of contraception over another." Different formulations 
of hormonal birth control may be indicated for different patients due to their symptomology and 
past medical history, and may be used for indications in addition to contraception. Generally, if 
a patient who has been stable on a brand-name medication for a significant period of time 
encounters side effects when switching to the generic formulation, continued maintenance on 
the  brand-name  version  of  the  medication  is  indicated.  Therefore,  NuvaRing  is  medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 62-year-old male enrollee has requested reimbursement for genetic testing performed on 
9/29/20. The Health Insurer has denied this request and reported that the services at issue were 
investigational for the evaluation of the enrollees medical condition. At issue is whether the 
services at issue were likely to have been more beneficial for evaluation of the enrollee's condition 
than  any  available  standard  therapy.  The  physician  reviewer  found  that  the  submitted 
documentation fails to demonstrate the superior efficacy of the services at issue. The initial 
diagnosis of squamous cell carcinoma is soon followed by a determination of the risk for distant 
metastasis or local recurrence. The various variables that figure into this determination involves 
the tumor size and evidence for perineural or lymphovascular invasion. The clinical features that 
figure into this include whether the lesion is recurrent or primary and is happening in the context 
of immunosuppression. There are also histologic parameters of the primary lesion and the depth 
of invasion that figure into the assessment of risk. The genetic analysis does not figure into the 
current National Comprehensive Cancer Network guidelines or in current publications. Therefore, 
the genetic testing performed on 9/29/20 was not likely to have been more beneficial than any 
available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 62-year-old male enrollee has requested reimbursement for genetic testing performed on 
9/29/20. The Health Insurer has denied this request and reported that the services at issue were 
investigational for the evaluation of the enrollees medical condition. At issue is whether the 
services at issue were likely to have been more beneficial for evaluation of the enrollee's condition 
than any available standard therapy. The physician reviewer found that several studies have 
evaluated tumor markers in cutaneous squamous cell carcinoma and identified associations with 
aggressive tumors. As the composite definition of high-risk cutaneous squamous cell carcinoma 
remains unclear, the identification of reliable biomarkers is particularly promising in aiding the 
recognition of patients at risk for poor outcomes and guiding clinical disease management. 
DecisionDx-SCC is a 40-gene expression profile test that has been developed to stratify patients 
with high-risk cutaneous squamous cell carcinoma into three classes based on the three-year 
metastasis risk. Per the article by Farberg and colleagues, the integration of the gene expression 
profile with the American Joint Committee on Cancer 8 (AJCC 8)  and the Brigham and Womens 
Hospital (BWH) staging systems identified a subgroup of 24 patients at very high risk of metastasis 
(16 of whom were T1/T2 according to the AJCC 8 and 17 of whom were T1/T2a according to the 
BWH staging system) who would benefit from high-intensity management. Conversely, subgroups 
of patients classified as AJCC 8 T3/T4 or BWH T2b/T3 were assigned to class 1 based on their 
risk of metastasis. These patients would have been appropriately managed with low-intensity 
treatment. Currently, high-risk is largely defined by tumor size and region of disease. The standard 
of care is to use clinical factors to decide risk. However, the services at issue were likely to have 
been of additional benefit. Therefore, the genetic testing performed on 9/29/20 was likely to have 
been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 62-year-old male enrollee has requested reimbursement for genetic testing performed on 
9/29/20. The Health Insurer has denied this request and reported that the services at issue were 
investigational for the evaluation of the enrollees medical condition. At issue is whether the 
services at issue were likely to have been more beneficial for evaluation of the enrollee's condition 
than any available standard therapy. The physician reviewer found that Decision Dx-SCC assay is 
a 40-gene assay exploring the genomic make-up of cutaneous invasive squamous cell cancer. This 
assay sorts the cancer into classes, each with a different rate of metastasis. The assay claims that 
it can predict the potential for metastasis, thereby changing the clinical approach to surveillance. 
At this time, however, it has not been shown to have a positive clinical impact above and beyond 
evaluation of the specific pathologic details of the individual cancer. It is not included within the 
National Comprehensive Cancer Network guidelines for squamous cell cancer. The medical 
evidence has not demonstrated the superior efficacy of the services at issue. Therefore, the genetic 
testing performed on 9/29/20 was not likely to have been more beneficial than any available 
standard therapy.