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

Summary Reviewer  
The patient is a 50-year-old male who presented with onset of lumbar radiculopathy. The patient 
has requested reimbursement for lumbar spine MRI performed on 4/30/21. The physician 
reviewer found that the submitted documentation supports the medical necessity of the services 
at issue. According to the literature, symptoms of radiculopathy are most commonly associated 
with nerve irritation from a compressive force, such as disc extrusion/herniation, hypertrophic 
spine changes, and sometimes even infectious processes. Berry and colleagues noted, The 
optimal imaging modality for the evaluation of radiculopathy is MRI of the lumbar spine without 
contrast, which can show compression of the nerve root. MRI can guide potential surgical 
intervention. Per American College of Radiology Appropriateness Criteria for the evaluation of 
progressive  symptoms  of  lumbar  spine  pain  and  radiculopathy,  MRI  of  lumbar  is  usually 
appropriate,  the  highest  category  for  recommendation  of  imaging.  The  current  medical 
evidence supports the services at issue for the evaluation of this patients progressive pain and 
radiculopathy. Therefore, lumbar spine MRI performed on 4/30/21 was medically necessary for 
the evaluation of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
A  52-year-old  female  enrollee  has  requested  authorization  and  coverage  for  the  Intracept 
procedure. The Health Insurer has denied this request and reported that the requested medication 
is investigational for the treatment of the enrollees low back pain. The Health Insurer indicated 
that the requested service is investigational for the treatment of the enrollees medical condition. 
Therefore, the Health Insurer has denied coverage for the requested service. The physician reviewer 
found that the patient has chronic low back pain. While the provider noted in a letter dated 12/8/22 
that there are Modic changes on MRI, the submitted MRI report dated 7/1/22 specifically states 
that the bone marrow signal in the vertebral bodies is normal. Fischgrund and colleagues along 
with  Truumees  and  colleagues  note  that  the  requested  procedure  is  more  effective  than 
conservative care in the setting of bone marrow changes associated with degenerative disc disease.  
However, in this clinical setting, given the lack of Modic endplate changes noted on the patients 
MRI report, the requested service is not likely to be more beneficial than standard, conservative 
care. Therefore, the Intracept procedure is not likely to be more beneficial for treatment of the 
patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
A  52-year-old  female  enrollee  has  requested  authorization  and  coverage  for  the  Intracept 
procedure. The Health Insurer has denied this request and reported that the requested medication 
is investigational for the treatment of the enrollees low back pain. The Health Insurer indicated 
that the requested service is investigational for the treatment of the enrollees medical condition. 
Therefore, the Health Insurer has denied coverage for the requested service. The physician reviewer 
found that the Intracept procedure is a promising, minimally invasive treatment option for patients 
with isolated vertebrogenic pain. Good therapeutic results can only be achieved through proper 
patient selection. Current medical literature includes data from randomized controlled studies 
including patients with isolated lumbar back pain as their chief complaint for treatment. The 
studies specified exclusion criteria in order to avoid overlapping pain sources including the 
presence of other concomitant symptoms related to spine pathology that could easily obscure the 
clinical presentation and make it difficult to isolate vertebrogenic pain as the main problem to be 
treated such as previous spinal surgery, radicular pain symptoms, neurogenic claudication, or 
radiographic evidence of spinal pathology or other possible pain sources. In this case, notes dated 
8/23/22 reported that the patient has had chronic back pain for many years that has not responded 
well to conservative measures such as medications, epidural injections, or physical therapy. While  MRI images were not provided for review, the MRI report dated 7/1/22 reported moderate facet 
arthropathy and canal narrowing at L3-L4 and L4-L5, which can present with back pain that is 
similar to the patients clinical picture and is difficult to differentiate from isolated vertebrogenic 
pain. More importantly, the MRI report does not mention Modic changes at L2-L3 level, as stated 
by the provider. Given that the MRI report does not mention Modic changes at L2-L3, along with 
the unclear course of the patients recent physical therapy program, it cannot be concluded at this 
point that the requested service would be more beneficial for the patient than other standard 
conservative therapies for management of low back pain. Therefore, the Intracept procedure is not 
likely to be more beneficial for treatment of the patients condition than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 48-year-old female who presented for a colonoscopy on 12/29/21. The patient 
has requested reimbursement for monitored anesthesia care provided during colonoscopy on 
12/29/21.  The  physician  reviewer  found  that  according  to  the  American  Society  of 
Anesthesiologists  guideline  for  anesthesia  care  during  endoscopic  procedures,  monitored 
anesthesia  care  is  warranted  in  prolonged  or  painful  procedures  such  as  complex  polyp 
resections,  endoscopic  retrograde  cholangiopancreatography  or  other  biliary  procedures, 
endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored 
anesthesia care is more likely necessary in patients with failed history of moderate sedation for 
the procedure or psychological impediments to cooperation. The provided records do not 
support any of these criteria, or other criteria in the literature, such as difficult intubation, airway 
obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in 
increased  tolerance  to  sedation  medications,  age  greater  than  70,  pregnancy,  increased 
aspiration risk, ASA class III or higher, or morbid obesity. According to the most recent guidelines 
from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike 
surgery)  consciousness  during  the  procedure  is  acceptable  and  is  the  goal  during  most 
procedures (which are performed with moderate sedation), and monitored anesthesia care is 
recommended  for  prolonged  procedures  requiring  deep  sedation,  previously  anticipated 
intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic 
variant. None of these conditions are documented. The submitted documentation fails to 
demonstrate the medical necessity of the services at issue. Therefore, monitored anesthesia care 
provided during colonoscopy on 12/29/21 was not medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 62-year-old female with a history of right foot pain and metatarsalgia of the right foot. 
The records available for review indicate that the patient had been experiencing pain in her foot and 
cramping of her toes for several years. The physician reviewer found that at issue is whether the 
osteotomy (CPT 28308) performed on 1/20/22 was medically necessary for the treatment of this 
patient.The current medical literature recommends an osteotomy with double screw fixation combined 
with plantar plate repair for the treatment of patients with a plantar plate tear and associated second 
MPJ metatarsalgia (Klein and Weil). The records available for review indicate that this patient presented 
with right foot pain for several years. The patient tried and failed conservative treatment measures such 
as local cortisone injections and off-loading arch supports. An ultrasound revealed a significant 
intermetatarsal neuroma and a plantar plate tear at the second MPJ. The current medical literature 
supports the use of an osteotomy to treat this patients foot pain after the failure of conservative 
measures. All told, the osteotomy (CPT 28308) performed on 1/20/22 was medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 67-year-old male who presented in 2021 with a prostate-specific antigen (PSA) 
level of 5.64. The patient has requested authorization and coverage for proton beam therapy. 
The physician reviewer found that the submitted documentation fails to demonstrate the 
medical necessity of the requested services. There is a lack of strong medical evidence to 
suggest that treatment with proton beam therapy is associated with a clinical benefit compared 
to standard treatment. Currently, there is insufficient clinical data to discern whether treatment 
with proton beam radiation offers a clinical benefit compared to conventional radiation therapy 
techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a recent 
multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The 
authors compared groups receiving hypofractionated radiation proton therapy and intensity 
modulated radiation therapy with photons. This analysis found no significant difference in 
gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found 
no difference in disease control between the two modalities. The American Society of Radiation 
Oncology (ASTRO) Model Policy stated, Proton beam therapy for primary treatment of 
prostate cancer should only be performed within the context of a prospective clinical trial or 
registry. At the present time, ASTRO believes the comparative efficacy evidence of proton 
beam therapy with other prostate cancer treatments is still being developed, and thus the role 
of proton beam therapy for localized prostate cancer within the current availability of 
treatment options remains unclear. The National Comprehensive Cancer Network guidelines 
endorse the position statement by ASTRO and state that no clear benefit of proton beam 
therapy has been demonstrated over standard treatment with photons and intensity 
modulated radiation therapy technique. Therefore, proton beam therapy is not medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 56-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 6/04/21. The Health Insurer has denied this request and reported that the services at 
issue  were  investigational  for  the  evaluation  of  the  enrollees  medical  condition. 
The physician reviewer found that the use of gene expression profiling (GEP) testing according to 
specific  American  Joint  Committee  on  Cancer  (AJCC)  melanoma  stage  requires  further 
prospective investigation in large, contemporary datasets of unselected patients. Prognostic GEP 
testing to differentiate melanomas at low versus high risk for metastasis should not replace 
pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I 
(T1) melanoma and a higher proportion of false-positive results, GEP testing should not guide 
clinical decision-making in this subgroup. Therefore, DecisionDx-Melanoma testing performed 
on 6/04/21 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 56-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 6/04/21. The Health Insurer has denied this request and reported that the services at 
issue  were  investigational  for  the  evaluation  of  the  enrollees  medical  condition. 
found that per the National Comprehensive Cancer Network guidelines, the recommended therapy 
for stage IA cutaneous melanoma is history and physical and only imaging to evaluate certain signs 
and symptoms.  The recommended primary category 1A treatment is wide excision of the 
melanoma.  There is no indication for a gene expression assay to determine the primary course of 
treatment as no sentinel lymph node biopsy is needed for stage IA cutaneous melanomas. Marchetti 
and colleagues concluded, The prognostic ability of GEP tests among patients with localized 
melanoma varied by AJCC stage and appeared to be poor at correctly identifying recurrence in 
patients with stage I disease, suggesting limited potential for clinical utility in these patients. 
Therefore, DecisionDx-Melanoma testing performed on 6/04/21 was not likely to have been more 
beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 56-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 6/04/21. 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 6/04/21 was not likely to have been more beneficial than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 26-year-old male with a history of suspected multiple sclerosis (MS). In an effort 
to treat the patients flare and as maintenance therapy for suspected MS, the provider has 
recommended treatment with intravenous immunoglobulin (IVIG) therapy with Gamunex-C. The 
Health Insurer has denied the requested treatment as not medically necessary for the treatment 
of the patients medical condition. The physician reviewer found that the records provided for 
review indicate that the patient experienced an exacerbation of symptoms from suspected MS. 
For patients who experience an acute MS exacerbation that results in neurologic symptoms and 
increased disability or impairments in vision, strength, or cerebellar function, a short course of 
high-dose glucocorticoid therapy is recommended (Olek, et al.). If the patient has a poor response 
to treatment with high-dose glucocorticoids, treatment with plasma exchange is considered for 
the next line of therapy. Other options for a second treatment course after a poor response to 
initial high-dose glucocorticoid therapy include adrenocorticotropic hormone (ACTH), a second 
cycle of high-dose glucocorticoid therapy, or immunoadsorption. There is a paucity of high-
quality medical studies demonstrating that IVIG therapy is an effective treatment option for 
patients who experience an exacerbation of symptoms from suspected MS. A small number of 
limited medical studies have demonstrated that IVIG therapy may be used for patients with 
relapsing-remitting MS who do not tolerate or have contraindications to approved therapies 
(Bayry, et al.). In this case, a diagnosis of relapsing-remitting MS has not been established for the 
patient. The records indicate that the patient experienced an acute exacerbation of symptoms 
from suspected MS. Based on the current medical literature, IVIG therapy is not recommended 
as a treatment option for patients with acute exacerbations of symptoms from suspected MS. 
Therefore, the requested Gamunex-C is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 35-year-old female enrollee has requested reimbursement for colorectal cancer screening 
using chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22. 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 as noted 
by  Marion  and  colleagues,  chromoendoscopy  is  supported  as  superior  to  alternatives  for 
localization  of  dysplasia  in  randomized  trials.  Per  American  Society  for  Gastrointestinal 
Endoscopy (ASGE) guidelines for inflammatory bowel disease, chromoendoscopy allows better 
characterization  of  visible  lesions  as  endoscopically  resectable  or  unresectable,  and 
chromoendoscopy with targeted biopsies is the preferred surveillance technique to maximize 
dysplasia  detection.  Per  American  Gastroenterological  Association  guidelines,  Dye  spray 
chromoendoscopy...should be considered in all persons with colonic inflammatory bowel disease 
undergoing surveillance colonoscopy, particularly if a standard definition endoscope is used or if 
there is a history of dysplasia. The patient has had a colon polyp (of the serrated type) in the 
past, and aside from that, warrants surveillance biopsies for dysplasia given the diagnosis of 
ulcerative colitis. Per the guidelines cited above, surveillance colonoscopies should be performed 
using  chromoendoscopy  when  possible.  Therefore,  colorectal  cancer  screening  using 
chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22 was likely 
to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 35-year-old female enrollee has requested reimbursement for colorectal cancer screening 
using chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22. 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 
Chromoendoscopy is a well-accepted adjunct to colonoscopy to look for dysplasia in patients 
with  longstanding  ulcerative  colitis.  Patients  undergo  a  standard  colonoscopy.  During  the 
examination, the mucosa is inspected and biopsied in standard fashion. Subsequent to this, the 
mucosa is sprayed with a vital dye that highlights subtle areas that may represent neoplasia. 
These areas are biopsied separately. Chromoendoscopy has become the standard of care for 
patients previously identified to have abnormal mucosa on a previous colonoscopy, such as this 
patient. The medical evidence supports the services at issue in this setting. Therefore, colorectal 
cancer  screening  using  chromoendoscopy  or  narrowband  imaging  optical  colonoscopy 
performed on 1/25/22 was likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A 35-year-old female enrollee has requested reimbursement for colorectal cancer screening 
using chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22. 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 supports the services at issue in this patients case. Most society 
guidelines  advocate  for  high-definition  endoscopy  with  surface  chromoendoscopy  or 
narrowband  imaging  as  the  strategy  that  optimizes  dysplasia  detection  in  patients  with 
inflammatory  bowel  disease,  including  ulcerative  colitis.  The  American  Society  for 
Gastrointestinal  Endoscopy  noted,  Recent  studies  utilizing  image-enhanced  endoscopy 
in inflammatory bowel disease (IBD) surveillance have led to new recommendations by several 
societies for optimal identification and management of IBD-related dysplasia. It is now believed 
that  most  neoplasia  is  endoscopically  visible  with high-definition  and/or  image-enhanced 
endoscopy (eg, chromoendoscopy). Most dysplasia previously detected during standard white-
light endoscopy (WLE) by random biopsy only and deemed invisible is, in fact, visible by enhanced 
imaging.  Therefore,  colorectal  cancer  screening  using  chromoendoscopy  or  narrowband 
imaging optical colonoscopy performed on 1/25/22 was likely to have been more beneficial than 
any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 27-year-old female with a history of lymphedema of the right lower extremity. The 
patient developed lymphedema of the right lower extremity in 2017, which spread to her calf and 
thigh by 2018. The provider recommended treatment with lymphaticovenous anastomosis (LVA) 
and vascularized lymph node transfer (VLNT) surgeries with inpatient hospital stay. The Health 
Insurer has denied the requested inpatient hospital stay associated with the approved LVA 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 current medical literature 
supports the use of LVA for treatment of patients with lymphedema. While LVA requires less 
hospitalization than VLNT, there is a lack of medical literature suggesting outpatient treatment is 
adequate for patients undergoing treatment with LVA. In a study by Cha and colleagues involving 
patients with advanced lymphedema that underwent LVA, the authors noted that, The patients 
were discharged on postoperative day 3 or 4, and they received education on proper compression 
therapy at discharge. In another study, Gallagher and colleagues reported that, The complication 
rate of LVA is low. These procedures can often be performed under local anesthesia, and there is 
minimal length of stay. In this case, the patient has a history of lymphedema of the right lower 
extremity and has been recommended treatment with LVA and VLNT surgeries. The records 
document that the patient has failed to improve despite treatment with SAPL of the right lower 
extremity, compression garments, and ablation procedures. Based on the medical literature, the 
requested inpatient hospital stay associated with approved LVA surgery is medically necessary for 
treatment of this patient.