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

Summary Reviewer  
 
The patient is a 40-year-old female who presented with an abnormal mammogram. The patient 
has requested authorization and coverage for proton beam radiation therapy. The physician 
reviewer found that guidelines do not endorse the routine use of proton beam radiation therapy 
in the treatment of breast cancer. There is a lack of data to suggest that proton beam radiation 
therapy would be beneficial in this case or that it would be associated with less side effects than 
standard  treatment  with  three-dimensional  conformal  or  standard  intensity  modulated 
techniques which are typically given with partial breast radiation. Furthermore, consensus group 
guidelines do not support the use of proton beam radiation therapy in this setting. Typically, 
photon treatments using deep inspiratory breath hold which moves the heart away from the 
chest wall are associated with very low cardiac doses in patients receiving radiation to the left 
chest wall. The comparative planning does not support the use of proton beam radiation therapy, 
as typically treatment with deep inspiratory breath hold using photons is associated with a mean 
heart dose of less than 4 Gy.  Additionally, there is a lack of level I evidence to support the use of 
proton beam radiation therapy for the treatment of breast cancer. Therefore, the requested 
proton beam radiation therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 55-year-old female who presented to her provider on 1/3/22. The records noted 
generalized abdominal pain, along with fibromyalgia, chronic low back pain, and migraines. The 
patient has requested authorization and coverage for Oxycontin (oxycodone HCL tablet ER 12 
hour deter 40 mg). The Health Plan has denied this request and reported 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. On determining when to initiate or 
continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy 
and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider 
opioid therapy only if expected benefits for both pain and function are anticipated to outweigh 
risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy 
and nonopioid pharmacologic therapy, as appropriate. The authors further note, Before starting 
opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, 
including realistic goals for pain and function, and should consider how opioid therapy will be 
discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if 
there is clinically meaningful improvement in pain and function that outweighs risks to patient 
safety. The Federation of State Medical Boards (FSMB) recommends prescribers use opioid 
therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, 
only when non-opioid and non-pharmacological options have not been effective. Maintain opioid 
dosage as low as possible and continue only if clear and objective outcomes are being met. 
Manchikanti and colleagues advise that providers establish appropriate physical diagnosis and 
psychological diagnosis if available, consider appropriate imaging, physical diagnosis, and 
psychological status to collaborate with subjective complaints, and establish medical necessity 
based on the average moderate-to-severe pain and/or disability. In this case, the patient has 
chronic pain involving  multiple areas, particularly in the abdomen and back. The patient is 
currently receiving specialty care from gastroenterology and neurology for pain management. 
She has been stable on Oxycontin with adequate pain control, prescribed by the same provider, 
without irregular urine toxicology screens, and with CURES reports consistent with therapy. The 
records did not document evidence of adverse drug reactions or aberrant behavior identified. 
Given that this patient is being treated in a manner consistent with current medical literature, the 
requested medication is medically indicated. Therefore, Oxycontin (oxycodone HCL tablet ER 
12 hour deter 40 mg) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 59-year-old female who has FLT3 positive acute myeloid leukemia status post a 
matched related donor peripheral blood stem cell transplant (SCT) on 1/17/22. The patient has 
requested authorization and coverage for Promacta (eltrombopag) 50 milligrams daily and 
increase depending on response. The physician reviewer found that the submitted 
documentation supports the medical necessity of the requested medication. The incidence of 
delayed thrombocytopenia in patients who undergo allogeneic hemopoietic stem cell 
transplant (SCT) is nearly 20-40%. Persistent thrombocytopenia after stem cell transplantation 
can lead to increased morbidity and mortality. Although the National Comprehensive Cancer 
Network (NCCN) guidelines recommend participation in a clinical trial for patients with 
thrombocytopenia after SCT, there are currently no clinical trials available. Use is supported by 
a phase II trial and a meta-analysis involving over 300 patients indicating safety and efficacy. 
This patient also requires HLA matched platelets in a current environment of severe shortages 
of blood products. There is sufficient support for the requested medication in this setting. 
Therefore, Promacta (eltrombopag) 50 milligrams daily and increase depending on response is 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 51-year-old female enrollee has requested authorization and coverage for 64628  thermal 
destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees low back 
pain. At issue is whether 64628  thermal destruction of intraosseous basivertebral nerve is likely 
to be more beneficial for treatment of the enrollee's condition than any available standard therapy. 
The physician reviewer found that in a single-arm metanalysis to provide an estimate of the 
effectiveness of basivertebral nerve radiofrequency ablation to treat vertebrogenic low back pain, 
Conger and colleagues noted a rate of 65% and 64% for equal or greater than 50% pain relief at 
six and 12 months, respectively. The authors further noted that rates of a 15-point or greater 
Oswestry Disability Index (ODI) score improvement were 75% and 75% at six and 12 months, 
respectively. The authors concluded that there is moderate-quality evidence that basivertebral 
nerve  radiofrequency  ablation  effectively  reduces  pain  and  disability  in  most  patients  with 
vertebrogenic low back pain. Sayed and colleagues report in best practice guidelines that the 
application of basivertebral nerve ablation for patients suffering from vertebrogenic low back pain 
is grounded in a solid foundation of both pre-clinical and clinical evidence. The authors further 
report that the United States Preventative Task Force (USPSTF) gives basivertebral nerve ablation 
a Level A grade, with high certainty that the net benefit is substantial in appropriately selected 
individuals. Fischgrund and colleagues found a reduction of visual analogue scale (VAS) pain 
score, an improvement in ODI scores, and complete pain resolution for 34% of patients at 6.4 years 
following treatment of chronic low back pain with basivertebral nerve ablation as compared to 
sham therapy. Therefore, 64628  thermal destruction of intraosseous basivertebral nerve 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 51-year-old female enrollee has requested authorization and coverage for 64628  thermal 
destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees low back 
pain. At issue is whether 64628  thermal destruction of intraosseous basivertebral nerve is likely 
to be more beneficial for treatment of the enrollee's condition than any available standard therapy. 
The  physician  reviewer  found  that  the  requested  service  suggested  for  the  treatment  of 
vertebrogenic back pain in patients with Modic changes on imaging. Conger and colleagues report, 
There is moderate-quality evidence that suggests this procedure is effective in reducing pain and 
disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic 
changes, among other inclusion and exclusion criteria used in the published literature to date. 
Success of the procedure appears to be dependent on effective targeting of the basivertebral nerve. 
Non-industry funded high-quality, large prospective studies are needed to confirm these findings.  
Fischgrund and colleagues concluded, Chronic low back pain patients treated with basivertebral 
nerve ablation exhibit sustained clinical improvements in function and pain with high responder 
rates at a mean of 6.4 years following treatment. Basivertebral nerve ablation is a durable, 
minimally invasive treatment for vertebrogenic chronic low back pain. Smuck and colleagues  report, Basivertebral nerve ablation demonstrates significant improvements in pain and function 
over standard care, with treatment results sustained through 12 months in patients with chronic 
low back pain of vertebrogenic origin. Standard therapy for chronic low back pain includes 
physical therapy, medications, activity modification, and weight loss. There is a lack of treatment 
options designed to specifically target patients with Modic changes. Current medical literature 
demonstrates that the requested treatment is expected to be superior to standard conservative care 
for the treatment of this patients condition. Further, the results from studies demonstrate a 
reduction in pain, improvement in function, and durability of efficacy even beyond five years. 
Therefore, 64628  thermal destruction of intraosseous basivertebral nerve 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 3 
A 51-year-old female enrollee has requested authorization and coverage for 64628  thermal 
destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees low back 
pain. At issue is whether 64628  thermal destruction of intraosseous basivertebral nerve is likely 
to be more beneficial for treatment of the enrollee's condition than any available standard therapy. 
The physician reviewer found that chronic low back pain is a debilitating condition. When Modic 
changes are present in the disc spaces, a vertebrogenic cause of back pain is considered an etiology 
of chronic back pain. The main source of innervation for the vertebral body are the basivertebral 
nerves. Ablation of the basivertebral nerve is a safe and effective procedure that is evidence based 
for  appropriately  selected  candidates.  Sayed  and  colleagues  report,  The  United  States 
Preventative Task Force (USPSTF) criteria for grading evidence gives basivertebral nerve ablation 
Level A grade evidence with high certainty that the net benefit is substantial in appropriately 
selected  individuals.  In  a  prospective,  randomized,  multicenter  study,    Khalil  report  that 
basivertebral nerve ablation led to significant improvement of pain and function at three-months 
in  patients  with  chronic  vertebrogenic  related  low  back  pain.  Fischgrund  and  colleagues 
demonstrated that patients treated with basivertebral nerve ablation patients sustained clinical 
improvements in pain and improvement in function at a mean of 6.4 years following treatment. In 
this case, the requested service is likely to be more beneficial than standard therapies such as 
conservative care with physical therapy, medications, and procedural interventions such as lumbar 
medial branch radiofrequency ablation. Therefore, 64628  thermal destruction of intraosseous 
basivertebral nerve is likely to be more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 41-year-old male with a history of ileocolonic Crohns disease since 2016. The 
patient has requested authorization and coverage for Humira 40 mg weekly for four months. The 
physician reviewer found that Humira 40 mg weekly is being requested. Empiric dose-escalation 
or guided by therapeutic drug monitoring is an appropriate intervention for patients with loss of 
response  to  biologic  therapy  per  guidelines  set  forth  by  the  American  Gastroenterology 
Association. A systematic review and meta-analysis by Srinivasan and colleagues showed that 
dose-intensification is clinically effective in patients with Crohns disease with secondary loss of 
response. The patient had initial response to Humira every other week, but had recurrent 
symptoms, which represents loss of response. The patient now has been on dose-escalation with 
weekly dosing, and now has clinical remission. Thus, Humira 40 mg weekly for four months is 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 17-year-old female with no significant medical or surgical history. The patients 
parent has requested reimbursement for emergency room physician services (CPT 99285) 
provided on 4/10/21. The physician reviewer found that in this case, the patient presented with 
severe abdominal pain, and underwent an interview to obtain history, a physical examination, 
imaging with both ultrasound and CT scan of the abdomen and pelvis, and laboratory testing 
(including blood count, chemistry, and gastrointestinal pathogen panel). The findings and plan 
were discussed with her primary care physician. The finding of colitis with differential of 
inflammatory bowel disease and infectious colitis constituted a high-risk finding (with threat to 
life or bodily function) given the possible complications of bowel perforation, toxic megacolon, 
sepsis, inflammatory bowel disease flare, peritonitis, hemolytic uremic syndrome, abscess, 
fistula, or other complications. For these reasons (number of problems, data reviewed, and risk 
level), the code of 99285 is supported. Therefore, emergency room physician services (CPT 
99285) provided on 4/10/21 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 64-year-old female. Notes dated 9/12/22 reported that the patient had eosinophilic 
esophagitis, complicated by stricture, status post dilation, resulting in esophageal perforation 
requiring esophagectomy. The patient has requested authorization and coverage for a Botox 
(onabotulinum toxin A) injection. The Health Insurer has denied this request and reported that the 
requested services is not medically necessary for the treatment of this patient. This denial is the 
subject  of  this  appeal  and  determination.  The  physician  reviewer  found  that  the  submitted 
documentation supports the medical necessity of the requested service. Fuchs and colleagues 
report that intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-
assisted transhiatal esophagectomy is feasible, safe, and effective and can prevent the need for 
pyloromyotomy. Bagheri and colleagues note that given the need to use less-aggressive techniques 
and facilitate greater use of endoscopic methods, botulinum toxin injection may be used instead of 
pyloroplasty as a simple, effective, and complication-free method to prevent delayed gastric 
emptying. In this case, the patient had an esophageal resection and subsequent development of 
pyloric stenosis. The records noted past successful improvement with an EGD with Botox. Given 
that current medical literature supports the use of chemical pyloromyotomy with Botox as safe and 
effective, the requested service is medically indicated. Therefore, a Botox (onabotulinum toxin A) 
injection is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The  patient  is  a  47-year-old  male  with  a  history  of  chronic  low  back  pain  with  lumbar 
radiculopathy, lumbar disc herniation with radiculopathy, and lumbar spondylosis. The provider 
has recommended treatment with lumbar spine surgery, open SI joint fusion, and one associated 
inpatient bed day. The Health Insurer has denied the requested services as not medically 
necessary for treatment of the patients medical condition. The physician reviewer found that 
there are limited large-scale, long-term references showing the safety and efficacy of the 
requested lumbar spine surgery and open SI joint fusion in this clinical setting. This patient is 
being treated for chronic low back pain with lumbar radiculopathy, lumbar disc herniation with 
radiculopathy, and lumbar spondylosis. The provider reported that the patient experiences 
minimal pain with lumbar forward flexion, with apprehension. The patients flexion motion is 
essentially full, but his extension is limited and causes lower back pain. However, dynamic flexion-
extension films are not documented in order to assess the amount of movement or instability at 
the requested surgical level. There is also a lack of documentation regarding potential temporary 
intraoperative instability. According to Resnick and colleagues, As a result of the decompression, 
the inherent instability associated with the spondylolisthesis may progress and lead to further 
misalignment that results in pain or recurrence of neurological complaints. In another study, 
Eismont and colleagues reported that, Although much has been published in the past two 
decades on the surgical management of degenerative spondylolisthesis, the optimal method 
remains controversial. Interbody fusion may improve arthrodesis rates and can be performed via 
numerous  surgical  approaches.  Minimally  invasive  techniques  continue  to  be  developed. 
Furthermore,  there  is  a  lack  of  imaging  or  radiographic  evidence  supporting  a  sacroiliitis 
pathology for this patient. Criteria supporting a sacroiliitis pathology include significant SI joint 
pain and a lack of alternative diagnoses that could be responsible for the patients pain (Lorio 
and Rashbaum). In this case, the records indicated SI joint testing showed minimal pain, and 
multiple other plausible pain generators including at the lumbosacral spine are evident. Finally, 
medical literature does support the use of open SI joint fusion as safe and effective for patients 
with degenerative sacroiliitis refractory to nonoperative management (Smith, et al.; Ledonio, et 
al.). Overall, there is a lack of diagnostic imaging studies corroborating degenerative sacroiliitis 
for this patient. For these reasons, the requested lumbar spine surgery, open SI joint fusion, and 
one associated inpatient bed day are not medically necessary for treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 46-year-old female insured has requested authorization and coverage for lymphedema surgery 
and two inpatient bed days. The Health Insurer has denied this request indicating that the requested 
services  are  considered  investigational  for  treatment  of  the  insureds  lymphedema.  
The  physician  reviewer  found  that  Garza  and  colleagues  noted  that,  Lymphaticovenular 
anastomosis (LVA) or lymphovenous bypass is a surgical procedure where lymphatic vessels in a 
lymphedematous limb are connected to nearby small veins and venules using microsurgical and 
super-microsurgical techniques. The authors found that Numerous studies have been published 
which show improved symptoms and as much as 61% reduction in volume difference of the 
affected limb after LVA at one year. In addition, Pereira and colleagues reported that LVA is an 
effective treatment option to reduce the volume in the affected limb and to improve associated 
symptoms. Moreover, Cheng and colleagues concluded that LVA was performed and the patients 
remained in an inpatient setting for up to three days to allow for an adequate stabilization of the 
anastomosis before being discharged. Overall, LVA is an established microsurgical technique for 
the treatment of patients with lymphedema. LVA can be employed as a second stage after 
liposuction removal of thick lymphedematous tissue for debulking or as an inpatient surgical 
procedure to allow for careful observation, positioning, and mobilization after the procedure. 
Therefore, the requested lymphedema surgery and two inpatient bed days 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 46-year-old female insured has requested authorization and coverage for lymphedema surgery 
and two inpatient bed days. The Health Insurer has denied this request indicating that the requested 
services  are  considered  investigational  for  treatment  of  the  insureds  lymphedema.  
The physician reviewer found that lymphedema surgery has slowly improved over time and has 
become more mainstream with the improvement in microsurgery techniques. With advances in 
super-microsurgery as well as findings from breakthrough studies, the surgical treatment of 
lymphedema has become widely accepted and is considered the gold standard for treatment of this 
disease process (Chang, et al.; Schaverien, et al.). Once the diagnosis is confirmed with tests, such 
as this patients evaluation with lymphoscintigraphy, treatment options include compression 
garments and or surgery, which have been demonstrated to be effective modalities to help alleviate 
symptoms in patients with lymphedema (Brown, et al.). Surgical options are based on the stage of 
the disease. Lymphovenous bypass is a treatment option described for her stage of disease. Based 
on the review of this case, the patient underwent evaluation and was diagnosed with lymphedema. 
The patient has undergone surgery on the left side twice. She appears to have recovered well after 
surgery and now seeks treatment for the other affected side. Given the patients history and the 
current literature, the requested lymphedema surgery and a two day hospital stay is likely to be 
significantly more beneficial for treatment of the patient than other available therapies. In addition, 
she has proven by her own medical history that this treatment has been successful for her left leg. 
All told, the requested lymphedema surgery and two inpatient bed days is likely to be more 
beneficial for treatment of the patients medical condition than any available standard therapy.