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

Summary Reviewer 1 
 
A 32-year-old female enrollee has requested authorization and coverage for a prescription for 
Qulipta  60  mg tablets. The  Health  Insurer has  denied this  request  and  reported  that  the 
requested medication is investigational for the treatment of the enrollees headaches. The 
physician reviewer found that Edvinsson and colleagues report that calcitonin gene-related 
peptide (CGRP) plays a crucial role in migraine pathophysiology and is now established as an 
important target for both preventive and acute treatment. The authors further note that CGRP-
targeting  monoclonal  antibodies  that  bind  either  the  CGRP  receptor  or  the  CGRP  ligand 
effectively prevent migraine attacks. Small molecule CGRP receptor antagonists are a newer drug 
class called gepants. The U.S. Food and Drug Administration (FDA) approves the use of Qulipta 
(atogenpant), a CGRP receptor antagonist, for the preventive treatment of episodic migraine in 
adults. Ailani and colleagues report that atogepant, an orally administered gepant, demonstrated 
efficacy and tolerability in the preventive treatment of migraine in a 12-week randomized, 
double-blind, placebo-controlled, parallel-group study of subjects with episodic migraine. The 
authors further noted that all atogepant dosage levels were more effective than placebo at 
reducing monthly migraine days and well tolerated. The American Headache Society notes that 
patients with migraine should be considered for preventive treatment in any of the following 
situations: (1) attacks significantly interfere with patients daily routines despite acute treatment, 
(2) frequent attacks, (3) contraindication to, failure, or overuse of acute treatments, with overuse 
defined as ten or more days per month for ergot derivatives, triptans, opioids, combination 
analgesics, and a combination of drugs from different classes that are not individually overused, 
(4) fifteen or more days per month for nonopioid analgesics, acetaminophen, and nonsteroidal 
anti-inflammatory drugs (NSAIDs), (5) adverse effects with acute treatments, or (6) patient 
preference. The AHS further notes that treatment plans involving the preventive use of gepants 
should be based on regimens used in clinical trials and personalized according to the needs of 
individual  patients.  In  this  case,  the  patient  has  a  history  of  episodic  migraines  that  are 
debilitating despite acute treatment, fulfilling the AHS criteria for preventative treatment. In this 
clinical setting, a treatment plan involving the preventive use of gepants that is personalized 
according to the needs of the individual patient, as recommended by the AHS, is likely to be more 
beneficial  than  any  available  standard  therapy  for  the  patients  condition.  Therefore,  a 
prescription for Qulipta 60 mg tablets is 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 2 
 
A 32-year-old female enrollee has requested authorization and coverage for a prescription for 
Qulipta  60  mg tablets. The  Health  Insurer has  denied this  request  and  reported  that  the 
requested medication is investigational for the treatment of the enrollees headaches. The 
physician reviewer found that in this case, the records document symptomatology including 
photophobia, phonophobia, and nausea lasting hours to days, supporting the diagnosis of  migraines. The FDA approves the use of Qulipta, a medication whose mechanism is related to the 
CGRP, for the management of migraines. Ailani and colleagues noted a significant reduction of 
migraine days with the use of atogepant. Goadsby and colleagues noted nearly four days of 
migraine reduction with the use of Qulipta. While current medical literature supports the use of 
Qulipta as a safe and effective treatment for migraines, there is a lack of evidence supporting the 
superiority of Qulipta to an alternative standard therapy. Therefore, a prescription for Qulipta 60 
mg tablets 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 32-year-old female enrollee has requested authorization and coverage for a prescription for 
Qulipta  60  mg tablets. The  Health  Insurer has  denied this  request  and  reported  that  the 
requested medication is investigational for the treatment of the enrollees headaches. The 
physician reviewer found that in this case, notes dated 4/26/22 reported that the patient has an 
average of one migraine monthly around her menstrual cycle that can last up to three days. Given 
that this patients headaches are centered around her menstrual period, there is evidence of the 
evidence of efficacy of other abortive and preventative interventions including prescription drugs 
and hormonal therapy in this clinical setting. Nierenburg Hdel and colleagues report that of all 
categories of treatment for menstrual migraine, triptans have the most extensive research with 
strong evidence for both acute and preventive treatment of menstrual migraine. There is a lack 
of evidence supporting the use of Qulipta in catamenial migraines. Therefore, a prescription for 
Qulipta 60 mg tablets 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 Overturned

Summary Reviewer  
The patient is a 62-year-old male who presented to his provider on 1/26/22 with cough for the 
past three weeks. The patient has requested reimbursement for a CT scan without contrast 
performed on 2/10/22. The physician reviewer found that at issue is whether the CT scan without 
contrast performed on 2/10/22 was medically necessary for the evaluation of this patient. The 
submitted documentation supports the medical necessity of the service at issue. The American 
College of Radiology (ACR) appropriateness criteria for the evaluation of chronic cough notes that 
for the evaluation of persistent symptoms of chronic cough, radiography and CT of the chest with 
or without contrast is usually appropriate. In this case, a CT scan, with or without contrast, would 
be an appropriate study in this clinical setting. Therefore, the CT scan without contrast performed 
on 2/10/22 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 70-year-old male. The patient has requested reimbursement for foreign claim  
Mexico, ambulance transportation on 4/30/21. The physician reviewer found that submitted 
documentation supports that the patient received emergency medical services on 4/30/21. In 
this case, the patient had a life-threatening injury with significant risk of morbidity and mortality 
resulting in neurologic deficits that had the potential to worsen and become irreversible with any 
treatment delay. The patient had an emergent neurosurgical procedure performed for the same 
reasons. He did not have access to neurosurgical care to receive his life and brain-saving 
treatment at the hospital in Mexico. Prompt treatment and the use of an ambulance in this 
emergency situation was justified and necessary. Non-medical transportation in this clinical 
setting would have posed a substantial risk of potential worsening of morbidity and potential 
mortality as patients with worsening neurologic deficits, as in this case, require close medical 
monitoring  both  during  the  hospital  stay  and  when  being  transported  between  hospitals. 
Therefore, foreign claim  Mexico, ambulance transportation on 4/30/21 was an emergency 
medical service and medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 44-year-old female who has been diagnosed with severe Raynauds with 
ulceration. The patient has requested authorization and coverage for Botox injectable 100 unit 
every 90 days for a year. The physician reviewer found that treatment of severe and refractory 
Raynauds disease must be individualized based on clinical findings, presentation, and other 
studies. As the presentation of the patient is advanced and rare, the literature has mainly case 
reports and small studies supporting the use of Botox for severe and ulcerating Raynauds 
disease, although more recently there have been larger clinical trials. Due to the patients low-
normal blood pressure, additional blood pressure agents (such as different calcium channel 
blockers) are contraindicated because of hypotensive risk. This patient has documented findings 
consistent with severe Raynauds disease, including digital ulceration of hands and toes. Recent 
literature supports the use of Botox for Raynauds syndrome for systemic sclerosis. In addition, a 
randomized controlled trial by Motegi and colleagues supported the efficacy of Botox for 
treatment of Raynauds disease and decrease in ulcerations. Given the refractory nature of the 
patients disease, the presence of ulcerations, which suggests potential loss of function if the 
disease continues, and support for use of Botox from clinical trials, there is sufficient support for 
Botox in this clinical setting. Therefore, Botox injectable 100 unit every 90 days for a year is 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 20-year-old female who sustained severe injuries with a Glasgow Coma Score 
(GCS) of 6 from a motor vehicle versus cyclist accident on 5/2/23. The provider noted that the 
patients pulse was 100 beats per minute on the date of transport. The patient has requested 
reimbursement for the air and ground ambulance services provided on 6/23/22. The physician 
reviewer found that the records provided for review document that this patient sustained TBI, 
SDH, SAH, complex pelvic fractures, and an open tibia fracture in a motor vehicle versus bicycle 
accident on 6/23/22. Based on review of the level of injuries sustained, including internal 
hemorrhage and brain injury, this patient would have warranted air transport in order to 
expedite  the  transfer.  The  provider  recommended  transfer  for  the  patient  to  undergo 
neurological rehabilitation from an intensive multidisciplinary approach to maximize functional 
independence. The records document that the patient had a pulse of 100 beats per minute on 
the day of transport, which could have represented ongoing or recurrent internal hemorrhage. 
Given the extent and severity of the patients injuries, transport by any other means such as 
ground ambulance for the entire transfer would have placed the patients long-term health at 
risk. Moreover, the use of air and ground transport for this patient was consistent with the 
recommendations from the Centers for Disease Control and Prevention (CDC). Therefore, the air 
and ground ambulance services provided on 6/23/22 were medically necessary for treatment of 
this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The  patient  is  a  63-year-old  female  with  a  history  of  chronic  bilateral  knee  pain  due  to 
osteoarthritis. The patient has requested authorization and coverage for Synvisc-One injections. 
The Health Insurer has denied this request and reported that the requested services 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 an exhaustive review of the current medical 
literature  pertaining  to  viscosupplementation  reveals  mixed  results.  Evidence  from  eight 
systematic  reviews  and  six  randomized  controlled  trials  indicates  that  although 
viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not 
known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid 
with  corticosteroids,  platelet-rich  plasma,  and  other  agents  to  make  it  more  effective.  The 
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 benefitted from viscosupplementation in the past. The injections lasted six months at a time 
and were provided on multiple occasions in 2018 and 2019. Corticosteroid injections were not 
successful. Furthermore, in light of the mild degree of osteoarthritis in both knees, the patient is 
an ideal candidate for viscosupplementation. Therefore, the requested Synvisc-One injections are 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 57-year-old male insured has requested reimbursement for a gene test (CPT 0047U) provided on 
3/10/22. The Health Insurer has denied this request indicating that the services at issue were considered 
investigational for the evaluation of the insureds prostate cancer. The physician reviewer found that the 
records available for review indicate that this patient presented with Gleason 3+3=6 prostate cancer 
with a PSA of 7.74 ng/mL. The current National Comprehensive Cancer Network (NCCN) guidelines 
recommend testing with Oncotype DX post-biopsy for patients with low or favorable intermediate-risk 
prostate cancer. Retrospective studies have shown that molecular assays following prostate biopsy or 
radical prostatectomy can provide prognostic information independent of NCCN risk groups (Chang, et 
al.). One review studied whether the score for a prostate genetic test was associated with prostate 
cancer pathology findings for patients who had their prostate removed (Covas Moschovas, et al.). The 
authors found that their findings may help surgeons in counseling patients on surgical options for 
prostate cancer. Overall, the data suggest that patients with clinically localized disease may be 
considered for the use of tumor-based molecular assays, and this testing is considered the standard of 
care in guiding treatment decision-making. Accordingly, the gene test (CPT 0047U) provided on 3/10/22 
was likely to have been more beneficial for the evaluation of the patients medical condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 57-year-old male insured has requested reimbursement for a gene test (CPT 0047U) provided on 
3/10/22. The Health Insurer has denied this request indicating that the services at issue were considered 
investigational for the evaluation of the insureds prostate cancer. The physician reviewer found that Per 
the available records, this patient presented with a history of Gleason 3+3=6 prostate cancer with a PSA 
of 7.74 ng/mL. The patient underwent evaluation with Oncotype DX genomic prostate score testing. 
Once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by analyzing 
the grade of tumor and PSA level. Current studies in the peer-reviewed medical literature have 
demonstrated that the Oncotype DX Prostate Cancer Assay is beneficial as an addition to standardized 
testing in the assessment and treatment planning of patients with prostate cancer (Klein, et al.). The 
Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a 
genomic prostate score. The Oncotype DX can help guide the most appropriate therapy for patients, as 
well as determine which patients will not require treatment with surgery or radiation (Van Den Eeden, 
et al.). Overall, the use of prognostic biomarker testing with Oncotype DX has been shown to improve 
patient health outcomes (Klein, et al.). Furthermore, NCCN guidelines also support the use of Oncotype 
DX to better stratify patients with localized disease (Cullen, et al.). Therefore, the gene test (CPT 0047U) 
provided on 3/10/22 was likely to have been more beneficial for the evaluation of the patients medical 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3  A 57-year-old male insured has requested reimbursement for a gene test (CPT 0047U) provided on 
3/10/22. The Health Insurer has denied this request indicating that the services at issue were considered 
investigational for the evaluation of the insureds prostate cancer. The physician reviewer found that 
Oncotype DX genomic prostate score testing has been used to predict higher-grade disease in patients 
undergoing active surveillance. Many studies suggest that Oncotype DX can predict higher-grade 
pathologic features in patients undergoing active surveillance and can help guide shared decision-
making for very low-risk or intermediate-risk prostate cancer. According to the current medical 
literature, the addition of Oncotype DX can provide important risk information about how an individual 
tumor will likely behave and help direct treatment. The recommendations for patients with localized, 
locally advanced, post-radical prostatectomy and recurrent prostate cancer are based on prognosis, 
which is estimated through risk stratification. Based on NCCN recommendation, patients with low-risk or 
favorable intermediate-risk disease should be considered for evaluation with one or more tumor-based 
molecular assays including Oncotype DX. This patients biopsy of the prostate demonstrated Gleason 
3+3=6 prostate cancer with a PSA of 7.74 ng/mL. This is clinically staged as cT1c with NCCN low risk. 
Based on current NCCN guidelines, Oncotype DX genomic prostate score testing is recommended to 
determine subsequent treatment options including surveillance in patients with clinical NCCN low-risk 
prostate adenocarcinoma. All told, the gene test (CPT 0047U) provided on 3/10/22 was likely to have 
been more beneficial for the evaluation of the patients medical condition than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is 34-year-old female. The patient has requested authorization and coverage for 
Prolastin-C injection 1,000 mg for 20,000 over 28 days. The physician reviewer found that at issue 
is whether Prolastin-C injection 1,000 mg for 20,000 over 28 days is medically necessary for the 
treatment of this patient. The submitted documentation supports the medical necessity of the 
requested service. Alpha-1 antitrypsin (AAT) is an inhibitor of the proteolytic enzyme elastase 
and is essential for the maintenance of the lung parenchyma. Patients with deficiencies in AAT 
develop lung destruction leading to emphysema and end-stage obstructive lung disease. In this 
case, the patient has a diagnosis of AAT deficiency with phenotype ZZ. AAT deficiency with ZZ 
phenotype  is  characterized by very  low  AAT  levels  driving precocious  emphysema, and  is 
frequently managed with augmentation therapy with Prolastin-C.  In this case, the patients ATT 
levels are at 16 mg/dL, well below the minimum protective threshold of 57 mg/dL, under which 
augmentation therapy is considered beneficial. While clinical guidelines and recommendations 
regarding the specific indications for AAT augmentation may vary, it is generally considered 
reasonable to start augmentation for non-smokers with an AAT genetic variant consistent with 
severe AAT deficiency at an AAT level below 57 mg/dL and with evidence of airflow limitation, as 
in this case. In this clinical setting, the requested medication is medically indicated for the 
management of AAT deficiency in this patient. Therefore, Prolastin-C injection 1,000 mg for 
20,000 over 28 days is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 24-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/06/21. 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. The current medical evidence has not established the superior 
efficacy of the services at issue in this clinical setting. Therefore, DecisionDx-Melanoma testing 
performed on 7/06/21 was not likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 24-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/06/21. 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 the 
DecisionDx-Melanoma 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 
7/06/21 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 24-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/06/21. 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 gene expression profile (GEP) testing, such as DecisionDx-Melanoma, can  help to make a melanoma diagnosis if the lesion is indeterminate and can help identify targetable 
mutations.  Testing can also help categorize risk for disease progression, but it is unclear if tests 
such as DecisionDx-Melanoma outperform current standards, including histopathology and 
sentinel lymph node biopsy. In this case, the lesion was early stage (T1a), and GEP testing is not 
recommended  by  National  Comprehensive  Cancer  Network  guidelines  in  this  setting.  The 
medical  evidence  has  not  demonstrated  that  DecisionDx-Melanoma  testing  is  superior  to 
standard testing, and DecisionDx-Melanoma testing does not change management as wide 
excision is the only recommend therapy per the guidelines. Therefore, DecisionDx-Melanoma 
testing performed on 7/06/21 was not likely to have been more beneficial than any available 
standard therapy.