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

Summary Reviewer 1 
 
A 27-year-old female insured has requested authorization and coverage for Besremi 500 mcg/mL 
syringe. A review of the record indicates the insured is currently pregnant and has a history of 
essential thrombocythemia. The Health Insurer indicates the requested treatment is considered 
investigational for the treatment of the insureds medical condition. Therefore, the Health Insurer 
has denied coverage for the requested treatment. This denial is the subject of this appeal and 
determination. The physician reviewer found that the records provided for review document that 
this patient presents with low-risk Janus kinase 2 (JAK2)-positive essential thrombocytosis. Per 
the provider, the patient does not have a prior history of thrombotic complications. The patient 
was started on Pegasys after she became pregnant. The patient has reportedly tolerated treatment 
with Pegasys other than injection site pain. The patients provider has recommended treatment 
with Besremi. However, The U.S. Food and Drug Administration (FDA) has not approved 
Besremi in the setting of essential thrombocytosis. Moreover, Besremi has not been listed on the 
National Comprehensive Cancer Network (NCCN) guideline as a recommended therapy option 
for patients with essential thrombocytosis. Therefore, the requested Besremi 500 mcg/mL 
syringe is not likely to be more beneficial for the treatment of the patients medical condition 
than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 27-year-old female insured has requested authorization and coverage for Besremi 500 mcg/mL 
syringe. A review of the record indicates the insured is currently pregnant and has a history of 
essential thrombocythemia. The Health Insurer indicates the requested treatment is considered 
investigational for the treatment of the insureds medical condition. Therefore, the Health Insurer 
has denied coverage for the requested treatment. This denial is the subject of this appeal and 
determination.  The  physician  reviewer  found  that  the  essential  thrombocythemia  is  a 
myeloproliferative disorder caused by specific mutations in the hematopoietic stem cells. Essential 
thrombocythemia manifests as a high platelet count, which predisposes patients to abnormal 
clotting.  As  noted  in  the  medical  literature,  there  is  a  large  overlap  between  essential 
thrombocythemia and polycythemia vera both in clinical manifestations and in molecular genetics. 
The mainstay of treatment is the reduction of the platelet count using hydroxyurea, anagrelide, or 
interferon. Pegylated interferon is an alternate formulation of interferon that has less toxicity. 
Current medical evidence shows that pegylated interferon can reduce the platelet counts of 
essential thrombocythemia patients. Since this patient has been able to tolerate treatment with the 
Pegasys formulation, but reports problems with tolerating weekly injections was not tolerated, then 
the Besremi is an excellent next choice (Okikiolu, et al.; Penna). Accordingly, the requested 
Besremi 500 mcg/mL syringe is likely to be more beneficial for the treatment of the patients 
medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
A 27-year-old female insured has requested authorization and coverage for Besremi 500 mcg/mL 
syringe. A review of the record indicates the insured is currently pregnant and has a history of 
essential thrombocythemia. The Health Insurer indicates the requested treatment is considered 
investigational for the treatment of the insureds medical condition. Therefore, the Health Insurer 
has denied coverage for the requested treatment. This denial is the subject of this appeal and 
determination. The physician reviewer found that the use of aspirin and interferon has been 
associated with increased numbers of live births without significant maternal or fetal adverse 
effects, according to current data from the peer-reviewed medical literature. One meta-analysis 
and review of the literature included 767 patients and 1,210 pregnancies from 22 studies on patients 
with myeloproliferative neoplasms, most of whom had essential thrombocythemia (Maze, et al.). 
The authors found that moderate-quality evidence suggests that aspirin or interferon is associated 
with higher odds of live birth in pregnant women with myeloproliferative disorder. Although 
Pegasys and Besremi are both pegylated interferon (peginterferon) alfa-2a, Besremi is better 
tolerated with fewer injections and it has been shown to be safe during pregnancy. All told, the 
requested Besremi 500 mcg/mL syringe is likely to be more beneficial for the treatment of the 
patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 49-year-old female. The patient has requested reimbursement for physiotherapy 
services from 11/22/21 through 8/5/22. The Health Insurer has denied this request and reported 
that the services at issue were not medically necessary for the treatment of this patient. The 
physician reviewer found that the submitted documentation supports the medical necessity of a 
portion of the services at issue. The treatment of chronic pain has been extensively studied and 
reviewed  in  medical  literature  over  the  past  few  decades.  Emphasis  has  been  placed  on 
minimizing disability, avoiding opiate use in most cases, and using complimentary medicine when 
a benefit can be shown. Physical therapy is expected to emphasize goal focused disability 
reduction through education and exercise aided by modalities such as heat, ultrasound, or aqua 
therapies. Chiropractic spinal manipulation in relation to chronic pain focuses on symptom 
reduction and well-being. Goertz and colleagues report that chiropractic care, when added to 
usual medical care, resulted in moderate short-term improvements in low back pain intensity 
and disability. Qassem and colleagues note that American College of Physician (ACP) guidelines 
regarding noninvasive treatments for acute, subacute, and chronic low back pain support trials 
of complementary medicine across the domains of acupuncture, chiropractic, or exercise for 
musculoskeletal pain. While the progression from acupuncture to physical therapy to chiropractic 
was appropriate, the records did not document benefits, save for headache reduction in physical 
therapy, in almost 18 months of treatment. In this clinical setting, given that the patient has tried 
and failed other modalities of therapy including physical therapy, acupuncture, and medication 
management, current medical literature supports six chiropractic sessions at a minimum prior to 
seeing benefit. Therefore, six sessions of physiotherapy services from 11/22/21 through 8/5/22 
were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 48-year-old female who presented to her provider on 10/5/22. The patient has 
requested authorization and coverage for a Humira 40/0.4 mL pen. The Health Insurer has denied 
this request and reported that the requested medication is not medically necessary for the 
treatment of this patient. The physician reviewer found that the submitted documentation does 
not support the medical necessity of the requested medication. Dactylitis, or inflammation of the 
whole digit, may respond to NSAIDs and some traditional, nonbiologic DMARDs such as 15 to 25 
mg once weekly dosing of methotrexate. Biologic DMARDs may be indicated, at times, in certain 
cases. In patients with enthesitis, improvements in dactylitis are reported as secondary outcomes 
in current medical literature regarding these agents. In this case, given that the records do not 
document a failure of, or contraindication to, traditional DMARDs, and as the patient has other 
manifestations of psoriatic arthritis besides dactylitis, the requested medication is not medically 
indicated. Therefore, Humira 40/0.4 mL pen is not medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 54-year-old female who presented to her provider on 3/1/22. The documentation 
noted a history of excision of back fat in 2018. The patient has requested authorization and 
coverage for suction lipectomy head/neck (15876). The Health Insurer has denied this request and 
reported that the requested service is not medically necessary for the treatment of this patient and 
is not reconstructive in nature. This denial is the subject of this appeal and determination. The 
physician reviewer found that at issue in this case is whether suction lipectomy head/neck (15876) is 
medically necessary for treatment of the patients medical condition. In addition, does the patients 
condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body 
caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; 
infection; tumors or disease? If so, is the requested surgery performed to do either of the following: 
improve function or create a normal appearance to the extent possible? If so, does the surgery 
provide more than a minimal improvement in the appearance of the patient? In this case, the patient 
is five feet and five inches tall and weighs 138 pounds. She is not obese, and a physical examination 
did not reveal any pain, trauma, masses, infections, congenital defects, wounds or any limitations 
in terms of range of motion.  In this case, the requested service is not medically indicated. 
Therefore, suction lipectomy head/neck (15876) is not medically necessary for the treatment of 
this patient. In this case, the patient is not obese, and a physical examination did not reveal any 
pain, trauma, masses, infections, congenital defects, wounds and or any limitations in terms of 
range of motion. The patient does not have tumor defects of the breast, deformities caused by 
infections and/or trauma, or lipedema causing pain. The patients condition does not constitute an 
abnormal structure to her body. Surgery would not be improving any function. While a surgery 
may  well  improve  the  appearance  of  the  involved  area,  this  would  only  be  a  cosmetic 
improvement. Thus, the requested procedure is not being performed to improve function or create 
a more than minimal improvement in the patients appearance. Therefore, suction lipectomy 
head/neck (15876) is not reconstructive in nature.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 50-year-old female enrollee has requested authorization and coverage for interstitial radiation 
source application, complex, includes supervision, handling, loading of radiation source, when 
performed. The Health Insurer has denied this request and reported that the requested service 
is investigational for the treatment of the enrollees oligoprogressive hepatic disease. The 
physician reviewer found that Y90 radioembolization has been shown to be an effective targeted 
treatment  for  tumors  of  the  liver.  In  this  case,  an  applicator  is  used  to  directly  infuse 
microspheres of Y90 into the tumors. These microspheres are delivered through arteries that 
feed directly into the tumor and emit a radionuclide which kills cancer cells. This allows for a very 
targeted dose to be delivered. Liver tissue is highly radiosensitive so targeted therapies are 
critical to ensure lower liver toxicity. At present, Y90 therapy has demonstrated a favorable 
therapeutic ratio with improved overall survival outcomes and low toxicity rates. While there is 
a lack of prospective, randomized trials directly comparing Y90 and other similar targeted liver 
therapies, Y90 has continued to demonstrate a good safety profile. Tsang and colleagues report 
that Y-90 was well-tolerated in patients with metastatic liver-dominant neuroendocrine tumors. 
In phase 3 data combining Y90 therapy with systemic therapy in the setting liver metastases, 
Chauhan and colleagues reported that the addition of the Y90 therapy showed significantly 
longer progression-free survival and hepatic progression-free survival. Current medical literature 
corroborates the low toxicity and improved overall survival data with Y90 therapy. Overall, Y90 
has a track record of improving overall survival in the setting of liver metastases with a fairly low 
toxicity  profile.  Given  the  disease  burden  seen  within  this  patients  liver,  directed  Y90 
radioembolization with targeting of the liver metastases will likely be more beneficial than other 
standard forms of treatment in this setting. Therefore, interstitial radiation source application, 
complex, includes supervision, handling, loading of radiation source, when performed, 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 50-year-old female enrollee has requested authorization and coverage for interstitial radiation 
source application, complex, includes supervision, handling, loading of radiation source, when 
performed. The Health Insurer has denied this request and reported that the requested service 
is investigational for the treatment of the enrollees oligoprogressive hepatic disease. The 
physician reviewer found that current medical literature does not support the use of liver 
radioembolization in the treatment of patients with widespread metastatic disease. Hong and 
colleagues report that the American College of Radiology (ACR), American Brachytherapy Society 
(ABS), American College of Nuclear Medicine (ACNM), American Society for Radiation Oncology 
(ASTRO),  Society  of  Interventional  Radiology  (SIR),  and  Society  of  Nuclear  Medicine  and 
Molecular Imaging (SNMMI) practice parameter on selective internal radiation therapy (SIRT) or 
radioembolization for treatment of liver malignancies note that liver radioembolization is only  recommended for patients with liver-dominant metastatic disease, where the cancer is primarily 
confined to the liver and has not spread to other parts of the body. Liver radioembolization 
carries  the  risk  of  complications  such  as  liver  damage  and  bile  duct  injury.  The  National 
Comprehensive  Cancer  Network  (NCCN)  guidelines  do  not  endorse  the  routine  use  of 
radioembolization  in  the  treatment  of  metastatic  lung  cancer.  In  the  case  of  widespread 
metastatic disease, the risks of liver radioembolization are likely to outweigh any potential 
benefits.  Overall,  the  available  evidence  and  national  guidelines  suggest  that  liver 
radioembolization is not necessary in the treatment of patients with widespread metastatic 
disease. The standard treatment for metastatic EGFR lung cancer typically involves the use of 
targeted therapies such as tyrosine kinase inhibitors, which block the activity of the EGFR protein, 
or systemic chemotherapy. These standard treatments are effective in slowing the growth and 
spread  of  cancer.  There  is  a  lack  of  trials  in  current  medical  literature  showing  that 
radioembolization is superior in any oncologic outcome compared to standard treatment with 
tyrosine kinase inhibitors or chemotherapy. Therefore, interstitial radiation source application, 
complex, includes supervision, handling, loading of radiation source, when performed, is likely 
not 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 50-year-old female enrollee has requested authorization and coverage for interstitial radiation 
source application, complex, includes supervision, handling, loading of radiation source, when 
performed. The Health Insurer has denied this request and reported that the requested service 
is investigational for the treatment of the enrollees oligoprogressive hepatic disease. The 
physician reviewer found that radioembolization has not been proven to yield superior survival 
probabilities for management of non-small cell lung cancer. In this case, the records do not 
indicate that the patient is symptomatic from her liver disease, for example, with pain secondary 
to tumor bulk, requiring palliative measures to improve quality-of-life. Furthermore, the patients 
disease has progressed outside of the liver and while treatment with radioembolization may 
provide control of the liver disease, it would not address the progressive nodal disease. In this 
case, the requested service is not likely to be more beneficial for the treatment of this patient 
than standard management of transitioning to the next-line systemic therapy, or to a clinical trial, 
as this would be a more comprehensive management approach that would address all of 
patients sites of disease. Therefore, interstitial radiation source application, complex, includes 
supervision, handling, loading of radiation source, when performed, 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 1 
 
A 72-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene 
expression profile assay performed on 8/30/19. 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 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 melanoma and a higher proportion of false-positive result, GEP testing should not guide 
clinical decision making in this group. Commercially available GEPs, such as DecisionDx 
melanoma are marketed as being able to classify cutaneous melanoma into separate categories 
based on risk of metastasis. However, it remains unclear where these GEP platforms provide 
clinically actionable prognostic information when used in addition to or in comparison with 
known clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, 
tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel 
lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or 
follow-up schedules has not been established. Various (mostly retrospective) studies of 
prognostic GEP testing suggest its role as an independent predictor of worse outcome, although 
not superior to Breslow thickness or sentinel lymph node status. It remains unclear whether 
this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. 
Prospective validation studies are required to more accurately define the clinical utility of 
molecular testing prior to widespread implementation of GEP for prognostication of cutaneous 
melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel 
lymph node biopsy, and adjuvant treatment decisions. Therefore, DecisionDx-Melanoma gene 
expression profile assay performed on 8/30/19 was not likely to have been more beneficial 
than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 72-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene 
expression profile assay performed on 8/30/19. 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 prognosis of cutaneous melanoma 
has classically been determined by the analysis of Balch. Mitotic index may add a bit to these 
statistics. DecisionDx-Melanoma gene expression profile assay is a 31-gene assay of an 
individuals melanoma cells. It then places that particular melanoma into either Class 1 or 2, 
with somewhat different risks of metastasis by five years. It is not clear how the five-year 
DecisionDx-Melanoma gene expression profile assay data compares to the ten-year Balch data.  Most importantly, there is a lack of data to support using DecisionDx-Melanoma gene 
expression profile assay in making clinical decisions, such as the need for sentinel node biopsy 
and/or adjuvant therapy. Therefore, DecisionDx-Melanoma gene expression profile assay 
performed on 8/30/19 was not likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 72-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene 
expression profile assay performed on 8/30/19. 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 gene expression profile assay 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 gene expression profile assay performed 
on 8/30/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 27-year-old female insured has requested reimbursement for the respiratory virus panel 
testing (CPT 87633, 87798, 87798-59) provided on 7/21/22. The Health Insurer has denied this 
request indicating that the services at issue were considered investigational for evaluation of the 
insureds respiratory illness and shortness of breath. The physician reviewer found that the 
records reflect that the respiratory virus panel services performed on 7/2/122 in the emergency 
room identified a parainfluenza virus. However, the respiratory virus panel testing did not meet 
the American Thoracic Society criteria for this type of testing (Evans, et al.). Medical literature 
has indicated that respiratory virus panel testing is appropriate to test when there is a suspicion 
of immune compromise, a high risk of complications from the infection and when the testing 
could be used to direct therapy (Calderaro, et al.). In the case at hand, the patient presented to 
the emergency room with shortness of breath and cough and, just prior to the visit, reported not 
feeling well. Further, the patients medical records indicate that the patient had treated with 
amoxicillin  for  only  five  days  prior  without  symptom  improvement.  The  record  lacks 
documentation of concerning immune compromise, complication risk, or the need for the panel 
testing to direct therapy. Therefore, the respiratory virus panel testing (CPT 87633, 87798, 87798-
59) provided on 07/21/22 was not likely to have been more beneficial than any other available 
standard treatment for the evaluation of the patients condition.