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

Summary Reviewer  
The patient is a two-year-old male who presented for his two-year checkup on 7/11/22. The 
patients parent has requested authorization and coverage for Synagis 100 mg/mL every 28 days 
x  five  months.  The  Health  Insurer  has  denied  this  request  and  reported  that 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 
does not support the medical necessity of the requested medication. The Committee on Infectious 
Disease  and  American  Academy  of  Pediatrics  recommend  the  use  of  palivizumab  for  the 
administration of prophylaxis for the following groups of patients: preterm infants with chronic 
lung disease (CLD) born at less than 32 weeks of gestation requiring supplemental oxygen for at 
least the first 28 days of life, with consideration for a second year of prophylaxis if ongoing medical 
support is required for CLD; children with hemodynamically significant congenital heart disease 
(CHD) in their first respiratory syncytial virus (RSV) season, including those with acyanotic heart 
disease receiving medication to control congestive heart failure and who will require surgical 
intervention and those with moderate to severe pulmonary hypertension; infants with cyanotic 
heart disease in their first RSV season in consultation with their cardiologist; infants with CHD 
that receive RSV prophylaxis following surgical procedures requiring cardiopulmonary bypass, 
due to a decrease in palivizumab serum concentration; children less than two years of age that 
undergo cardiac transplantation during an RSV season; preterm infants born before 29 weeks of 
gestation; infants with neuromuscular disease or congenital anomaly that impairs airway clearance; 
children younger than 24 months that will be profoundly immunocompromised during the relevant 
RSV season; and infants with cystic fibrosis complicated by CLD and/or nutritional compromise 
for their first RSV season, and for a second season in the presence of severe lung disease. 
Palivizumab prophylaxis is not recommended for any children over the age of 24 months. There 
is lack of medical literature supporting its use or efficacy in this population. Luna and colleagues 
report that expert consensus on palivizumab use for RSV recommends palivizumab for preterm 
infants, former preterm children aged at or less than 24 months with CLD/bronchopulmonary 
dysplasia, children aged at or less than 24 months with significant CHD, and other high-risk 
populations,  such  as  children  aged  at  or  less  than  24  months  with  Down  syndrome, 
pulmonary/neuromuscular  disorders,  immunocompromised,  and  cystic  fibrosis.  Given  that 
palivizumab prophylaxis is not recommended in children over the age of 24 months, the requested 
medication is not medically indicated. Therefore, Synagis 100 mg/mL every 28 days x five months 
is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 61-year-old female. In a letter dated 9/19/22, the provider reported that the patient 
has post-menopausal osteoporosis and scoliosis, with a T-score of -3.0 at the hip. The patient has 
requested authorization and coverage for teriparatide (FORTEO) injection pen, inject 20 mcg 
under skin. 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. Khosla and Hofbauer state, Osteoporosis is an enormous 
and growing public health problem. Once considered an inevitable consequence of ageing, it is 
now  eminently  preventable  and  treatable.    While  anti-resorptive  drugs,  especially 
bisphosphonates, have traditionally been considered the treatment of choice, Li and colleagues 
report that pro-formative anabolic drugs, such as Forteo, have attracted wide attention in recent 
years. The authors further note that randomized controlled trials show a higher efficacy in the 
reduced incidence of vertebral and non-vertebral fractures with the use of teriparatide (brand name 
Forteo)  than  bisphosphonates  such  as  risedronate.  Forteo  influences  both  cartilaginous  and 
mineralized callus formation in the fracture healing process, in contrast to other agents such as 
Prolia and Tymlos, which do not increase rates of bony fusion. Therefore, teriparatide (FORTEO) 
injection pen, inject 20 mcg under skin, is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 49-year-old female enrollee has requested reimbursement for laboratory services performed 
at Diagnostic Solutions Laboratory on 3/29/22. The Health Insurer has denied this request and 
reported that the services at issue were investigational for the evaluation of the enrollee. The 
physician reviewer found that there is a lack of evidence-based guidelines and well-constructed 
randomized  clinical  studies  to  support  the  use  of  a  gastrointestinal  map  panel.  Mao  and 
colleagues report that fecal calprotectin (FC) is a relatively new marker of intestinal inflammation. 
Fecal calprotectin correlates to some degree with endoscopic findings and serum markers of 
inflammation  in  inflammatory  bowel  disease.  Kopylov  and  colleagues  note  that  fecal 
inflammatory biomarkers such as calprotectin and lactoferrin are direct products of bowel 
inflammation and provide an accurate and noninvasive diagnostic and monitoring modality for 
Crohn's disease and ulcerative colitis.  However, the appropriateness of this test in the diagnosis 
and  management  of  patients  without  known  inflammatory  bowel  disease  has  not  been 
demonstrated. In this case, polymerase chain reaction testing for stool pathogens showed 
Clostridioides difficile toxin. The records did not document chronic or persistent diarrhea prior to 
the performance of the services at issue. Guidelines for the management of Clostridioides difficile 
do not recommend a full panel of gastrointestinal pathogen testing with polymerase chain 
reaction for evaluation of the documented symptoms and the service at issue was not consistent 
with initial recommended workups for abdominal pain, constipation, or bloating. The service at 
issue has not been shown to be superior to the use of evidence-based guidelines for diagnosis 
and clinical management of irritable bowel syndrome. Therefore, laboratory services performed 
at Diagnostic Solutions Laboratory on 3/29/22 were not likely to have been more beneficial for 
evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
A 49-year-old female enrollee has requested reimbursement for laboratory services performed 
at Diagnostic Solutions Laboratory on 3/29/22. The Health Insurer has denied this request and 
reported that the services at issue were investigational for the evaluation of the enrollee. The 
physician reviewer found that while there has been some investigation into the link between the 
gut microbiome and gastrointestinal health and disease, there are no formal or scientifically 
sound clinical trials evaluating microbiome testing and its utility in the workup and management 
of irritable bowel syndrome. While Tap and colleagues note in an observational study that certain 
microbiome profiles can help predict the severity of symptoms in irritable bowel syndrome, this 
knowledge would not necessarily change the workup and management of the condition. In a 
similar observation study, Zhu and colleagues found that patients with irritable bowel syndrome 
had a significantly differential metabolite profile as compared to healthy controls, but again, such 
information does not affect the manner in which irritable bowel syndrome would be tested for 
or managed. There are no available studies for review that have investigated the general benefit 
of comprehensive gastrointestinal mapping or its benefit over standard testing in the workup and  management of irritable bowel syndrome. Notes dated 6/6/22 reported diagnoses of irritable 
bowel syndrome with constipation and noted that the patients predominant symptoms were 
constipation and bloating. The records noted that gastrointestinal mapping revealed detectable 
Clostridium difficile toxin and elevated anti-Gliadin IgA levels. In this clinical setting, the positive 
Clostridium difficile toxin that was identified in the gastrointestinal mapping could have been 
identified through standard, widely available, focused stool testing. Further, the elevated anti-
Gliadin IgA could have been evaluated for with standard serum testing for celiac serologies. 
Therefore, laboratory services performed at Diagnostic Solutions Laboratory on 3/29/22 were 
not likely to have been more beneficial for evaluation of the patients condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
A 49-year-old female enrollee has requested reimbursement for laboratory services performed 
at Diagnostic Solutions Laboratory on 3/29/22. The Health Insurer has denied this request and 
reported that the services at issue were investigational for the evaluation of the enrollee. The 
physician reviewer found that with gastrointestinal mapping continued to be studied, multiple 
studies are emerging to show the importance of microbiota in the diagnosis and treatment of 
disease process such as infection and malignancy. Ahluwalia and colleagues note, Patients with 
irritable bowel syndrome have a distinct faecal microbiota and metabolite profile linked to bowel 
habits. Intestinal microenvironment profiling, based on fecal microbiota and metabolites, may 
be considered as a future non-invasive diagnostic tool, alongside providing valuable insights into 
the pathophysiology of irritable bowel syndrome. Vasapolli and colleagues note that distinct 
fecal microbiota profiles are reported to be associated with various subtypes of irritable bowel 
syndrome. Gingras and Maggiore reported that the GI-MAP assay displayed a sensitivity of 80%. 
Buss and colleagues reported that gastrointestinal mapping panels showed high sensitivity and 
specificity in detecting gastrointestinal infections. Lam and colleagues report regarding mapping 
the microbial communities in the gastrointestinal tract that disturbances in these communities 
have been associated with GI cancers and that an interplay between microbes in carcinogenesis 
seems conceivable, especially in colorectal cancer. In this case, notes dated 3/18/22 reported 
that the patient had multiple gastrointestinal symptoms and a history of iron deficiency anemia 
and breast cancer. She had undergone laboratory testing and an invasive colonoscopy and 
continued to present a diagnostic challenge. In this case, given the patients diagnostic challenge, 
unresolving symptoms, and history of malignancy and iron deficiency anemia, gastrointestinal 
mapping was likely to have been more beneficial than standard diagnostic testing, particularly 
since the number of microorganisms tested with the service at issue were not all commercially 
available.  Therefore,  laboratory  services  performed  at  Diagnostic  Solutions  Laboratory  on 
3/29/22 were likely to have been more beneficial for evaluation of the patients condition than 
any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 45-year-old male who presented with a seizure in 2022.  The patient has 
requested authorization and coverage for proton beam therapy. The physician reviewer found 
that guidelines do not endorse the routine use of proton therapy in the treatment of brain 
tumors. In this case, the patients brain tumor invades into the brain stem and hippocampus. 
Proton therapy is absent of the low dose bath associated with conventional treatment using 
photon techniques and is able to limit the integral radiation dose compared to treatment with 
photons. The comparative planning submitted shows a significant reduction in the dose the brain 
stem and hippocampus using proton therapy. Treatment with protons would be expected to be 
associated with less neurocognitive toxicities compared to standard treatment with photons. 
Therefore, the requested proton beam therapy is medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 63-year-old male who has a history of back pain. The patient has requested 
authorization and coverage for MRI of the lumbar spine. The physician reviewer found that the 
submitted documentation fails to demonstrate the medical necessity of the requested services. 
According to the American College of Radiology (ACR), In  the  absence of  red  flags,  first-line  
treatment  for chronic  low back pain  remains conservative therapy  with  both pharmacologic 
and non-pharmacologic (e.g., exercise, remaining active) therapy. However, patients presenting 
with  subacute or  chronic low back pain,  with  or  without  radiculopathy,  who  have  failed  six  
weeks of  conservative therapy should be imaged if they are believed to be candidates for surgery 
or  intervention  or  if  diagnostic  uncertainty remains.  The goal of imaging is to identify potential 
actionable pain generators that could be targeted for intervention or surgery. The current 
documentation indicates that physical therapy was done in 2019, but the records do not 
document more recent failure of physical therapy. There is no documentation of a surgical 
consultation with plan for invasive therapy. The records do not document neurological deficits. 
Therefore, the requested MRI of the lumbar spine is not medically necessary for the evaluation 
of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
An  83-year-old  male  enrollee  has  requested  reimbursement  for  Guardant360  CDx  testing 
performed on 3/31/21. 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  molecular  diagnostic  studies  in  non-small  cell  lung  cancer  (NSCLC)  are 
considered a standard of care. Numerous gene alterations have been identified that impact 
therapy selection. The National Comprehensive Cancer Network (NCCN) NSCLC Guidelines Panel 
strongly advises broader molecular profiling with the goal of identifying rare driver mutations for 
which effective drugs may already be available, or to appropriately counsel patients regarding 
the availability of clinical trials. Broad molecular profiling is a key component of the improvement 
of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important 
for identification of potentially efficacious targeted therapies, as well as avoidance of therapies 
unlikely to provide clinical benefit. Integration of plasma next-generation sequencing testing into 
the routine management of stage IV NSCLC demonstrates a marked increase of the detection of 
therapeutically targetable mutations and improved delivery of molecularly guided therapy. 
Therefore, Guardant360 CDx testing performed on 3/31/21 was likely to have been more 
beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
An  83-year-old  male  enrollee  has  requested  reimbursement  for  Guardant360  CDx  testing 
performed on 3/31/21. 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 medical evidence supports the services at issue in this clinical setting. Non-
small cell lung cancer, particularly adenocarcinoma, should be tested for multiple mutations, 
including EGFR, ALK, ROS, and BRAF. Usually, this is done from a tissue biopsy, but it is accepted 
that liquid assay of cancer DNA in blood (Guardant assay) can substitute for tissue biopsy, if tissue 
biopsy is considered not feasible or not safe. According to the records in this case, this was the 
situation in this patients case. Therefore, Guardant360 CDx testing performed on 3/31/21 was 
likely to have been more beneficial for evaluation of the patients medical condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
  An  83-year-old  male  enrollee  has  requested  reimbursement  for  Guardant360  CDx  testing 
performed on 3/31/21. 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 therapy of advanced NSCLC has been revolutionized by the finding of EGFR 
mutations in certain adenocarcinomas. The mutations are more common in those who have 
never smoked.  Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results 
in prolonged survival when compared with standard chemotherapy regimens. In this case, it was 
important to know whether the patient had developed an EGFR T790M mutation. This mutation 
confers resistance to erlotinib and has been observed in 60% of patients with progressive disease 
on erlotinib. There is a new tyrosine kinase inhibitor available that can target this mutation, 
osimertinib, which could have been used if this mutation was observed. In order to analyze for 
this mutation, a liquid biopsy was ordered. The Guardant360 test is commonly referred to as a 
liquid biopsy since it involves sampling of tumor cells that may be circulating in the peripheral 
blood. Up to 70 genes can be analyzed for mutations. The test is known for high specificity but 
low sensitivity. According to the NCCN guidelines, it is associated with false negative rates of up 
to 30%. The guidelines note that the test is acceptable if the patient is unfit to pursue more 
invasive methods for tumor sampling. If a simple core biopsy of an accessible metastatic lymph 
node, like a supraclavicular or axillary lymph node, was feasible, then a Guardant360 testing 
would have been unreasonable; but that is not the case here. Per the submitted records, the 
tumor sample was noted as being inadequate for subsequent analysis. There was sufficient 
support  for  Guardant360  testing  in  this  setting  since  disease  was  inaccessible.  Therefore, 
Guardant360 CDx testing performed on 3/31/21 was likely to have been more beneficial for 
evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 57-year-old male with a medical history of human immunodeficiency virus (HIV) 
infection with associated cachexia. The patient has requested authorization and coverage for 
Serostim (somatropin (non-refrigerated) for subcutaneous injectable 6 mg). The physician 
reviewer found that Serostim has been approved by the U.S. Food and Drug Administration 
(FDA) for use in adults with a diagnosis of growth hormone deficiency, HIV-associated wasting, 
cachexia or short bowel syndrome. There is a high prevalence of anorexia-cachexia syndrome in 
individuals with chronic illnesses, including advanced HIV/acquired immune deficiency 
syndrome (AIDS). In this case, the documentation does not support that the patient has HIV 
wasting, as his body mass index (BMI) is within normal limits at 28.2. Furthermore, his medical 
provider has stated his HIV is well-controlled, and there is not a medical indication for the 
requested Serostim. Therefore, Serostim (somatropin (non-refrigerated) for subcutaneous 
injectable 6 mg) is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 51-year-old female enrollee has requested authorization and coverage for Botox. The Health 
Insurer has denied this request and reported that the requested service is investigational for the 
treatment of the enrollee. The physician reviewer found that Temporomandibular joint disorders 
usually present with symptoms and signs such as pain, mandibular movement, dysfunction, or 
joint sounds. Bruxism is characterized by teeth grinding. Botulinum toxin A (Botox) is a biologic 
toxin which inhibits skeletal muscle through hindering the production of acetylcholine in the 
nerve endings. The use of Botox for treatment of temporomandibular joint disorders and bruxism 
is not consistent with U.S. Food and Drug Administration (FDA) indications. While there are 
reports of the clinical use of Botox for the treatment of temporomandibular joint disorders and 
bruxism, the clinical evidence in current medical literature is insufficient to demonstrate the 
clinical efficacy of Botox in the treatment of temporomandibular joint disorders and bruxism or 
that it is more beneficial than standard therapies including the use of occlusal devices, NSAIDs, 
and physical therapy. Therefore, Botox 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 2 
 
A 51-year-old female enrollee has requested authorization and coverage for Botox. The Health 
Insurer has denied this request and reported that the requested service is investigational for the 
treatment of the enrollee. The physician reviewer found that in this case, the patient has a history 
of temporomandibular joint disorder which has been present for years. The records note that the 
patient has failed treatment with warm compresses and NSAIDs but responded well to Botox 
therapy of the masseters. Standard therapy currently consists of oral muscle relaxants to help 
reduce muscle spasms, which relax all muscles in the body and therefore have significant side 
effects in order to be effective, physical therapy, which may only provide temporary relief of a 
few hours, and oral appliances, which may prevent dental wear without stopping the bruxism 
that is the primary cause of the temporomandibular joint disorder. Current medical literature 
supports the use of Botox for treatment for bruxism-induced temporomandibular joint disorder. 
Botox treats the bruxism locally and works for three months at a time, allowing the patient three 
months of relief following an injection. In this clinical setting, the use of Botox for the treatment 
of temporomandibular joint disorder is more beneficial than standard treatment as patient's 
condition is caused by bruxism and not cause by arthritis of the temporomandibular joint. 
Therefore, Botox is likely to be more beneficial for treatment of the patients condition than any 
available standard therapy.