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

Summary Reviewer  
 
The patient is a 59-year-old male who presented to his provider on 9/15/21. The patient has 
requested authorization and coverage for liver cancer radiation therapy using two treatments of 
selective internal radiation therapy (SIRT). The Health Insurer has denied this request and 
reported that the requested service is not medically necessary for the treatment of this patient. 
The physician reviewer found that the submitted documentation supports the medical necessity 
of the requested service. 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 Y90 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 when combined with 
chemotherapy or immunotherapy. Current medical literature corroborates the low toxicity and 
improved overall survival data with Y90 therapy. In this case, there are a few key factors to take 
into account. Firstly, the liver is a very radiosensitive organ, making targeted treatment delivery 
critical. Y90 can deliver the radiation dose through the artery in a manner that touches only the 
tumor. This cannot be achieved by external radiation methods such as stereotactic radiation 
therapy (SBRT). Secondly, this patients liver metastases are very large with some of the lesions 
measuring over 17 cm. Neither surgical resection nor external radiation treatment can safely 
treat liver lesions that are this large. Only a directed trans-arterial method can safely deliver a 
targeted treatment in this setting. 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 
is medically indicated. Therefore, liver cancer radiation therapy using two treatments of SIRT is 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 66-year-old male who has requested reimbursement for magnetic resonance 
imaging (MRI) of the pelvis performed on 11/08/21. The patient has requested reimbursement for 
MRI of the pelvis provided on 11/08/21. The Health Insurer has denied this request and reported 
that the services at issue were not medically necessary for the evaluation of this patient. This denial 
is the subject of this appeal and determination. The physician reviewer found that the submitted 
documentation fails to demonstrate the medical necessity of the services at issue. Based on the 
clinical records, the patient had a normal PSA after antibiotic treatment and normal PSA density. 
Performing an MRI would not be considered a clinically appropriate or generally accepted 
standard for management of this patients medical condition. The current medical literature does 
not support utility of MRI in patients with a normal PSA and PSA density. Therefore, the MRI of 
the pelvis provided on 11/08/21 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 39-year-old female with a history of large breasts, low back pain, rheumatoid 
arthritis, spinal stenosis, degenerative disease, and herniated disc. The patient underwent breast 
reduction surgery on 9/12/22. The Health Insurer has denied the service at issue as not medically 
necessary for the treatment of the patients medical condition. This denial is the subject of this 
appeal and determination. The physician reviewer found that the American Society of Plastic 
Surgeons (ASPS) guidelines state that reduction mammaplasty should be performed based on 
documentation of the severity of the symptoms of macromastia and its impact on health-related 
quality of life. The guidelines indicate that reduction mammaplasty may be performed if at least 
two of the following quality-of-life signs are present: chronic breast pain due to breast weight, 
intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, backache, 
thoracic kyphosis, shoulder grooving from bra straps, upper extremity paresthesia due to brachial 
plexus compression syndrome secondary to the weight of the breasts being transferred to the 
shoulder strap area, headache, and congenital breast deformity. In this case, the patient has a 
history of back and neck pain. The patient also presented with rheumatoid arthritis, spinal stenosis, 
degenerative disc disease, and herniated disc. There is a lack of documentation of chronic breast 
pain  due  to  weight  of  the  breasts,  thoracic  kyphosis,  shoulder  grooving,  upper  extremity 
paresthesia, headache, or congenital breast deformity. The patient complained of intertrigo, but 
there is a lack of documentation that the patients condition was unresponsive to adequate medical 
management. Overall, there are fewer than two documented quality-of-life signs as defined by the 
ASPS. Therefore, the breast reduction surgery performed on 9/12/22 was not medically necessary 
for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 54-year-old male. In a letter dated 2/18/22, the provider reported that the patient 
presented with neck, thoracic, and radiating arm pain. The patient has requested reimbursement 
for cervical spine MRI provided on 2/21/22. The physician reviewer found that the patient is a 
54-year-old male. In a letter dated 2/18/22, the provider reported that the patient presented 
with neck, thoracic, and radiating arm pain. The patient reported that his symptoms had started 
on Sunday morning, necessitating a visit to the emergency room by Monday night. He reported 
similar symptoms a year back, which had been treated with acupuncture. The records noted that 
computed tomography (CT) of the cervical spine dated 2/14/22 demonstrated diffuse spondylitis 
changes. The provider recommended magnetic resonance imaging (MRI) to evaluate for the 
possibility of disc disease. An MRI dated 2/21/22 showed severe disc protrusions at both C5-C6 
and C6-C7 where it narrowed the central canal to 0.2 cm, with severe stenosis. The patient has 
requested reimbursement for cervical spine MRI provided on 2/21/22. The Health Insurer has 
denied this request and reported that the service at issue was not medically necessary for the 
evaluation of this patient. This denial is the subject of this appeal and determination.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 45-year-old female with a history of severe Raynauds disease with ulceration. 
The patient reported being diagnosed with the condition for the past four to five years with 
worsening symptoms. The provider recommended Botox injections of 100 units for a quantity of 
2 per 30 days for the treatment of the patients Reynards disease symptoms. The Health Insurer 
has denied the requested medication as not medically necessary. This denial is the subject of this 
appeal and determination. The physician reviewer found that the treatment of severe and refractory 
Raynauds disease must be individualized based on clinical findings, presentation, and other 
studies. The medical literature contains mainly case reports and small studies supporting the use 
of Botox for severe and ulcerating Raynauds disease in patients with atypical presentation and in 
such an advanced stage. A randomized controlled trial by Motegi and colleagues supported the 
efficacy of Botox for the treatment of Raynauds disease and indicated a decrease in ulcerations. 
Further, recent medical literature supports the use of Botox for Raynauds syndrome for systemic 
sclerosis (Jerjen, et al.). In this case, the patient has documented findings consistent with severe 
Raynauds disease including ulceration of the digits. The record reflects that the patient reported 
increased vasospasm with associated pain and nail dystrophy having a significant impact on her 
quality of life. The patient is currently on nifedipine 30 mg, but per a clinic note dated 3/15/23, the 
effect of the medication has waned. The record reflects that the patient has experienced a good 
response to Botox on her hands and feet. The refractory nature of the patients disease and the 
presence of ulcerations suggests potential loss of function if the disease continues, thus Botox is 
indicated for the treatment of the patient. Therefore, the requested Botox injections of 100 units 
for a quantity of two per 30 days are medically necessary for the treatment of the patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 26-year-old female enrollee has requested reimbursement for myPath Melanoma test performed 
on 12/30/21. The Health Insurer has denied this request indicating that the services at issue were 
considered  investigational  for  evaluation  of  the  insureds  melanoma.  
The physician reviewer found that for a melanocytic lesion of uncertain malignant potential, 
current standard of care generally involves wide excision of the lesional site with appropriate 
margins. The lesion in question was biopsied on 11/29/21 and the pathology report of 12/14/21 
described the clinicopathologic features of the lesion as a severely atypical compound melanocytic 
neoplasm, favoring melanoma of 0.4 mm thickness. The provider recommended further evaluation 
with the myPath Melanoma gene expression test. Although the studies are less clear for patients 
with severely atypical nevi, there are data to support re-excision with appropriate margins followed 
by routine dermatologic surveillance (Soleymani, et al.). The most recent National Comprehensive 
Cancer Network (NCCN) guidelines state that it is unclear whether gene expression profiling 
platforms  provide  clinically  actionable  prognostic  information  when  compared  with  known 
clinicopathologic factors. In addition, the impact of these tests on treatment recommendations has 
not been established. It also remains unclear whether gene expression profiling tests can reliably 
predict outcome across the risk spectrum of cutaneous melanoma. The current consensus statement 
by the Melanoma Prevention Working Group (MPWG) indicates that more evidence is needed to 
support the use of gene expression profiling testing to inform recommendations about sentinel 
lymph node biopsy, follow-up, or other adjuvant treatment (Grossman, et al.). Thus, the myPath 
Melanoma test was unlikely to have added any significant benefit above the recommended 
standard of care treatment with re-excision with appropriate margins. All told, the  myPath 
Melanoma test performed on 12/30/21 was not likely to be more beneficial for evaluation of the 
patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
A 26-year-old female enrollee has requested reimbursement for myPath Melanoma test performed 
on 12/30/21. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insureds melanoma. The physician reviewer found 
that the records document that this patient has a history of  right lateral posterior shoulder 
melanoma. The patient underwent the myPath Melanoma test for further evaluation of her lesion. 
Per  the  American  Society  of  Dermatopathology,  appropriate  use  criteria  for  evaluation  of 
melanocytic lesions is of uncertain appropriateness for the vast majority of clinical scenarios 
(Fung, et al.). On review of the available documentation, this patients lesion did not require 
assessment with the myPath Melanoma test. In the clinical setting with findings that could be 
interpreted as ambiguous, the standard of care is to consult with another pathologist before 
reaching the conclusion that the histomorphologic findings are truly ambiguous and warrant an 
ancillary gene expression profiling test that is largely of uncertain clinical benefit. Therefore, the 
myPath Melanoma test performed on 12/30/21 was not likely to be more beneficial for evaluation 
of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
A 26-year-old female enrollee has requested reimbursement for myPath Melanoma test performed 
on 12/30/21. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insureds melanoma. The physician reviewer found 
that there is a lack of precedent for the myPath test to determine the malignant nature of the lesion 
in this patients clinical setting. As noted in the medical literature, the standard of care includes 
biopsy with removal of tissue for histopathologic examination to determine whether the lesion is 
a melanoma. Occasionally, a second opinion may be sought by a second provider for confirmation. 
Current data suggest that although the myPath Melanoma test holds promise, there is a paucity of 
data on the long-term outcomes with a lack of rigorous analysis of ambiguous lesions. The NCCN 
guidelines  referring  to  molecular  assays  for  melanoma  reports  that  these  assays  are  not 
recommended for routine use since they have not been shown to provide clinically actionable 
prognostic  information.  Furthermore,  the  impact  of  these  tests  on  diagnosis  or  treatment 
recommendations has not been established. Given these findings, the myPath Melanoma test 
performed on 12/30/21 was not likely to be more beneficial for evaluation of the patients medical 
condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 51-year-old female patient. Notes dated 9/2/22 reported that the patient presented 
on 8/5/22 with mid-back pain after lifting her 80 pound dog three months ago. The patient has 
requested authorization and coverage for kyphoplasty and vertebroplasty. 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 the submitted documentation supports the medical necessity of the requested 
services. Kyphoplasty can be used for a variety of clinical and radiographic findings. It may 
provide rapid pain relief in patients with spinal compression fractures, whether osteoporotic or 
traumatic in nature. Although there is significantly more literature addressing the osteoporotic 
population, these findings may be extrapolated to patients with traumatic compression fractures 
and  acute  vertebral  body  pain.  Vertebroplasty  is  similarly  clinically  useful  in  significantly 
decreasing pain in patients with acute spinal compression fractures. The differences between these 
two procedures are  subtle, including initially greater vertebral body height restoration  with 
kyphoplasty. Additionally, there appears to be a slightly greater incidence of cement extravasation 
in vertebroplasty as compared to kyphoplasty. These differences do not appear to be clinically 
significant. In this case, the patient experienced an onset of acute thoracic pain after lifting a heavy 
object. Given that current medical literature supports the treatment of such pain with kyphoplasty 
and vertebroplasty for rapid pain relief and a return to normal functioning, the requested services 
are medically indicated. Therefore, kyphoplasty and vertebroplasty are medically necessary for the 
treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 59-year-old male enrollee has requested reimbursement for Guardant 360 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 cell-free/circulating tumor DNA testing should not be used in lieu of a 
histologic tissue diagnosis. Some laboratories offer testing for molecular alterations examining 
nucleic acids in peripheral circulation, most commonly in processed plasma (sometimes referred 
to as liquid biopsy). Studies have demonstrated cell-free tumor DNA testing to generally have 
very high specificity, but significantly compromised sensitivity, with up to 30% false-negative 
rate. Standards for analytical performance characteristics of cell-free tumor DNA have not been 
established,  and  in  contrast  to  tissue-based  testing,  no  guidelines  exist  regarding  the 
recommended performance characteristics of this type of testing. Cell-free tumor DNA testing 
can  identify  alterations  that  are  unrelated  to  a  lesion  of  interest,  for  example,  clonal 
hematopoiesis of indeterminate potential. This patient did not have enough tissue for molecular 
testing for driver mutations, and liquid biopsy was performed. The medical evidence supports 
the services at issue in this setting. Therefore, Guardant 360 testing performed on 3/31/21 was 
likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 59-year-old male enrollee has requested reimbursement for Guardant 360 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 non-small cell lung cancer 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. The mutational landscape of non-small cell lung cancer has significantly expanded in 
the past 2-3 years to encompass gain of function in multiple oncogenes with major prognostic 
and therapeutic consequences. It is generally accepted that the panel of mutations that was 
analyzed in the patient in question is for mutually exclusive somatic driver mutations. Generally, 
KRAS, TP53, and BRAF are included in these panels and are informative. KRAS mutation may 
confer a poor prognosis on patients with wild type EGFR sequence treated with erlotinib as 
second-line therapy. Patients on targeted therapy do develop resistance to erlotinib, and this too 
may be appreciated at the genetic level by recognition of new mutations or amplifications in 
parallel  signal  transduction  pathways.  BRAF  mutations  may  suggest  alternative  targeted 
therapies that may be better than those selected empirically. ALK mutation or rearrangement is 
present in another subset of non-small cell lung cancer that may be amenable to targeted therapy 
with crizotinib. Blood-based testing is supported by the National Comprehensive Cancer Network 
guidelines and medical literature if the primary tumor sample is inaccessible or if repeat biopsy  is not feasible. In this case, the panel of mutations that were analyzed were appropriate in the 
clinical care of this patient. Therefore, Guardant 360 testing performed on 3/31/21 was likely to 
have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A 59-year-old male enrollee has requested reimbursement for Guardant 360 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 National Comprehensive Cancer Network guidelines state, The use of 
cell-free/circulating tumor DNA testing can be considered in specific clinical circumstances, most 
notably: in the initial diagnostic setting, if following pathologic confirmation of a non-small cell 
lung cancer diagnosis there is insufficient material for molecular analysis, cell-free or circulating 
tumor DNA should be used only if follow-up tissue-based analysis is planned for patients in which 
an oncogenic driver is not identified. In this case, the patient did not have sufficient material on 
the biopsy to evaluate for driver mutations. The medical evidence supports the services at issue 
in this clinical setting. For patients with advanced non-small cell lung cancer, liquid biopsy-based 
test is reliable as standard of care tissue testing. Therefore, Guardant 360 testing performed on 
3/31/21 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 55-year-old female who presented to her provider on 9/12/22. The records noted a 
history  of  post-menopausal  osteoporosis.  The  patient  has  requested  reimbursement  for 
complement antigen on 9/13/22. The Health Insurer has denied this request and reported that the 
service at issue was not medically necessary for the evaluation 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 service at issue. In this case, the blood work 
at issue was an array of tests designed to screen for a variety of autoimmune and inflammatory 
conditions such as lupus, rheumatoid arthritis, celiac disease, or autoimmune thyroiditis, that could 
present with inflammation of the small joints, the PIP and MCP, of the hand. The records note that 
the provider ordered complement levels, C3 and C4, double stranded deoxyribonucleic acid 
(dsDNA), and a variety of cytoplasmic antigens such as RNP and Smith antigens to complete a 
workup for systemic lupus. Given that these tests were required to rule out a diagnosis of systemic 
lupus erythematosus, the service at issue was medically indicated. Therefore, complement antigen 
on 9/13/22 was medically necessary for the evaluation of this patient.