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

Summary Reviewer 3 
A 52-year-old male insured has requested authorization and coverage for Panzyga (immune globulin 
(Human)-ifas). The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insureds small fiber neuropathy and paresthesia of 
the feet. The physician reviewer found that the records indicate that this patient has a history of small 
fiber neuropathy and CISP. A study by Koh and colleagues reported that early, aggressive  immunotherapy with IVIG is an effective treatment option for patients with CISP. Similarly, Shelly and 
colleagues found that immunotherapy benefitted 93% of patients with CISP. In this case, the patient has 
previously undergone treatment with IVIG with an improvement of symptoms and function. The 
discontinuation of IVIG led to a resumption of the patients symptoms. Moreover, the patient has tried 
and failed numerous medications, including Effexor, Elavil, Lyrica, Cymbalta, gabapentin, meloxicam, 
mexiletine, and topical lidocaine. Overall, the medical literature and the patients past treatment 
success with IVIG indicate that IVIG therapy is likely to be efficacious for this patient. All told, the 
requested Panzyga (immune globulin (Human)-ifas) is likely to be more beneficial for the treatment of 
the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 40-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral, on 8/26/21. The Health Insurer has 
denied this request and reported that the service at issue was investigational for the treatment of 
the enrollees bilateral eustachian tube dysfunction. The physician reviewer found that that balloon 
dilation of the eustachian tube is supported in current medical literature and has been accepted as 
a  standard  therapy  in  the  otolaryngology  community.  Tucci  and  colleagues  report  that  the 
American Academy of Otolaryngology  Head and Neck Surgery (AAO-HNSF) reports that 
balloon dilation of the eustachian tube is an option for the treatment of patients with obstructive 
eustachian tube dysfunction that is supported by multiple peer-reviewed studies. In a prospective, 
multicenter, randomized controlled trial, Meyer and colleagues showed that eustachian tube 
balloon dilation is a safe and effective treatment for persistent eustachian tube dysfunction based 
on improved 7-item Eustachian Tube Dysfunction Questionnaire (ETDQ-7) scores. The authors 
concluded,  Balloon  dilation  is  superior  to  continued  medical  management  for  persistent 
eustachian tube dysfunction. In a prospective, multicenter, randomized, controlled trial, Poe and 
colleagues concluded, This study demonstrated superiority of balloon dilation of the eustachian 
tube with balloon catheter and medical management compared to medical management alone to 
treat Eustachian tube dilatory dysfunction in adults. Regarding the long-term efficacy of balloon 
dilation for treating patients with persistent Eustachian tube dysfunction, Cutler and colleagues 
reported that balloon dilation results in durable improvements in symptoms and middle ear 
assessments for patients with persistent eustachian tube dysfunction at mean follow-up of longer 
than two years. In this case, the patient has eustachian tube dysfunction and had failed PE tube 
placement and medical therapy. Repeat PE tube placement was complicated by a history of 
difficult in-office PE tube placement due to pain and syncope. In this clinical setting, the service 
at issue was likely to have been more beneficial than standard therapy with continued medical 
management.  Therefore,  nasopharyngoscopy,  surgical,  with  dilation  of  eustachian  tube  (i.e. 
balloon dilation); bilateral, on 8/26/21, was likely to have been more beneficial for treatment of 
the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
A 40-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral, on 8/26/21. The Health Insurer has 
denied this request and reported that the service at issue was investigational for the treatment of 
the enrollees bilateral eustachian tube dysfunction. The physician reviewer found that based on 
available clinical documentation, the service at issue was likely to have been more beneficial in 
managing the patients eustachian tube dysfunction, as compared to other available standard 
therapies. In this case, notes dated 8/26/21 reported that the patient had previously failed intranasal 
corticosteroid therapy, and tympanostomy tube placement had resulted in various adverse side 
effects.  In  a  meta-analysis  of  studies  regarding  medical  management  for  eustachian  tube 
dysfunction, Mehta and colleagues found that intranasal corticosteroids were not efficacious, 
improving only 11% to 18% of chronic cases. In a meta-analysis of eustachian tube balloon dilation  outcomes, including data from two randomized controlled trials comparing it to medical therapy, 
Froehlich and colleagues found improvement in subjective symptoms and objective clinical 
metrics  after  eustachian  tube  balloon  dilation  lasting  up  to  12  months.  Therefore, 
nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e. balloon dilation); bilateral, on 
8/26/21, was likely to have been more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
A 40-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral, on 8/26/21. The Health Insurer has 
denied this request and reported that the service at issue was investigational for the treatment of 
the enrollees bilateral eustachian tube dysfunction. The physician reviewer found that there are 
limited treatments for eustachian tube dysfunction, including medical management, myringotomy 
and tube placement, and more recently, eustachian tube balloon dilation. Tucci and colleagues 
report, At this time, additional randomized controlled trials with longer follow-up are still 
necessary to establish a higher level of evidence for balloon dilation of the eustachian tube 
efficacy.  The authors further noted a lack of consensus regarding the overall short-term or long-
term effectiveness of Eustachian tube balloon dilation. Froehlich and colleagues note, Eustachian 
tube balloon dilation appears to be associated with improvement in subjective and objective 
treatment outcome metrics at three to 12 months after dilation. However, the authors noted that 
only  50.5%  of  patients  had  improved  tympanograms  and  55.4%  had  normal  otoscopy 
examinations in the long term. In a randomized controlled trial comparing balloon dilation to 
medical management that evaluated patients ETDQ-7 scores at six weeks and at 12 months, 
Meyer and colleagues reported that balloon dilation was a safe and effective treatment. However, 
this trial included only 31 patients treated with balloon dilation and 29 patients as control. There 
are a lack of studies comparing balloon dilation to myringotomy tube placement. In this setting, 
clinical evidence in published current medical literature is insufficient to show that eustachian tube 
balloon dilation is more effective for the treatment of eustachian tube dysfunction than standard 
treatment  with  medical  management  or  with  myringotomy  and  tube  placement.  Therefore, 
nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e. balloon dilation); bilateral, on 
8/26/21, was not likely to have been more beneficial for treatment of the patients condition than 
any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 66-year-old female with a history of spondylolisthesis of the lumbar region, lumbar 
post-laminectomy syndrome, lumbar radiculitis, and lumbar degenerative disc disease. The patient 
has requested arthrodesis of the SI joint, percutaneous, or minimally invasive, for the treatment of 
her back pain. The Health Insurer has denied the requested service 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  records  provided  for  review  fail  to 
corroborate a diagnosis of SI joint pain for this patient. According to Lorio and colleagues, SI 
joint pain diagnosis is typically accomplished via a clinical diagnostic algorithm involving history, 
physical exam, diagnostic block, and ruling out other pain contributors. Patients with SI joint pain 
typically report pain in the buttock(s), with possible radiation into the groin or upper legs. 
Although the patients CT scan on 9/29/22 did demonstrate mild bilateral SI joint degenerative 
changes, Lorio and colleagues further noted that, No specific imaging modality has demonstrated 
acceptable sensitivity and specificity in the diagnosis of noninflammatory, nontraumatic SI joint 
pain, including plain radiographs, CT, magnetic resonance imaging, and radionucleotide studies. 
In this case, multiple other plausible pain generators, including at the lumbosacral spine, are 
evident. Furthermore, per Shamrock and colleagues, Minimally invasive SI joint fusion is a 
relatively safe procedure but is not without certain risks. Further work must be done to optimize 
the procedure's complication profile. The records provided for review indicate that this patient 
presents with ongoing low back pain and a history of spondylolisthesis of the lumbar region, 
lumbar post-laminectomy syndrome, lumbar radiculitis, and lumbar degenerative disc disease. 
However, there is a lack of documentation reporting a diagnosis of SI joint pain for this patient. 
Overall, there is limited medical literature indicating that arthrodesis of the SI joint, percutaneous 
or minimally invasive is an effective and/or safe treatment for the patients pathology. For these 
reasons, the requested arthrodesis, SI joint, percutaneous, or minimally invasive (CPT 27279 RT) 
is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 64-year-old male who presented to his provider on 10/10/22. The patient has 
requested authorization and coverage for Botox (onabotulinumtoxinA for injectable 100 unit). 
The physician reviewer found that the submitted documentation supports the medical necessity 
of  the  requested  service.  Current  medical  literature  supports  the  use  of  botulinum  toxin 
injections for the treatment of hemifacial spasm, as medications for peripheral myoclonus are 
generally ineffective long-term and surgery is reserved only for extreme cases. Hallett and 
colleagues report that hemifacial spasm evidence supports a Level B recommendation for 
onabotulinumtoxinA. In a study that included 68 patients with hemifacial spasm, Sorgun and 
colleagues noted a 73.7% improvement with an average of 34.5 units, with less than 5% incidence 
of minor side effects. The authors concluded that Botox is an effective and safe treatment option 
for hemifacial spasm.  In a study on the clinical success and incidence of adverse events of 
repetitive botulinum toxin treatment of 15 years or greater, Czyz and colleagues reported an 
average treatment efficacy of 127 days using an average of 70.2 units of botulinum toxin. In this 
clinical setting, as current medical literature supports the use of onabotulinumtoxinA for the 
treatment of hemifacial spasm, and as it has been three months or more since the patients last 
treatment, the requested service is medically indicated. Therefore, Botox (onabotulinumtoxinA 
for injectable 100 unit) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 58-year-old male enrollee has requested reimbursement for therapeutic phlebotomy from 
1/6/21 through 1/26/21. The Health Insurer has denied this request and reported that the service 
at issue was investigational for the treatment of the enrollees hereditary hemochromatosis. The 
physician reviewer found that therapeutic phlebotomy is the preferred approach to removing 
iron in patients with hereditary hemochromatosis because it is highly effective and relatively 
devoid of toxicities. In this case, phlebotomy was indicated as the records noted a biopsy proven 
iron overload. While there is a range of ferritin and iron saturation goals, the recommended 
ferritin goal is 30 to 150 ng/mL and the recommended iron saturation goal is greater than 20%. 
In this case, laboratory results dated 12/14/20 showed a ferritin of 369 ng/mL and an iron 
saturation over 85%. Therefore, therapeutic phlebotomy from 1/6/21 through 1/26/21 was likely 
to have been more beneficial for treatment of the enrollee's condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A 58-year-old male enrollee has requested reimbursement for therapeutic phlebotomy from 
1/6/21 through 1/26/21. The Health Insurer has denied this request and reported that the service 
at issue was investigational for the treatment of the enrollees hereditary hemochromatosis. The 
physician  reviewer  found  that  hereditary  hemochromatosis  is  an  inherited  disorder  most 
commonly caused by a point mutation in the HFE gene, typically C282Y, or less commonly by 
other genes related to iron regulation such as H63D. Most of these disorders result in increased 
intestinal iron absorption that can eventually cause serious tissue damage. The goal of treatment 
in hereditary hemochromatosis is to prevent organ dysfunction from excess iron and/or to 
improve organ function if it has already been affected. Patients with iron overload, or at risk for 
iron overload, are treated with phlebotomy. Patients who cannot tolerate phlebotomy, for 
example, due to concomitant anemia, may be treated with an iron chelator instead if their iron 
overload is significant. Patients without iron overload who have a hereditary hemochromatosis 
genotype, such as homozygosity for HFE C282Y or compound heterozygosity for C282Y and 
another HFE variant, may be monitored regularly. The American College of Gastroenterology 
supports phlebotomy for hereditary hemochromatosis with evidence of iron overload. In this 
case, the patient has evidence of iron overload with organ damage based on liver biopsy result 
and MRI of the liver. Therefore, therapeutic phlebotomy from 1/6/21 through 1/26/21 was likely 
to have been more beneficial for treatment of the enrollee's condition than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 50-year-old female with a history of hyperlipidemia and hypertension. The records 
note a family history of heart disease. The patient has requested authorization and coverage for 
Praluent (alirocumab) 75 mg/ml injection, two injections every 28 days. 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 American College of Cardiology (ACC) has developed an expert consensus 
decision pathway regarding the role of non-statin therapies for low-density lipoprotein (LDL) 
lowering for management of atherosclerotic cardiovascular disease risk. Alirocumab (Praluent) 
and evolocumab may be considered if the goals of therapy have not been achieved on maximally 
tolerated statin and ezetimibe in higher risk patients with clinical atherosclerotic cardiovascular 
disease risk or familial hypercholesterolemia. An LDL cholesterol level greater than 190 mg/dl is 
considered a Class I indication for maximally tolerated statin therapy according to ACC guidelines. 
This patient had an LDL level of 196 mg/dl on 7/01/20. Given that this patient was intolerant to 
multiple  statins  as  well  as  ezetimibe,  Praluent  is  medically  indicated.  Therefore,  Praluent 
(alirocumab) 75 mg/ml injection, two injections every 28 days are medically necessary for the 
treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A  49-year-old  male  enrollee  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation. The Health Insurer has denied this request and reported that the 
requested service is investigational for the treatment of the enrollees chronic low back pain. At 
issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial for 
treatment of the enrollee's condition than any available standard therapy. The physician reviewer 
found that in a randomized control trial evaluating the effectiveness of intraosseous radiofrequency 
ablation of the basivertebral nerve to standard care for the treatment of chronic low back pain in a 
specific subgroup of patients suspected to have vertebrogenic related symptomatology, Khalil and 
colleagues noted that the study showed clear statistical superiority for all primary and secondary 
patient-reported outcome measures in the radiofrequency ablation arm compared with the standard 
care arm. The authors noted that in comparing the radiofrequency ablation arm to the standard 
care arm, there were statistically significant improvements in Oswestry Disability Index (ODI) 
scores and in Visual Analogue Scores (VAS) in the treatment arm compared to the standard of 
care arm.  In a study reporting on the two-year clinical outcomes for patients with chronic low 
back  pain  treated  with  radiofrequency  ablation  of  the  basivertebral  nerve,  Fischgrund  and 
colleagues noted clinically meaningful improvements in both ODI and VAS sustained at two years 
following treatment. Lorio and colleagues note that guidelines by the International Society for the 
Advancement of Spine Surgery support the use of intraosseous ablation of the basivertebral nerve 
for chronic low back pain for patients who have had chronic low back pain for at least six months, 
have tried and failed six months of non-surgical management, and demonstrate Modic changes on 
at least one endplate on magnetic resonance imaging (MRI). In this case, the patient has a history 
of several years of persistent non-radicular chronic low back pain that has been refractory to 
multiple modes of standard care including physical therapy, medications, spinal injections of the 
facet joints, medial branch nerves, and epidural steroid injections. In this clinical setting, current 
medical literature supports the Intracept procedure as superior to standard care both in improving 
pain scores and disability scores, with results lasting for at least two years. Therefore, intraosseous 
basivertebral nerve ablation is likely to be more beneficial for treatment of the patients condition 
than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A  49-year-old  male  enrollee  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation. The Health Insurer has denied this request and reported that the 
requested service is investigational for the treatment of the enrollees chronic low back pain. At 
issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial for 
treatment of the enrollee's condition than any available standard therapy. The physician reviewer 
found that Conger and colleagues report regarding the effectiveness of intraosseous basivertebral 
nerve radiofrequency when compared with a placebo procedure, There is moderate-quality 
evidence that suggests this procedure is effective in reducing pain and disability in patients with 
chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion  and exclusion criteria used in the published literature to date. In a prospective randomized 
multicenter study for basivertebral nerve ablation for the treatment of chronic low back pain, 
Koreckij and colleagues determined that disability and pain were improved at 24 months after the 
procedure. Macadaeg and colleagues reported similar results at twelve months of follow-up in a 
prospective single arm study of intraosseous basivertebral nerve ablation for chronic low back pain 
including participants who had failed six months of non-surgical treatments. In this case, the 
patient has exhausted and failed the standard treatments for vertebrogenic low back pain for over 
six months. Given that current medical literature indicates that basivertebral nerve ablation 
consistently demonstrates good results for pain relief and improved disability, the requested 
service is likely to be more beneficial for treatment of the patients medical condition than any 
available standard therapy. Therefore, intraosseous basivertebral nerve ablation is likely to be more 
beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A  49-year-old  male  enrollee  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation. The Health Insurer has denied this request and reported that the 
requested service is investigational for the treatment of the enrollees chronic low back pain. At 
issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial for 
treatment of the enrollee's condition than any available standard therapy. The physician reviewer 
found that chronic low back pain is a debilitating condition. When Modic changes are present in 
the disc spaces, a vertebrogenic cause of back pain is considered an etiology of chronic back pain. 
The main source of innervation for the vertebral body are the basivertebral nerves. Ablation of the 
basivertebral nerve is a safe and effective procedure that is evidence based for appropriately 
selected candidates. Becker and colleagues note that the ablation of the basivertebral nerve for the 
treatment of chronic lumbar back pain significantly improves patients self-reported outcome early 
in the follow-up period, with improvement persisting throughout the one-year study period. 
Fischgrund and colleagues report that basivertebral nerve represents a potential minimally invasive 
treatment for the relief of chronic low back pain. In this this case, other interventional procedures 
targeting different etiologies of back pain have not provided benefit. Therefore, basivertebral nerve 
ablation is likely to be more beneficial for treating this patients vertebrogenic back pain than other 
treatments already tried. Therefore, intraosseous basivertebral nerve ablation is likely to be more 
beneficial for treatment of the patients condition than any available standard therapy.