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

Summary Reviewer 1 
 
A 36-year-old female enrollee has requested authorization and coverage for Sunosi 75 mg tablet. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  requested  medication  is 
investigational for the treatment of the enrollees idiopathic hypersomnia. The physician reviewer 
found that Idiopathic hypersomnia (IH) is a syndrome with no known cause. Standard treatment is 
first addressing treatable causes of sleepiness and then using wake-promoting medications and 
stimulants to combat daytime sleepiness. While there is a lack of published studies on the use of 
solriamfetol  in  IH, improvement  to  daytime  sleepiness  may  be  extrapolated  from  literature 
showing the efficacy of these agents in the treatment of conditions such as narcolepsy type 1. In 
terms of addressing the treatable causes of sleepiness, the American Academy of Sleep Medicine 
confirms the necessity of sleep-tracking by actigraphy or sleep logs prior to testing. In this case, 
the  records  did  not  include  enough  data  to  exclude  insufficient  sleep  as  a  cause  of 
hypersomnolence, and less than seven hours of sleep were confirmed before the MSLT on the 
overnight sleep study. The patient's average subjective sleep time of only seven hours during the 
week and eight to eight and half hours on the weekend may warrant a trial of sleep extension of 
eight to nine hours per night, with confirmation using sleep tracking methods, as a first step prior 
to  wake-promoting  medications.  Current  medical  literature  supports  the  use  of  medications 
including modafinil, methylphenidate, oxybate salts, pitolisant, and clarithromycin. In this case, 
the records did not document that armodafinil, which is identical to modafinil, was prescribed at 
the maximum dosage of 250 mg daily, or that oxybate salts, pitolisant, and clarithromycin were 
previously used or contraindicated. The records indicate that Adderall is prescribed as needed, but 
without an explanation on why it, or its extended-release version, cannot be used regularly at a 
higher dose if well-tolerated. In this clinical setting, there is a lack of support in current medical 
literature that Sunosi is likely to be more beneficial than standard therapies such as sleep-extension, 
increased dosage of current medications, or other medications recommended in current medical 
literature for the treatment of idiopathic hypersomnia. Therefore, Sunosi 75 mg tablet 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 36-year-old female enrollee has requested authorization and coverage for Sunosi 75 mg tablet. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  requested  medication  is 
investigational for the treatment of the enrollees idiopathic hypersomnia. The physician reviewer 
found that the current medical literature supports the use of solriamfetol (brand name Sunosi) as 
successfully improving wakefulness in central disorders of hypersomnolence. In a phase 3 study, 
Thorpy and colleagues reported that  solriamfetol improved wakefulness on the Maintenance of 
Wakefulness  Test  (MWT)  and  reduced  Epworth  Sleepiness  Scale  (ESS)  scores  in  a  large 
population of patients with narcolepsy. The authors also noted the safety and tolerability profile of 
solriamfetol.  However,  there  is  a  lack  of  comparative  studies  showing  that  the  requested 
medication is superior to other available standard therapies. Therefore, Sunosi 75 mg tablet is not 
likely to be more beneficial for treatment of the patients condition than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
A 36-year-old female enrollee has requested authorization and coverage for Sunosi 75 mg tablet. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  requested  medication  is 
investigational for the treatment of the enrollees idiopathic hypersomnia. The physician reviewer 
found that IH is a diagnosis of exclusion. Its true incidence is unknown and there is a lack of 
specific trials for treatment of excessive daytime sleepiness due to IH. There is currently only one 
medication, Xywav, a mixed-salt oxybate, specifically indicated by the FDA for the treatment of 
IH. All the commonly prescribed agents for IH are used on an off-label basis. These agents are 
specifically labeled for the treatment of other hypersomnolence states, such as residual sleepiness 
after adequate treatment of obstructive sleep apnea with continuous positive airway pressure 
(CPAP) therapy or in narcolepsy. As Sunosi has only been on the market since 2019, there is a 
lack of data or studies in current medical literature regarding its use in IH. Therefore, Sunosi 75 
mg tablet is not likely to be more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 47-year-old male with a history of lumbar pain and lumbar radiculopathy. The 
provider has recommended a right laminotomy (hemilaminectomy), with decompression of nerve 
root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral 
disc; one interspace, lumbar. The Health Insurer has denied the requested services 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 this patient has a history of lumbar 
pain and lumbar radiculopathy. According to Zaina and colleagues, there is insufficient evidence 
to conclude whether surgical treatment or a conservative approach is better for patients with lumbar 
spinal stenosis. Moreover, the patients exam findings from 3/8/23 were relatively normal with no 
evidence  of  any  neurological  deficits,  which  was  unchanged  throughout  the  follow-up 
examinations. The patients pain decreased from the 3/8/23 exam to the 3/29/23 exam. In addition, 
the  records  provided  for  review  fail  to  document  a  trial  and  failure  of  recent,  reasonable, 
comprehensive, less invasive conservative care measures. The records provided fail to document 
the timing of the conservative treatment attempted by the patient, as well as any benefits from 
those treatments. Overall, there are limited large-scale, long-term studies showing the safety and 
efficacy of the requested surgery in this clinical setting. Given these findings, the requested right 
laminotomy  (hemilaminectomy),  with  decompression  of  nerve  root(s),  including  partial 
facetectomy,  foraminotomy  and/or  excision  of  herniated  intervertebral  disc;  one  interspace, 
lumbar are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 42-year-old female with a history of treatment resistant, recurrent major 
depressive disorder. The patient has requested reimbursement and prospective authorization 
and coverage for adult mental health transcranial magnetic stimulation provided from 10/15/21 
forward. The physician reviewer found that per the medical literature, transcranial magnetic 
stimulation is indicated for severe, recurrent major depressive disorder that has not responded 
to traditional medication and psychotherapy treatment.  This patient qualifies for the diagnosis 
of treatment refractory depression given her two failed antidepressant trials in addition to 
psychotherapy.  This  patient  had  also  tried  electroconvulsive  therapy.  She  completed  five 
treatments but could not tolerate the confusion and headaches.  Additionally, she was evaluated 
by a psychiatrist who recommended transcranial magnetic stimulation at this point in her 
treatment. Based on the records, transcranial magnetic stimulation was the appropriate next 
step  in  treatment  for  this  patient.  Therefore,  adult  mental  health  transcranial  magnetic 
stimulation provided from 10/15/21 forward was and is medically necessary for the treatment of 
this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 75-year-old male initially diagnosed with a prostate cancer in 2022. The patient 
has requested authorization of coverage for SBRT. The Health Insurer has denied coverage stating 
that SBRT is not medically necessary. The physician reviewer found that the management of 
metastatic prostate cancer has been focused on systemic therapies such as hormonal therapy, 
chemotherapy,  or  immunotherapy.  However,  the  advent  of  newer  molecular  sequencing 
techniques and targeted systemic treatments has allowed providers create tailored systemic 
therapies to address unique tumors in individual metastatic prostate cancer patients. Patients 
who respond well to these targeted systemic therapies demonstrate good disease response, yet 
it is still common for certain localized metastatic tumor deposits to continue to grow despite 
good  overall  disease  control  in  the  rest  of  the  body.  This  disease  state  is  referred  to  as 
oligometastatic disease, and this is considered a strong indicator for SBRT. As noted in the 
medical literature, SBRT uses special beam technique that allows for delivery of high doses of 
radiation while sparing adjacent normal tissue. There is strong evidence showing improved 
overall survival and progression-free survival with the addition of SBRT to immunotherapy in an 
oligometastatic setting (Pla, et al.; Lin, et al.). In addition, SBRT technique allows for higher doses 
to be delivered with greater precision and these higher ablative doses have demonstrated high 
local control when treating localized lesions (Navarria, et al.; Ning, et al.). Moreover, standard 
radiation therapy has shown some detriment in this setting compared to SBRT, due mainly to a 
less effective immune response (Gong, et al.; Khalife, et al.). This patient has a number of 
treatment targets located in the thorax and pelvis, so decreased radiation dose is critical in this 
setting. In conclusion, the safest way to deliver the necessary radiation dose to this patient is 
with SBRT technique. Therefore, the requested per fraction to one or more lesions, including 
image guidance, entire course not to exceed five fractions, is medically necessary for treatment 
of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The  patient  is  a  43-year-old  male  with  ongoing  neck  pain.  The  patient  has  requested 
authorization and coverage for artificial disc arthroplasty. The physician reviewer found that the 
current medical evidence supports the medical necessity of the requested services in this clinical 
setting. Kim and colleagues performed a prospective study of patients treated with cervical disc 
arthroplasty for one-level and two-level pathology. The authors noted that the Results through 
10 years were comparable to seven-year outcomes, demonstrating that cervical disc arthroplasty 
with Mobi-C continues to be a safe and effective surgical treatment for patients with one- or two-
level cervical degenerative disc disease. The article by Gornet and colleagues supports the 10-
year efficacy of cervical disc arthroplasty compared to fusion surgery. In this case, the patient has 
nerve root compression from degenerative disc disease. There is sufficient support for the 
requested services in this setting. Therefore, the requested artificial disc arthroplasty is medically 
necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 36-year-old female with a history of class 3 obesity complicated by prediabetes and 
dyslipidemia. The records available for review indicate that the patient had a body mass index (BMI) 
over 40 kg/m2 in September 2021. The physician reviewer found that at issue is whether the requested 
Wegovy is medically necessary for the treatment of this patient. According to Gadde and colleagues, 
while lifestyle modification is recommended as the cornerstone of obesity management, many patients 
do not achieve long-lasting benefits due to difficulty with adherence as well as physiological and 
neurohormonal adaptation of the body in response to weight loss. There are multiple pharmacologic 
therapies available for weight management. Wegovy is a member of a class of medications known as 
glucagon-like peptide 1 (GLP-1) analogs. As noted in the medical literature, GLP-1 analogs have been 
shown to improve glycemic control, reduce body weight, and decrease cardiovascular risk (Knudsen and 
Lau). Studies have demonstrated Wegovys ability to promote weight loss via reduced appetite and 
energy intake and delayed gastric emptying (Cornell). In this case, the patient has a history of class 3 
obesity complicated by prediabetes and dyslipidemia. The records reflect that the patient has attempted 
treatment with diet management and exercise without significant benefit. The patient has also tried and 
failed treatment with medications such as phentermine. Overall, Wegovy has been shown to effectively 
promote weight loss for patients in conjunction with diet and exercise. Therefore, the requested 
Wegovy is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 27-year-old female enrollee has requested authorization and coverage for E1399 durable 
medical equipment RT300 FES arm therapy system. The Health Insurer has denied this request 
and reported that the requested device is investigational for the treatment of the enrollees 
medical condition. The physician reviewer found that a functional electrical stimulation cycle 
ergometer is not proven to improve function or other outcomes in the setting of this patients 
condition (relatively mild hemiparesis, sensory dysfunction and tone abnormalities related to a 
brain lesion that was resected in April 2021). A recent meta-analysis in the setting of subacute 
stroke by Ambrosini and colleagues did not find that functional electrical stimulation-induced 
cycling improved outcomes better than usual care for subacute stroke survivors. The use of this 
type of device is not an evidence-based component of non-progressive brain injury 
management, rehabilitation, or prevention of complications, as noted on multiple recent 
reviews. The device in question is not likely to be more beneficial for treatment of the patients 
medical condition than any available standard therapy, which would include, but not be limited 
to, occupational therapy, independent exercise and splinting, even if a full neurological and 
functional recovery is not expected to be elicited by these standard therapies. Therefore, the 
requested for E1399 durable medical equipment RT300 FES arm therapy system is not likely to 
be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 27-year-old female enrollee has requested authorization and coverage for E1399 durable 
medical equipment RT300 FES arm therapy system. The Health Insurer has denied this request 
and reported that the requested device is investigational for the treatment of the enrollees 
medical condition. The physician reviewer found that the E1399 RT300 FES arm therapy system 
is not likely to be more beneficial than other available standard therapy. It is uncertain whether 
FES  can  restore  upper-extremity  function  or  improve  the  quality  of  life.  The  evidence  is 
insufficient to determine the effects of the technology on health outcomes. The evidence for the 
effectiveness of the RT300 FES cycling in people with stroke is limited. There is insufficient 
evidence in the literature that supports that the use of the RT300 FES will be effective for this 
patients hemiplegia from stroke in long-term improvement of muscle strength, vascular blood 
flow, bone mineral density, reduction of spasticity and atrophy, facilitation of functional motor 
movement  or  reduction  muscle  atrophy  in  the  upper  and  lower  extremities.  Eraifej  and 
colleagues performed a meta-analysis of 20 studies on the benefits of FES on activities of daily 
living. Only three studies showed a significant benefit of FES on activities of daily living when 
initiated within two months post-stroke. In three studies where FES was initiated more than one 
year after stroke, no significant activities of daily living improvements were seen. Limitations of 
the evaluable studies included, very low quality evidence in all analyses due to heterogeneity,  low participant numbers and lack of blinding. The authors concluded that FES is a promising 
therapy that could play a part in future stroke rehabilitation. They noted that there is a need for 
high quality large-scale randomized controlled trials of upper limb FES after stroke to draw firm 
conclusions regarding its efficacy or its optimum therapeutic window. The evidence that FES 
cycling can have a long-term effect on bone mineral density is not found in the literature. An 
additional study done on the prevention and treatment of osteoporosis by Soleyman-Jahi and 
colleagues revealed very low-quality evidence that low-intensity cycling (three days per week) 
with FES provided a benefit for reducing bone mineral density loss in individuals with chronic 
spinal  cord  injury  or  neurologic  injury.  All  told,  the  current  medical  evidence  has  not 
demonstrated the superior efficacy of the requested device. Therefore, the requested for E1399 
durable medical equipment RT300 FES arm therapy system is not likely to be more beneficial 
than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 27-year-old female enrollee has requested authorization and coverage for E1399 durable 
medical equipment RT300 FES arm therapy system. The Health Insurer has denied this request 
and reported that the requested device is investigational for the treatment of the enrollees 
medical condition. The physician reviewer found that there is support for the requested device 
in  this  clinical  setting.  Zheng  and  colleagues  demonstrated  significant  shortened  time  of 
improving upper extremity function in early-phase stroke in the treatment group compared to 
the control group. Shimodozono and colleagues conducted a randomized controlled pilot study 
that demonstrated neuromuscular electrical stimulation demonstrated greater improvement 
compared to a conventional arm rehabilitation program for post-stroke hemiplegia. There are 
many significant health consequences that can occur with untreated spastic hemiplegia and the 
neurodeficits described by the patients provider, including severe spasticity with contracture. 
Avoiding this issue will take daily treatment. There is documented improvement in the patients 
function with the RT300 FES therapy system. The documentation indicates that occupational 
therapy without functional electrical stimulation was most likely inadequate. Therefore, the 
requested for E1399 durable medical equipment RT300 FES arm therapy system is likely to be 
more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 52-year-old male enrollee has requested reimbursement for ExoDx Prostate/ExosomeDx 
Prostate (Intelliscore) performed on 12/23/20. 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 there is sufficient support for the services 
at issue in this clinical setting. This patient has a family history of prostate cancer and a rising 
PSA level. The use of ExoDx Prostate/ExosomeDx Prostate (Intelliscore) provided additional 
guidance to assess the acute need for biopsy which was unattainable by PSA factors alone. The 
medical literature supports the services at issue in this clinical scenario to further evaluate at-
risk individuals. The ExoDx Prostate/ExosomeDx Prostate (Intelliscore) was a non-invasive 
method to guide care in this case. Therefore, ExoDx Prostate/ExosomeDx Prostate (Intelliscore) 
performed on 12/23/20 was likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A  52-year-old  male enrollee  has  requested  reimbursement  for  ExoDx  Prostate/ExosomeDx 
Prostate (Intelliscore) performed on 12/23/20. 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 several ancillary tests have been developed 
to  better  define  a  patient  in  need  of  an  initial  biopsy  or  repeat  biopsy.  ExoDx  Prostate 
(IntelliScore) is a non-invasive, urinary 3-gene expression test in which the results of the assay 
are adjunctive to the ordering providers clinical judgment and work-up of the patient in the 
determination of whether a prostate biopsy is necessary. The ExoDx Prostate (IntelliScore) was 
clinically validated to discriminate patients with higher grade prostate cancer from those with 
more indolent lower grade cancer and benign disease. For this reason, it may be useful in deciding 
whether  a  patient  would  benefit  from  a  prostate  biopsy.  National  Comprehensive  Cancer 
Network (NCCN) guidelines recommend ExoDx testing for some men as an option prior to 
invasive prostate biopsy in order to further risk stratify them. In this case, the services at issue 
were appropriate to assist in better delineating this patients risk for prostate cancer. Therefore, 
ExoDx Prostate/ExosomeDx Prostate (Intelliscore) performed on 12/23/20 was likely to have 
been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
  A 52-year-old male enrollee has requested reimbursement for ExoDx Prostate/ExosomeDx 
Prostate (Intelliscore) performed on 12/23/20. 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 ExoDx Prostate/ExosomeDx Prostate 
(Intelliscore) is a noninvasive liquid biopsy that quantifies three RNA targets in urine exosomes. 
The urine exosome gene expression assay is associated with improved identification of patients 
with higher-grade prostate cancer among men with elevated PSA levels and could reduce the 
total number of unnecessary biopsies. Despite these findings, currently there is not enough 
clinical evidence that this testing can be utilized instead of prostate biopsy to diagnose prostate 
cancer. This patients prostate ultrasound was unremarkable. This patient has risk factors for 
developing prostate cancer. Furthermore, PSA levels can be misleading due to testosterone 
replacement therapy. There is a lack of support for the services at issue in this clinical setting. 
Therefore, ExoDx Prostate/ExosomeDx Prostate (Intelliscore) performed on 12/23/20 was not 
likely to have been more beneficial than any available standard therapy.