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

Summary Reviewer  
 
The patient is a 61-year-old male who was admitted for hospitalization on 8/5/21. The patient 
has requested reimbursement for inpatient hospital level of care from 8/5/21 through 8/7/21. 
The Health Insurer has denied this request and reported that the services at issue were not 
medically necessary for the treatment of this patient. The physician reviewer found that the 
submitted documentation supports the medical necessity of the services at issue. In this case, 
the patient presented with non-ST-elevation myocardial infarction (NSTEMI), a form of heart 
attack, and pulmonary edema in the setting of rapid atrial fibrillation requiring rate control by 
continuous intravenous diltiazem infusion. At the time of presentation on 8/5/21, the patient 
was at risk due to persisting rapid atrial fibrillation, worsening/evolving heart failure, respiratory 
failure,  and  sudden  cardiac  death.  Given  this  adverse  risk  profile,  the  patient  warranted 
admission to inpatient status to facilitate intravenous diuresis or volume removal, close cardiac 
monitoring with telemetry and repeat biomarkers, and continued intravenous infusion for rate 
control to treat the underlying cause of his condition. Moreover, at the time of the inpatient 
order, it was reasonable to anticipate the patient would cross two midnights while receiving 
medically necessary care, often considered the benchmark for inpatient admission, which was 
the case for this hospital stay. In addition, the patient required ICU level care due to (1) his 
pulmonary edema and tenuous respiratory status, and (2) his need for continuous intravenous 
infusion of diltiazem, which cannot be safely delivered on the regular medicine floor in most 
hospital systems. Therefore, inpatient hospital level of care from 8/5/21 through 8/7/21 was 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 52-year-old female with psoriasis and psoriatic arthritis affecting her skin including 
on her palms and soles. The patient has requested authorization and coverage for Cosentyx two 
pens 150 mg/ml pen injector. 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 Cosentyx is a U.S. Food 
and Drug Administration (FDA) approved medication for the treatment of psoriasis.  It receives 
an A rating from the American Academy of Dermatology and National Psoriasis Foundation 
guidelines of care. This medication has good safety and efficacy profiles. It is recommended as 
treatment for chronic psoriasis by the American Academy of Dermatology and National Psoriasis 
Foundation. It has been shown in the FIXTURE study to be a safe and efficacious medication for 
the treatment of psoriasis. The requested medication is medically indicated for the treatment of 
this patients chronic psoriasis, psoriatic arthritis and hand and foot psoriasis. Therefore, Cosentyx 
two pens 150 mg/ml pen injector is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 51-year-old female. An operative report dated 4/28/22 reported that the patient 
underwent transanal excision of circumferential rectal mass with recto-anal anastomosis for treatment 
of a circumferential tubulovillous adenoma. The physician reviewer found that the issue is whether 
inpatient admission from 4/28/22 to 4/29/22 was medically necessary for the treatment of this patient. 
The submitted documentation does not support the medical necessity of the services at issue. In this 
case, the records showed that the patient was relatively young, at 51 years of age, without severe 
comorbidities or complications after surgery. Given that, the additional care, such as pain control and 
Foley catheter placement, could have been provided at a lower level of care such as in observation. 
Accordingly, the services at issue were not medically necessary for the treatment of this patient. 
Therefore, inpatient admission from 4/28/22 to 4/29/22 was not medically necessary for the treatment 
of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
The parent of a 16-year-old female enrollee has requested reimbursement for autonomic testing 
performed on 8/19/20. 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 experienced repeated episodes of near syncope, some of which are associated with 
injury. She describes that the episodes are often positional. Use of autonomic nervous system 
testing is appropriate when signs and/or symptoms of autonomic dysfunction are present, a 
definitive diagnosis cannot be made from clinical examination and routine laboratory testing 
alone, and diagnosis of the suspected autonomic disorder will lead to a change in management 
or will eliminate the need for further testing. The American Academy of Neurology Model 
Coverage Policy noted, Autonomic testing may not be able to differentiate between similar 
disorders that both cause autonomic dysfunction, but can quantify the severity of autonomic 
dysfunction,  in  other  cases  exclude  autonomic  dysfunction,  and  thereby  lead  to  specific 
recommendations for treatment. Low and colleagues noted, Modern autonomic function tests 
can  non-invasively  evaluate  the  severity  and  distribution  of  autonomic  failure.  They  have 
sufficient  sensitivity  to  detect  even  subclinical  dysautonomia.  Standard  laboratory  testing 
evaluates cardiovagal, sudomotor and adrenergic autonomic functions. Cardiovagal function is 
typically evaluated by testing heart rate response to deep breathing at a defined rate and to the 
Valsalva maneuver. Sudomotor function can be evaluated with the quantitative sudomotor axon 
reflex test and the thermoregulatory sweat test. Adrenergic function is evaluated by the blood 
pressure and heart rate responses to the Valsalva maneuver and to head-up tilt. Tests are useful 
in defining the presence of autonomic failure, their natural history, and response to treatment. 
They can also define patterns of dysautonomia that are useful in helping the clinician diagnose 
certain autonomic conditions. For example, the tests are useful in the diagnosis of the autonomic 
neuropathies and distal small fiber neuropathy. The American Academy of Neurology stresses 
the importance of being able to distinguish benign from life-threatening forms of autonomic 
nervous  system  dysfunction  by  the  use  of  autonomic  nervous  system  testing.  Therefore, 
autonomic testing performed on 8/19/20 was likely to have been more beneficial than any 
available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
The parent of a 16-year-old female enrollee has requested reimbursement for autonomic testing 
performed on 8/19/20. 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 medical evidence supports the services at issue in this clinical setting. 
Prior to engaging in any course of treatment, it is imperative to have a working diagnosis. Despite  being recognized as a very real clinical entity, the underlying etiology (or etiologies) of postural 
orthostatic tachycardia syndrome (POTS) remain unclear, and there continues to be debates 
about whether POTS is due to dysautonomia from peripheral nerve dysfunction versus central 
nervous system dysfunction versus both. While salt tablets have been used empirically, there is 
considerable room in the therapeutic armamentarium to consider clinical trials such as the 
hyperpolarization-activated cyclic nucleotide-gated (HCN) channel blocker ivabradine. The first 
step in the care of a patient with POTS-like symptoms is a thorough evaluation of the autonomic 
nervous system, which was performed in this patients case.  Therefore, autonomic testing 
performed on 8/19/20 was likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
The parent of a 16-year-old female enrollee has requested reimbursement for autonomic 
testing performed on 8/19/20. 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 patient reported several symptoms consistent with 
autonomic dysfunction including positional dizziness, balance problems, urinary incontinence, 
skin changes, and others. In addition, in this case, the patient had skin color changes and other 
symptoms, such as swelling and burning pain, that could be consistent with a small fiber 
neuropathy.  The spectrum of disorders that can lead to this presentation is broad and includes 
disorders in the POTS spectrum, including POTS or orthostatic intolerance to disorders caused 
by autonomic failure, including small fiber neuropathies, degenerative neurological disorders or 
innate central disorders of autonomic dysregulation. Per current standards of care, autonomic 
reflex testing may be indicated. Testing includes tilt table testing, which stresses the bodys 
autonomic vascular systems. In addition, small fiber tests, such as quantitative sudomotor axon 
reflex test (QSART) or quantitative axon reflex sweat test (QSWEAT) may be performed to 
determine if there is autonomic failure due to neuropathies.  Axon-reflex-based small fiber test 
of sudomotor, vasomotor, and pilomotor function is a well described test for evaluation of 
post-ganglionic function in cases where there is a suspicion of such dysfunction.  Though it is 
not widely used outside of specialized centers (due to technical demands), it is currently 
considered a standard of care test. Autonomic reflex testing is considered a standard of care for 
patients with autonomic symptoms. There is no other effective way of evaluating for and 
diagnosing certain autonomic disorders. Therefore, autonomic testing performed on 8/19/20 
was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 28-year-old female who presented to her provider on 12/27/22. The patient has 
requested reimbursement for knee orthosis on 12/27/22. The Health Insurer has denied this 
request and reported that the equipment at issue was not medically necessary for the treatment 
of this patient. The physician reviewer found that the submitted documentation does not support 
the medical necessity of the equipment at issue. The use of functional ACL bracing following ACL 
reconstruction has been debated over the past several years. In a systematic review of functional 
bracing  after  ACL  reconstruction,  Lowe  and  colleagues  report,  The  effectiveness  of 
postoperative  functional  bracing  following  ACL  reconstruction  remains  elusive.  Some  data 
suggest that functional bracing may have some benefit with regard to in vivo knee kinematics 
and may offer increased protection of the implanted graft after ACL reconstruction without 
sacrificing  function,  range  of  motion,  or  proprioception.  However,  limited  evidence  exists 
supporting the use of routine functional bracing to decrease the rate of reinjury after ACL 
reconstruction. Smith and colleagues conclude, Biomechanical and clinical evidence suggests 
current functional bracing technologies do not sufficiently restore normal biomechanics to the 
ACL-deficient knee, protect the reconstructed ACL, and improve long-term patient outcomes. 
Yang and colleagues note, Knee bracing does not appear to improve the clinical outcomes on 
the function and stability for ACL-reconstructed knees. Thus, bracing for patients treated with 
ACL reconstruction should not be recommended routinely. Andrade and colleagues report, 
Immediate knee mobilisation and strength/neuromuscular training should be used. Continuous 
passive  motion  and  functional  bracing  should  be  eschewed.  Given  that  current  medical 
literature  does not  recommend continued  passive  motion and post-operative bracing, the 
equipment at issue was not medically indicated. Therefore, knee orthosis on 12/27/22 was not 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 43-year-old male enrollee has requested authorization and coverage for thermal destruction 
of intraosseous basivertebral nerve first two bodies, lumbar or sacral. The Health Insurer has 
denied  this  request  and  reported  that  the  requested  services  are  investigational  for  the 
treatment of the enrollees medical condition. The physician reviewer found that current medical 
literature supports the use of the requested procedure in leading to statistically significant 
improvement over continuation of standard treatment. Fischgrund and colleagues report that 
patients treated with radiofrequency ablation of the basivertebral nerve for the treatment of 
chronic back pain maintained benefits at two years following treatment in both Oswestry 
Disability Index (ODI) and Visual Analog Scale (VAS). The requested procedure is more effective 
than continued conservative care particularly in the setting of Modic endplate changes as seen 
on this patients MRI. Therefore, thermal destruction of intraosseous basivertebral nerve first 
two bodies, lumbar or sacral 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 43-year-old male enrollee has requested authorization and coverage for thermal destruction 
of intraosseous basivertebral nerve first two bodies, lumbar or sacral. The Health Insurer has 
denied  this  request  and  reported  that  the  requested  services  are  investigational  for  the 
treatment of the enrollees medical condition. The physician reviewer found that current medical 
literature  supports  the  use  of  the  Intracept  procedure  as  a  minimally  invasive  outpatient 
procedure that has been demonstrated as safe, effective and durable. It is implant-free and 
preserves spinal integrity by negating the need for extensive tissue exposure and disruption, and 
in most cases, pain relief is fairly rapid. Fischgrund and colleagues found that patients with 
chronic low back pain treated with ablation of the basivertebral nerve exhibited sustained clinical 
improvements in function and pain with high responder rates at a mean of 6.4 years following 
treatment, confirming the long-term effectiveness and durability of basivertebral nerve ablation. 
In this case, in a letter dated 5/20/22, the provider reported that the patient has a history of 
severe chronic low back pain that severely limits his activities of daily living. He has tried and 
failed the full measure of conservative treatment including NSAIDs, facet injections, extensive 
physical  therapy,  acupuncture,  chiropractic  treatments,  massage  treatments,  and  a  home 
exercise program. An MRI demonstrated Modic changes at the L3-L4 disc space, which is strongly 
associated with chronic vertebrogenic low back pain. The submitted records did not demonstrate 
that  more  invasive  interventions,  such  as  extensive  decompression  and  fusions  or  disc 
replacements,  would  be  warranted.  Given  this  patients presentation,  which  included  MRI 
findings that showed Modic endplate changes, and young age, the requested service is likely to 
be more beneficial than a more invasive surgery. Therefore, thermal destruction of intraosseous 
basivertebral nerve first two bodies, lumbar or sacral is likely to be more beneficial for treatment 
of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 37-year-old male who presented to his provider on 2/22/22. The patient has 
requested reimbursement for anesthesia provided on 3/14/22. The physician reviewer found 
that the submitted documentation supports the medical necessity of the service at issue. Current 
medical  literature  supports  the  use  of  sedation  to  facilitate  gastrointestinal  endoscopic 
procedures such as colonoscopy. The two main options for sedation in the United States are 
either  traditional  moderate  sedation,  with  an  intravenous  benzodiazepine  and  opioid,  or 
propofol-based. A growing number of hospitals, ambulatory care centers, and other endoscopy 
sites  are  moving  toward  propofol-based  sedation  for  endoscopic  procedures.  Wang  and 
colleagues report, Propofol is safe and effective for gastrointestinal endoscopy procedures and 
is associated with shorter recovery and discharge periods, higher post-anesthesia recovery 
scores, better sedation, and greater patient cooperation than traditional sedation, without an 
increase  in  cardiopulmonary  complications.  The  American  Society  for  Gastrointestinal 
Endoscopy (ASGE) suggests the use of propofol-based sedation when it is expected to improve 
patient  safety,  comfort,  procedural  efficiency,  and/or  successful  procedure  completion. 
Generally, the endoscopist determines whether sedation will be propofol-based or a traditional 
moderate sedation. Secondary to the individual factors in this case, the anesthesia provided on 
3/14/22 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 52-year-old female. The patient has requested reimbursement for anesthesia 
provided on 8/30/21. The physician reviewer found that according to the American Society of 
Anesthesiologists guideline for anesthesia care during endoscopic procedures, monitored 
anesthesia care is warranted in prolonged or painful procedures such as complex polyp 
resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, 
endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored 
anesthesia care is more likely necessary in patients with a failed history of moderate sedation 
for the procedure or psychological impediments to cooperation. The provided records do not 
support any of these criteria, or other criteria in the literature, such as difficult intubation, 
airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting 
in increased tolerance to sedation medications, age greater than 70, pregnancy, increased 
aspiration risk, ASA class III or higher, or morbid obesity. According to the most recent 
guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic 
procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal 
during most procedures (which are performed with moderate sedation), and monitored 
anesthesia care is recommended for prolonged procedures requiring deep sedation, previously 
anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction 
due to anatomic variant. For these reasons, the provided patient records do not support the 
medical necessity of monitored anesthesia care over conscious sedation in this case. Therefore, 
anesthesia provided on 8/30/21 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 74-year-old male who has been diagnosed with ulcerative colitis. The patient has 
requested authorization and coverage for Lialda. The physician reviewer found that the current 
medical evidence supports the requested medication in this clinical setting. Mesalamine has 
proven effective for the treatment of ulcerative colitis in randomized, double-blind, multicenter 
trials, although various formulations result in release at distinct times and locations in the 
gastrointestinal tract, making them clinically different from each other. Specifically, Lialda is 
different from mesalamine and 5-aminosalicylate alternatives such as sulfasalazine, balsalazide, 
Asacol, Salofalk, Mezavant XL, and Pentasa, and their respective generic formulations, each with 
release in different portions of the gastrointestinal tract and at different pH levels. The result of 
changing therapy can be inadequate control by a different formulation which directs the drug to 
a different part of the gastrointestinal tract. Additionally, ulcerative colitis flares can be induced 
by salicylate medications, and changing therapy can expose the patient to this risk. The request 
for Lialda is supported as medically necessary for the treatment of this patients ulcerative colitis 
as the patient is stabilized on Lialda, and a change could potentially cause a destabilization. 
Therefore, Lialda is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 42-year-old male with a medical history including obesity, dyslipidemia, and fatty 
liver. The patient has requested authorization and coverage for Wegovy (semaglutide solution 
auto-injector 2.4 mg/0.75 ml). The physician reviewer found that Semaglutide is an antidiabetic 
agent, glucagon-like peptide-1 (GLP-1) receptor agonist.  The initial management of individuals 
who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of 
diet, exercise, and behavioral modification. All patients who would benefit from weight loss 
should receive counseling on diet, exercise, and goals for weight loss.  When a patient with a 
body mass index (BMI) greater than 30 kg/m2 or a BMI of 27-29.9 kg/ms with comorbidities, such 
as hypertension or diabetes mellitus, and has failed to achieve weight loss goals through diet and 
exercise  alone,  a  pharmacologic  therapy  is  suggested.  Wegovy  is  a  brand-named  form  of 
semaglutide that is indicated for chronic management of obesity. It is U.S. Food and Drug 
Administration (FDA) approved for the use as an adjunct to diet and exercise in individuals with 
a BMI greater 30 kg/m2 or for individuals with a BMI greater than 27 kg/m2 and one or more 
weight-associated comorbidity. The initiation of Wegovy is as follows: week 1 through week 4: 
0.25 mg once weekly; week 5 through week 8: 0.5 mg once weekly; week 9 through week 12: 1 
mg once weekly; week 13 through week 16: 1.7 mg once weekly; and week 17 and ongoing 
maintenance dose is 2.4 mg once weekly. Of note, there were discrepancies in the submitted 
documentation. The records noted that the patient has been treated with Wegovy, but the 
submitted prior authorization form indicated that this is a new prescription and does not start 
him at the correct dosage. The provider letter appears to be from supporting staff and not truly 
part of the medical records. There are assumptions that the author is making that are not well-
documented in the medical record. The submitted documentation fails to support that the 
medication  is  being  prescribed  correctly  and  monitored  effectively.  Additionally,  the 
documentation does not indicate that the patient is participating in an appropriate diet/exercise 
plan. Therefore, Wegovy (semaglutide solution auto-injector 2.4 mg/0.75 ml) is not medically 
necessary for the treatment of this patient.