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

Summary  
The patient is a seven-year-old female with a history of spinal muscular atrophy (SMA). The 
patient has been diagnosed with decreased functional mobility and has been limited in all areas of 
gross motor development. The patients provider has recommended a wheelchair power seat 
elevation system. The Health Insurer has denied the services at issue as not medically necessary 
for treatment of the patients medical condition. This denial is the subject of this appeal and 
determination. The physician reviewer found that the mobility methods of pediatric patients with 
neuromuscular disorders and impaired mobility include manual and power wheelchairs depending 
on the patients ability to propel themselves and the risk of complications from their underlying 
neurological condition. Power wheelchairs provide a means for pediatric patients with motor 
impairment to achieve age-appropriate self-generated mobility that would not be possible without 
assistance. Developmental benefits, including social, language, and cognitive skill development, 
may be observed in young patients with motor disability who use power wheelchairs. This patient 
requires seat elevation to perform daily activities at school and at home. The wheelchair power 
seat elevation system would provide independence, safety, and efficiency for the patient in 
everyday settings and activities. Additionally, the patients current wheelchair does not provide 
proper femur, pelvic, or lumbar support. The patient demonstrates significant postural deviations 
due to spinal weakness and neuromuscular scoliosis. The power chair elevation system will 
provide appropriate positioning for the patient to help reduce musculoskeletal complications such 
as worsening scoliosis, contractures, pain, and hip deformities. For these reasons, the requested 
wheelchair power seat elevation system is medically necessary for treatment of the patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 37-year-old male who presented to his provider on 5/10/22. The patient has 
requested authorization and coverage for Stelara 90 mg/mL syringe. The physician reviewer 
found that the submitted documentation supports the medical necessity of the requested 
medication regimen. Current medical literature supports dose escalation of Stelara to 90 mg 
every four weeks in this case. The mechanism of Stelara (ustekinumab) is entirely different than 
that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab 
has been demonstrated to be safe and effective for induction and maintenance of remission in 
patients with moderate-to-severe Crohns disease that was resistant to anti-TNF therapy. In a 
study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an 
initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed 
dosing at 90 mg every four weeks was used frequently to address inadequate disease control, 
and a large proportion of patients were able to maintain response with dose escalation to 90 mg 
every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing 
every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, 
the patient has a history of severe Crohns disease diagnosed before age 30, with a history of 
stricture, fistula, and recent need for surgery. He has failed multiple biologic and conventional 
alternatives, and the records note ongoing disease symptoms while on Stelara every eight weeks. 
While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, laboratory 
testing  results  noted  an  undetectable  Stelara  level  and  lack  of  anti-Stelara  antibodies. 
Continuation of dosing at every eight weeks or discontinuation of Stelara may result in loss of 
disease  control,  with  complications  such  as  fistula,  stricture,  bowel  obstruction,  flare, 
hospitalization, need for surgery, or other complications. Therefore, Stelara 90 mg/mL syringe is 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 43-year-old male enrollee has requested reimbursement for injection(s), platelet rich plasma, 
any site, including image guidance, harvesting, and preparation when performed, on 3/7/22. 
The Health Insurer has denied this request and reported that the service at issue was 
investigational for the treatment of the enrollees left elbow pain and bicipital tendinitis of the 
left shoulder. The physician reviewer found that there is insufficient medical literature 
supporting the use of platelet rich plasma (PRP) injections in the treatment of lateral 
epicondylitis and biceps tendonitis. In a metanalysis, Karjalainen and colleagues conclude, 
Data in this review do not support the use of autologous blood or PRP injection for treatment 
of lateral elbow pain. These injections probably provide little or no clinically important benefit 
for pain or function (moderate-certainty evidence), and it is uncertain (very low-certainty 
evidence) whether they improve treatment success and pain relief greater than 50%, or 
increase withdrawal due to adverse events. Wong and colleagues report, Overall there is 
limited robust evidence to recommend PRP therapy for tennis elbow. There is even less 
evidence to support the use of PRP in patients with biceps tendonitis. In this case, the patient is 
a 43-year-old male with left common extensor tendinopathy and biceps tendinopathy. Notes 
dated 9/23/21 reported that meloxicam and topical Voltaren were not helpful in reducing his 
pain. Magnetic resonance imaging (MRI) of the elbow with contrast neurography dated 1/31/22 
showed high signal intensity at the lateral aspect of the epicondyle and distal biceps. The 
patient received an ultrasound guided left distal biceps tendon and left lateral epicondyle 
injection with PRP on 3/7/22. Notes dated 6/13/22 reported that the patients history of 
glucose-6-phosphate dehydrogenase (G6PD) deficiency was the reason a PRP injection was 
provided rather than a steroid injection. It is unclear why G6PD deficiency was a concern for not 
utilizing corticosteroid injection when nonsteroidal anti-inflammatory drugs (NSAIDs) were 
prescribed, which appear to have a higher degree of concern for exacerbating the patients 
condition. Regardless of the patients medical history of G6PD deficiency, current medical 
literature does not support the use of PRP over other standard, conservative treatment options 
such as continued physical therapy. Therefore, injection(s), PRP, any site, including image 
guidance, harvesting, and preparation when performed, on 3/7/22, was not likely to have been 
more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
A 43-year-old male enrollee has requested reimbursement for injection(s), platelet rich plasma, 
any site, including image guidance, harvesting, and preparation when performed, on 3/7/22. The 
Health Insurer has denied this request and reported that the service at issue was investigational 
for the treatment of the enrollees left elbow pain and bicipital tendinitis of the left shoulder. The 
physician reviewer found that in this clinical setting, the PRP injection at issue was not likely to  have been more beneficial than standard therapy with a physical therapy program. In fact, in a 
follow-up visit dated 4/30/22, the records noted no significant improvement of pain  post 
injection and the provider recommended a functional assessment with physical therapy. Notes 
dated  6/13/22  reported  that  the  physical  therapy  program  provided  addressed  specific 
musculoskeletal dynamics along with the provision of a home program. Case reports on the use 
of PRP injections for tendinitis generally show resolution of symptoms over time, however, the 
reported  outcomes  do  not  state  that  the  injections  treated  the  primary  etiology  of  the 
tendinopathies. Rather, there is an association inferred between the time of injections and 
reported symptom relief. There are no current guidelines regarding the use of PRP injections for 
tendinopathies. In a review of current literature on PRP for elbow pathologies, Kwapisz and 
colleagues report that their results showed that more studies on larger cohorts, with comparable 
formulations, and with longer follow-up are required to give optimal suggestions concerning the 
use of PRP in elbow pathologies. More research is needed regarding the indications, efficacy, 
post injection therapy services, and specific techniques of harvest and delivery of the service at 
issue.  Therefore,  injection(s),  PRP,  any  site,  including  image  guidance,  harvesting,  and 
preparation when performed, on 3/7/22, was not  likely to have been more beneficial for 
treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
A 43-year-old male enrollee has requested reimbursement for injection(s), platelet rich plasma, 
any site, including image guidance, harvesting, and preparation when performed, on 3/7/22. The 
Health Insurer has denied this request and reported that the service at issue was investigational 
for the treatment of the enrollees left elbow pain and bicipital tendinitis of the left shoulder. The 
physician reviewer found that while current medical literature supports the use of PRP injections 
for the treatment of lateral epicondylitis in specific patients, there are only very limited studies 
available regarding the use of PRP for the treatment of bicipital tendonitis. In a systemic review 
of PRP versus corticosteroids for the treatment of elbow epicondylitis, Li and colleagues found 
that after long-term follow-up at 24 weeks post treatment, PRP injections had improved pain and 
function more effectively than corticosteroid injections. In a systematic review of the efficacy of 
PRP on tendon and ligament healing, Chen and colleagues conclude, PRP may reduce pain 
associated with lateral epicondylitis and rotator cuff injuries. While evidence regarding the 
success of PRP therapy is not conclusive, the risks associated with it are minimal. In light of the 
foregoing, PRP injection for treatment of lateral epicondylitis and bicipital tendonitis can only be 
recommended in carefully selected cases where all other therapies have been tried and the 
options are limited. In this case, notes dated 3/7/22 reported that  the patient has G6PD 
deficiency. For such a patient, the risks of corticosteroid injections may outweigh the benefits, 
especially given that PRP injections carry minimal risks. A patient with G6PD deficiency has a risk 
for hemolytic anemia which can be triggered by certain medications. In this clinical setting, the 
benefits of PRP far outweigh the current standard treatment of with corticosteroids, as they are 
more effective in improving pain and function than corticosteroid injections, with reduced risk as 
there are minimal risks with PRP injections over corticosteroid injections. Therefore, injection(s),  PRP, any site, including image guidance, harvesting, and preparation when performed, on 3/7/22, 
was likely to have been 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 24-year-old male who presented to the emergency room on 5/21/22 with severe 
right-sided lower back pain and one concerning episode of bloody emesis. The patient has 
requested reimbursement for an inpatient stay from 5/21/22 through 5/23/22. The Health Insurer 
has denied this request and reported that the services at issue were 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 services at 
issue. Antiphospholipid syndrome is a multisystem disease characterized by arterial, venous, or 
microvascular  thromboses.  Denas  and  colleagues  note  that  patients  with  antiphospholipid 
syndrome are at increased risk for developing coronary artery disease resulting from coronary 
thromboembolism, accelerated atherosclerosis leading to a plaque rupture, or microvascular 
thrombosis. While not all troponin elevations are a result of acute coronary syndromes, all troponin 
elevations are abnormal and in the absence of clinical evidence of ischemia, a search for an 
alternative cause of myocardial necrosis is recommended. Several of these causes require urgent 
medical evaluation, as does an ischemic evaluation in the setting of elevated troponin levels. 
Myocarditis is one such cause, especially given its highly variable presentation, and was on the 
differential in the evaluation of this patients elevated troponin levels.  In this case, the patient was 
at a particularly high risk for thromboses secondary to his antiphospholipid syndrome at the time 
of admission due to the cessation of anticoagulation in preparation for a dental procedure. In this 
clinical setting, given the timing of the patients presentation with stopping anticoagulation and an 
otherwise unexplained troponin elevation, the services at issue were medically indicated to 
evaluate for both ischemic and non-ischemic potentially life-threatening etiologies. Therefore, the 
inpatient stay from 5/21/22 through 5/23/22 was medically necessary for the treatment of this 
patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 59-year-old female insured has requested authorization and coverage for Rinvoq 45 mg tablets 
(30 tablets every 30 days). The Health Insurer has denied this request indicating that the requested 
medication is considered investigational for the treatment of the insured's Chron's disease. 
The physician reviewer found that the medical literature has established Rinvoq as a safe and 
effective treatment option for patients with Crohn's disease. In one study by Sandborn and 
colleagues involving patients with Crohn's disease, Rinvoq demonstrated a significant increase in 
efficacy for all doses tested as compared with placebo, with the efficacy maintained for one year. 
Rinvoq is also U.S. Food and Drug Administration (FDA) approved for the treatment of patients 
with Crohn's disease. A recent study of high-dose, 45 mg Rinvoq demonstrated safety findings 
consistent with previous studies, with no new safety risks observed (Sandborn, et al.). In this case, 
the patient presents with a history of Crohn's disease. The patient has tried and failed treatment 
with standard biologic therapy agents such as budesonide, high-dose infliximab with azathioprine, 
and high-dose Stelara with azathioprine. Without an effective treatment, the patient is at risk for 
complications including stricture, fistula, and a need for surgery or hospitalization. Rinvoq is FDA-
approved and supported by the medical literature for the treatment of patients with Crohn's disease. 
Given these findings, the requested Rinvoq 45 mg tablets (30 tablets every 30 days) are 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 2 
A 59-year-old female insured has requested authorization and coverage for Rinvoq 45 mg tablets 
(30 tablets every 30 days). The Health Insurer has denied this request indicating that the requested 
medication is considered investigational for the treatment of the insured's Chron's disease. 
The physician reviewer found that Rinvoq has been found to safely induce endoscopic remission 
in a significant proportion of patients with Chrons disease (Sandborn, et al.). Rinvoq has also been 
shown to improve quality-of-life and work productivity for patients with Chrons disease (Peyrin-
Biroulet, et al.). In this case, the patient has a history of Chrons disease since 2014. The patient 
has tried and failed treatment with biologics such as budesonide, high-dose infliximab with 
azathioprine, and high-dose Stelara with azathioprine. Rinvoq is the only treatment option that 
may be effective for the treatment of the patient, as no remaining treatment options are FDA-
approved for patients with Chrons disease. Therefore, the requested Rinvoq 45 mg tablets (30 
tablets every 30 days) are 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 3 
A 59-year-old female insured has requested authorization and coverage for Rinvoq 45 mg tablets 
(30 tablets every 30 days). The Health Insurer has denied this request indicating that the requested 
medication is considered investigational for the treatment of the insured's Chron's disease. 
The physician reviewer found that comparing Rinvoq 45 mg with placebo for patients with 
moderate-to-severe Chrons disease, Rinvoq resulted in higher clinical remission rates at 12 weeks 
(Loftus, et al.). Moreover, Rinvoq is FDA-approved for patients with moderate-to-severe Chrons 
disease who have not responded to anti-tumor necrosis factor (TNF) therapy. The records reflect  that this patient presents with a long history of Chrons disease. While the patient is medically 
stable, she is not optimally treated on her current regimen, which has significantly affected her 
quality-of-life. Rinvoq is FDA-approved and supported by the medical literature for the treatment 
of patients with Crohn's disease. For these reasons, the requested Rinvoq 45 mg tablets (30 tablets 
every 30 days) are 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 69-year-old female enrollee has requested reimbursement for Guardant 360 testing 
performed on 1/11/21. 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 integration of plasma next generation sequencing (NGS) 
testing into the routine management of stage IV non-small cell lung cancer demonstrates a 
marked increase of the detection of therapeutically targetable mutations and improved 
delivery of molecularly guided therapy. This is recommended by the National Comprehensive 
Cancer Network (NCCN) if there is insufficient tissue for NGS from tumor. Per the NCCN, The 
use of cell-free/circulating tumor DNA testing can be considered in specific clinical 
circumstances, most notably: if a patient is medically unfit for invasive tissue sampling; 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/circulating tumor DNA 
should be used only if follow-up tissue-based analysis is planned for all patients in which an 
oncogenic driver is not identified; in the initial diagnostic setting, if tissue-based testing does 
not completely assess all recommended biomarkers owing to tissue quantity or testing 
methodologies available, consider repeat biopsy and/or cell-free circulating tumor DNA 
testing. In this patients case, the Guardant 360 requisition noted that tissue-based 
comprehensive genomic profiling from a recent biopsy was not feasible. Thus, there is sufficient 
support for the services at issue in this clinical setting. Therefore, Guardant 360 testing 
performed on 1/11/21 was likely to have been more beneficial than other methods of 
evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 69-year-old female enrollee has requested reimbursement for Guardant 360 testing 
performed on 1/11/21. 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 proper evaluation of adenocarcinoma of the lung requires assay 
for multiple specific mutations. This is performed on the tissue biopsy. Per the records, this was 
done on her initial biopsy specimen of 2017. It is also noted that she had a multi-genomic 
Foundation One assay in 2018. It is not clear why a further genomic assay, Guardant 360 testing 
was needed, in view of the other assays. Additionally, there is a note at the office visit of 
2/02/21 that indicated that the recurrent tumor was found to be EGFR mutation positive. It is 
not clear where this assay was performed, but it could have been done on the surgical 
specimen from the neck dissection. Although liquid biopsies can be used when it is not safe or 
easy to get tissue, this is not the case here. Tissue was available from the neck dissection.  Therefore, Guardant 360 testing performed on 1/11/21 was not likely to have been more 
beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A 69-year-old female enrollee has requested reimbursement for Guardant 360 testing performed 
on 1/11/21. 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. Even if stage IV disease is present, 
therapy targeted to EGFR with erlotinib results in prolonged survival when compared with 
standard chemotherapy regimens. In this case, it was important to know whether the patient 
had developed an EGFR T790M mutation. This mutations confers resistance to erlotinib. A liquid 
biopsy was ordered to analyze for this mutation. The Guardant 360 test is commonly referred to 
as a liquid biopsy since it involves sampling of tumor cells that may be circulating in the peripheral 
blood. The NCCN guidelines note that the test is acceptable if the patient is unfit to pursue more 
invasive methods for tumor sampling. If a simple core biopsy of an accessible metastatic lymph 
node, like a supraclavicular or axillary lymph node was feasible, then a Guardant 360 would have 
been unreasonable; but that is not the case here. It was reasonable to have the Guardant 360 
test done since disease is inaccessible. Therefore, Guardant 360 testing performed on 1/11/21 
was likely to have been more beneficial than other methods of evaluating this patient.