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

Summary Reviewer 1 
 
A 74-year-old male enrollee has requested reimbursement for laboratory testing provided on 
10/12/20. 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 local treatment for primary uveal melanoma is effective in preventing local 
recurrence in over 95 percent of cases, yet up to 50 percent of patients are at risk for 
metastatic disease. The high risk of metastatic disease is thought to be due to a propensity for 
early micrometastasis followed by a variable latency period prior to the emergence of overt 
metastatic disease. Gene expression profiling (GEP) has been shown to be superior to 
chromosomal markers, as well as clinical and histopathological prognostic factors, for defining 
groups at high risk for the development of metastatic disease. Using primary uveal melanoma 
samples obtained by fine needle biopsy, GEP classifies tumors as having low (class 1) or high 
(class 2) metastatic potential depending on the expression of 12 discriminating genes and three 
control genes. This profile test has been validated a prospective multicenter study and is a 
standard of care and now recommended by the National Comprehensive Cancer Network 
guidelines. Therefore, laboratory testing provided on 10/12/20 was likely to have been more 
beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 74-year-old male enrollee has requested reimbursement for laboratory testing provided on 
10/12/20. 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 this patient has a rare disease, ocular melanoma. Ocular melanomas that 
have metastasized are markedly resistant to standard chemotherapy regimens. However, 
knowledge of the risk for metastasis directly affects surveillance of patients by computed 
tomography (CT) scan. The DecisionDX-UM  test analyzes gene expression and has been shown 
to be highly informative for prognosticating metastatic risk. This gene expression classifier is 
discussed in the Physicians Data Query of the National Cancer Institute and the National 
Comprehensive Cancer Network guidelines on uveal melanoma. There is no other standard 
prognostic indicator that could serve as an alternative. Therefore, laboratory testing provided 
on 10/12/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A 74-year-old male enrollee has requested reimbursement for laboratory testing provided on 
10/12/20. 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 in this case, prognostic analysis conducted on the biopsy specimen showed 
a gain of chromosome 6p which puts the melanoma at low risk. There is no indication for a 
gene expression assay to determine systemic imaging surveillance. The recommendation is for 
imaging to evaluate signs and symptoms as clinically indicated and to consider imaging every 12 
months due to the low risk profile. Per the National Comprehensive Cancer Network guidelines, 
a gain of chromosome 6p deems the melanoma low risk. Since the patients biopsy yielded a 
gain of chromosome 6p, gene expression profiling was not indicated. Therefore, laboratory 
testing provided on 10/12/20 was not likely to have been more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
The parent of a 16-year-old male insured has requested reimbursement for a laboratory test 
performed on 2/10/23. The Health Insurer has denied this request indicating that the services at 
issue were considered investigational for the evaluation of the insureds Chrons disease. 
The physician reviewer found that Therapeutic drug level monitoring (TDM) has become an 
essential procedure in the management of inflammatory bowel disease. Measuring the drug level 
and the presence of antibodies can help the treating physician differentiate between primary 
treatment failures versus insufficient dosing. It can also allow dosing titration and adjustments. 
The clinical practice guidelines adopted by the American College of Gastroenterology (ACG) 
support the use of therapeutic drug monitoring in the management of patients with inflammatory 
bowel disease (Vande Casteele, et al.). According to Singh and Dubinsky, Therapeutic drug 
monitoring allows for optimized, individualized dosing and improved care for inflammatory bowel 
disease patients of all ages. Finally, Fernandes and colleagues published a prospective study 
showing that proactive TDM is associated with fewer surgeries and higher rates of mucosal healing 
than conventional non-TDM-based management. Overall, TDM is well-supported by the medical 
literature and was performed appropriately in this patients case. Therefore, the laboratory test 
performed on 2/10/23 was likely to have been more beneficial for the evaluation of the patients 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
The parent of a 16-year-old male insured has requested reimbursement for a laboratory test 
performed on 2/10/23. The Health Insurer has denied this request indicating that the services at 
issue were considered investigational for the evaluation of the insureds Chrons disease. 
The physician reviewer found that the use of infliximab trough levels and antibodies have become 
standard in clinical practice to determine if infliximab dosing is appropriate and whether a patient 
has lost, or is likely to lose, responsiveness to treatment due to the formation of antibodies to 
infliximab. These lab tests lead to adjustments in treatment, as low serum drug troughs and 
elevated antibody levels are predictive and explanatory of disease flare. Routine monitoring of 
asymptomatic patients is now being done to prevent flares by ensuring appropriate drug levels. 
According to Hyams and colleagues, It is clear that whether monotherapy or combination biologic 
therapy is used, we are now in the age where monitoring drug and antibody levels should be 
considered standard of care. Although the use of proactive versus reactive monitoring remains in 
question, measurement of infliximab levels and antibodies is considered the standard of care. In 
this case, the lab testing was performed in response to a dosage change and was thus appropriate. 
All told, the laboratory test performed on 2/10/23 was likely to have been more beneficial for the 
evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3  The parent of a 16-year-old male insured has requested reimbursement for a laboratory test 
performed on 2/10/23. The Health Insurer has denied this request indicating that the services at 
issue were considered investigational for the evaluation of the insureds Chrons disease. 
The physician reviewer found that according to Cheifetz and colleagues, When infliximab de-
escalation (dose reduction) is considered in patients in remission, proactive TDM both before and 
after de-escalation should be performed. In this case, the patients Inflectra dosage was reduced. 
Evaluating Inflectra drug levels and antibody levels both before and after changing dose is the 
standard of care for this patient. For this reason, the laboratory test performed on 2/10/23 was 
likely to have been more beneficial for the evaluation of the patients condition than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is an 80-year-old male with a history of psoriatic arthritis and osteoarthritis of both 
knees with associated chronic bilateral knee pain. The patient has requested reimbursement for 
hyaluronan injections (Synvisc-One) performed on 9/09/21. The physician reviewer found that 
an exhaustive review of the current medical literature pertaining to viscosupplementation 
reveals mixed results. Evidence from eight systematic reviews and six randomized controlled 
trials indicates that although viscosupplementation may relieve knee pain in some individuals 
with osteoarthritis, it is not known as to which individuals will benefit. Different studies have 
tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make 
it more effective. Guidelines from organizations such as the American Academy of Orthopedic 
Surgeons  indicate  that  the  evidence  is  not  conclusive.  In  light  of  the  foregoing, 
viscosupplementation can only be recommended in individuals with a history of lasting benefit 
from prior injections and in carefully selected cases where everything else has been tried and the 
options are limited. In this case, the medical records dated 9/09/21 state that the patient had 
received Synvisc-One injections into both knees in the past with good results. Therefore, he 
presented with recurrent bilateral knee pain for additional injections. There is sufficient support 
for the services at issue in this clinical setting. Therefore, hyaluronan injections (Synvisc-One) 
performed on 9/09/21 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is an eight-year-old male with a past psychiatric history of attention 
deficit/hyperactivity disorder (ADHD), combined presentation, oppositional defiant disorder, 
and rule out autism spectrum disorder. The patients parent has requested authorization and 
coverage for dextroamphetamine-amphetamine ER 10 mg capsules SR 24H (#60 per 30 days). 
The physician reviewer found it is a fairly common occurrence in clinical practice to prescribe a 
long-acting stimulant (with a marketed duration of action of 12 hours) and have patients return 
to the clinic saying that the medication only lasts for a much shorter period of time. Despite 
the wide availability of long-acting stimulants which would eliminate the need for dosing 
multiple times a day, many patients (or their parents) report relief of symptoms with taking 
long-acting stimulant medications more than once per day or repeated use of short-acting 
stimulants following a long-acting stimulant dose. According to the FDAs Medication Guide for 
Adderall XR, On a mg/kg weight basis, children eliminated amphetamine faster than adults. 
The elimination half-life (t1/2) is approximately 1 hour shorter for d-amphetamine and 2 hours 
shorter for l-amphetamine in children than in adults. However, children had higher systemic 
exposure to amphetamine (Cmax and AUC) than adults for a given dose of Adderall XR, which 
was attributed to the higher dose administered to children on a mg/kg body weight basis 
compared to adults. Upon dose normalization on a mg/kg basis, children showed 30% less 
systemic exposure compared to adults. Individuals vary in the way they metabolize 
medication, and this has led to the development of pharmacogenetic testing. Some individuals 
may metabolize certain medications more rapidly than others and conversely there are others 
who are considered slow metabolizers when compared to the majority of individuals who 
metabolize medications at a typical rate. Those who metabolize medication more rapidly than 
normal may require higher than usual medication doses or greater frequency of dosing as 
seems to be the case with this patient. Given that the patient has had documented benefit from 
twice daily dextroamphetamine-amphetamine ER (Adderall XR) dosing with no significant side 
effects, dextroamphetamine-amphetamine ER 10 mg capsules SR 24H (#60 per 30 days) are 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 1 
 
A 19-year-old male enrollee has requested authorization and coverage for lumbar disc 
arthroplasty and two inpatient days. 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 lumbar disc arthroplasty (LDA) remains a 
controversial surgical strategy for the treatment of low back pain related to isolated 
degenerative disc disease, mostly based on its comparison to what is perceived as the gold 
standard surgical procedure, lumbar spinal fusion. When attempting to discern the efficacy and 
safety of lumbar disc arthroplasty, it is important to note that there are meaningful data both 
favorable and unfavorable regarding the technique, in particular when comparing it to lumbar 
fusion surgery. Guntin and colleagues systematically reviewed 57 seminal publications and 
noted that only 39 of them reported favorable results for lumbar disc arthroplasty in this 
context. The main thrust of their review, however, was to analyze how conflicts of interest 
influence the outcomes of studies in the lumbar disc arthroplasty literature. They noted that 
manuscripts where conflicts of interest were present were significantly more likely to report 
favorable outcomes of lumbar disc arthroplasty versus non-conflicted studies.  A number of 
other systematic reviews and meta-analyses have failed to demonstrate superiority of lumbar 
disc arthroplasty to fusion but found it equivalent. The standard therapies for the treatment of 
the patient include the following: medications, physical therapy (including traction), spinal 
injections, bracing, alternative therapies (i.e. acupuncture) and lifestyle modifications. The gold 
standard surgical treatment is a fusion surgery. This patient has already attempted and failed 
meaningful non-surgical strategies. On the basis that the abundance of accumulating evidence 
supports at best equivalence of lumbar disc arthroplasty to fusion surgery in this setting, the 
superior efficacy of the requested services has not been demonstrated. The requested services 
are not likely to be more beneficial than other surgical strategies, like decompression and 
fusion. Therefore, the requested lumbar disc arthroplasty and two inpatient days are not likely 
to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 19-year-old male enrollee has requested authorization and coverage for lumbar disc 
arthroplasty and two inpatient days. 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 the medical evidence does not support the 
requested services in this clinical setting. This patient has a large disc protrusion causing severe 
central canal and right lateral recess stenosis, with no prior surgeries. The most straightforward 
and lowest risk operation indicated is for a posterior decompression procedure (lumbar  laminotomy versus laminectomy and a microdiscectomy). A lumbar arthroplasty is not 
indicated as the initial operation for a disc herniation causing central and lateral recess stenosis. 
Central stenosis and lateral recess stenosis, resulting in single nerve root compression, are 
listed as contraindications to lumbar disc arthroplasty in the published literature according to 
the referenced U.S. Food and Drug Administration (FDA) ProDisc patient insert. Therefore, the 
requested lumbar disc arthroplasty and two inpatient days are not likely to be more beneficial 
than any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 3 
 
A 19-year-old male enrollee has requested authorization and coverage for lumbar disc 
arthroplasty and two inpatient days. 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 lumbar disc arthroplasty is indicated for 
discogenic low back pain. In this case, the records noted both back and leg pain. MRI 
demonstrated a large herniated L4-5 disc. Anterior approaches to the lumbar spine are not 
appropriate for resection of a herniated lumbar disc. There is a lack of support for the 
requested services in this clinical setting. Therefore, the requested lumbar disc arthroplasty and 
two inpatient days are not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
 
The patient is a 36-year-old female who presented to her provider on 9/15/22. The patient has 
requested authorization and coverage for Acthar 80 unit/milliliter (mL) injection gel. The Health 
Plan has denied this request and reported that the requested medication is 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 requested medication. There are 
only limited studies on the use of Acthar gel for rheumatoid arthritis. In a study of eight patients 
with refractory rheumatoid arthritis who were given repository corticotropin injections, Gillis and 
colleagues noted improvement of tender and joint swelling counts, in disease activity scores for 
rheumatoid arthritis (DAS28), and in patient global visual analog scale (VAS) scores. In a study 
including nine patients with refractory rheumatoid arthritis who had previously been on at least 
three biologic disease-modifying antirheumatic drugs (DMARDs) and did not respond to previous 
treatment, Fischer and colleagues found an improvement of DAS28 scores and in quality of life 
measured by the Health Assessment Questionnaire  Disability Index (HAQ-DI). However, both 
of these studies were limited by small sample sizes, were not placebo-controlled, and were not 
double blinded. The studies both looked at patients who had failed multiple biologics and had 
active rheumatoid arthritis with joint swelling. In this case, the records do not document that the 
patient has been on more than one biologic, or that the patient has tried and failed therapies for 
rheumatoid arthritis including DMARDs such as methotrexate, sulfasalazine, or leflunomide, 
tumor necrosis factor (TNF) inhibitors, abatacept, rituximab, tocilizumab, sarilumab, tofacitinib, 
and baricitinib. The clinical records submitted for review did not document joint swelling or 
uveitis. Given the lack of data in current medical evidence regarding Acthar as a treatment option 
for rheumatoid arthritis, the requested medication is not medically indicated. Therefore, Acthar 
80 unit/mL injection gel is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
 
The patient is a 48-year-old female with a history of episodic migraine headaches with associated 
nausea, severe weakness, and ataxia. The provider has recommended continued treatment with 
Qulipta. The Health Insurer has denied the requested treatment 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 Qulipta is in class of drugs called gepants, 
developed for the preventive treatment of episodic migraines in adult patients. Gepants play a 
crucial role in migraine pathophysiology and  are now established for preventive and acute 
treatments (Edvinsson, et al.). Gepants demonstrated efficacy and tolerability in the preventive 
treatment of migraines and are effective at reducing monthly migraine days (Ailani, et al.). 
According to the American Headache Society (AHS) consensus statement, patients with migraines 
should be considered for preventive treatment when attacks significantly interfere with patients 
daily routines despite acute treatment, attacks are frequent, and there is failure or overuse of acute 
treatments. The AHS further states that gepants should be personalized according to the needs of 
individual patients. In this case, the patient has a history of episodic migraines and has tried and 
failed multiple acute treatments, which fulfills the AHS criteria for preventative treatment. The 
AHS recommends that treatment plans involving the preventive use of gepants be personalized 
according to the needs of individual patients. For these reasons, the requested Qulipta 60 mg tablet 
is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 36-year-old male with a history of posterior scleritis. The patient has requested 
authorization  and  coverage  for  Acthar  Gel.  The  physician  reviewer  found  that  Scleritis  is 
inflammation  of  the  sclera,  the  wall  of  the  eye,  and  is  frequently  associated  with  the 
rheumatologic/autoimmune spectrum of diseases. It generally presents with significant pain and 
can result in severe vision-threatening problems if left untreated. The first line of treatment for 
uveitis is nonsteroidal anti-inflammatory drugs (NSAIDs). The second line of treatment is steroids.  
Unfortunately, treatment with these agents is not without the risk of side effects such as 
glaucoma and cataracts, as well as serious systemic side effects. This patient has failed to respond 
to both. If the scleritis cannot be controlled adequately and safely with steroids, the third line of 
treatment is a disease modifying antirheumatic drugs (DMARD), such as methotrexate. DMARDs 
likewise  carry  the  risk  of  serious  side  effects.  This  patient  has  also  been  treated  with 
methotrexate, and his scleritis is still not controlled. When steroids and DMARDs are unable to 
control the disease process, then the patient is advanced to the fourth line of agents, which 
includes use of a tumor necrosis factor inhibitor, such as Remicade (infliximab) or Humira 
(adalimumab). Unfortunately, this patients disease has not been controlled even with the 
addition of adalimumab.  Therefore, his provider has recommended that the patient be started 
on the last line of treatment, Acthar Gel. This patient has already demonstrated good clinical 
response to this medication in the past, with resolution of symptoms and without intolerable 
side effects. Although Acthar Gel is not an appropriate treatment for uveitis when used as a first 
or second line treatment, this is not the case with this patient. This patient has been treated with 
every class of medication other than Acthar Gel, and his uveitis is still not under control, despite 
a level of treatment that has already resulted in serious side effects. He requires additional 
treatment  in  an  attempt  to  bring  his  scleritis  under  control.  Additionally,  he  has  already 
demonstrated prior resolution on Acthar Gel. There is sufficient support for the requested 
medication in this clinical setting. Therefore, Acthar Gel is medically necessary for the treatment 
of this patient.