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

Summary Reviewer  
 
The patient is a 45-year-old male who presented to his provider on 1/12/22. The patient has 
requested authorization and coverage for implant neuro-electrodes  CPT code 64555 (times 
two)  (implantation  of  neuro-electrodes  for  PNS).  The  physician  reviewer  found  that  the 
submitted documentation supports the medical necessity of the requested service. Strand and 
colleagues report that evidence supports the efficacy of PNS for treatment of failed back surgery 
syndrome via subcutaneous peripheral field stimulation and lower extremity neuropathic pain. 
The authors conclude, PNS should be used judiciously as an adjunct for chronic and acute 
postoperative pain following adequate patient screening and positive diagnostic nerve block or 
stimulation trial. Deer and colleagues report that percutaneous PNS of the medial branch nerves 
for the treatment of chronic axial back pain in patients after radiofrequency ablation is effective. 
The authors noted that a majority of patients reported highly clinically significant reductions, 
equal to or greater than 50%, in average pain intensity two months after PNS, with a majority 
experiencing  clinically  significant  improvements  in  functional  outcomes,  as  measured  by 
disability and pain interference. The authors further noted that five months after PNS, 93% of 
patients reported clinically meaningful improvement in one or more outcome measures, and a 
majority experienced clinically meaningful improvements in pain intensity, disability, and pain 
interference. In a prospective multicenter case series study for populations with chronic axial low 
back pain who had failed multiple prior treatments, Gilmore and colleagues found that patients 
treated with percutaneous PNS reported clinically significant reductions in back pain intensity at 
the end of the two months and that a majority reported sustained relief through eight months 
after the start of treatment. The authors further noted clinically meaningful and statistically 
significant improvements in functional and other outcomes, such as depression, opioid analgesic 
consumption, and health-related quality of life. In this case, the patient is status post lumbar 
surgery  with  ongoing  axial  chronic  back  pain.  The  patient  has  diagnoses  of  lumbar  facet 
arthropathy and lumbar degenerative disc disease shown on lumbar MRI, along with a diagnosis 
of  failed  back  syndrome,  which  cause  axial  back  pain.  The  patient  has  tried  and  failed 
conservative therapies. The patient has had positive diagnostic nerve blocks that did not last. In 
this clinical setting, current medical literature supports the requested service as medically 
indicated. Therefore, implant neuro-electrodes  CPT code 64555 (times two) (implantation of 
neuro-electrodes for PNS) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
The patient is a 28-year-old female who presented to her provider on 11/4/22. The patient has 
requested authorization and coverage for omalizumab (Xolair) 150 mg. The Health Insurer has 
denied this request and reported that the requested medication is not medically necessary for the 
treatment of this patient. This denial is the subject of this appeal and determination. The physician 
reviewer found that the submitted documentation supports the medical necessity of the requested 
medication. Xolair is a biologic therapy that targets specific inflammatory pathways involved in 
the  pathogenesis  of  asthma,  particularly  in  patients  with  an  endotype  driven  by  type  2 
inflammation. This targeted therapy has been shown to reduce asthma exacerbations, improve lung 
function, reduce oral corticosteroid use, and improve quality of life in appropriately selected 
patients. The U.S. Food and Drug Administration (FDA) approves the use of omalizumab for 
patients with moderate-to-severe asthma over age six, with a positive skin test or in vitro reactivity 
to at least one perennial allergen, and with symptoms that are inadequately controlled with inhaled 
corticosteroids. In this case, the records documented a serum Ig E level of 384.1 IU/mL on 
10/26/22, along with positive serum allergen specific IgE levels for dust mite, mold, and pollens. 
The patient has continued to experience persistent asthma symptoms such as dyspnea despite 
combination therapy of inhaled corticosteroids and a long-acting bronchodilator. Given that 
current  medical  literature  supports  the  use  of  the  requested  medication  for  patients  with 
uncontrolled  allergic  asthma  symptoms  in  this  clinical  setting,  the  requested  medication  is 
medically indicated. Therefore, omalizumab (Xolair) 150 mg is medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 61-year-old male with a history of bilateral knee pain and a diagnosis of primary 
osteoarthritis of both knees. Upon his initial consultation on in 2021, the provider noted that both 
of the patients knees have end-stage degenerative joint disease. The Health Insurer has denied the 
requested services as not medically necessary. The physician reviewer found that the records 
indicate that this patient is being treated for unilateral primary osteoarthritis of the left knee. In 
April 2022, the patient presented status post right knee replacement with satisfactory results. The 
patient has since expressed interest in proceeding with left total knee replacement. The provider 
noted that physical examination of the left knee revealed a mild varus deformity, significant pain 
along the medial aspect to palpation, and crepitus with range of motion. The provider has 
recommended treatment with left total knee arthroplasty. However, the available documentation 
does not include evidence a follow-up examination since 4/6/22. In the absence of an updated 
examination including both subjective and objective findings, the available records do not support 
the medical necessity for the requested left total knee arthroplasty. Riddle and colleagues noted 
that the risk-to-benefit for total knee arthroplasty favors patients who have intense or severe 
symptoms of knee osteoarthritis (OA), are at least 55 years old, have limited mobility, and have a 
body mass index (BMI) less than 40 kg/m2. The authors concluded that, Outcomes are much 
less favorable for patients who have slight or moderate symptoms and functional loss, making the 
procedure not appropriate. On the 4/6/22 examination, this patients left knee symptoms were not 
described as severe and the patients BMI was reported at 34.86 kg/m2. In the absence of current 
physical examination findings, the severity of the patients condition and/or BMI may have 
significantly changed (Calek and Behrend). Additionally, detailed documentation is not evident 
regarding a trial and failure of recent, reasonable, and comprehensive less invasive conservative 
care measures for the patients left knee (Van Zaanen, et al.). For these reasons, the requested 
arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella 
resurfacing (total knee arthroplasty) is not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 52-year-old female with a history of refractory back pain, depression, anxiety, 
and chronic pain disorder status post pain pump placed in 2019. The provider has recommended 
placement of a percutaneous implantation of spinal cord stimulator. The physician reviewer 
found that at issue is whether the requested percutaneous implantation of neurostimulator 
electrode array, epidural, is medically necessary for treatment of this patient. A prospective, 
multicenter, randomized controlled trial was conducted evaluating the long-term quality of life 
improvement for patients with chronic intractable back and leg pain using spinal cord stimulation 
(Amirdelfan, et al.). The authors reported that of the 171 patients who received a permanent 
spinal cord stimulation device implant, a higher proportion of spinal cord stimulation patients 
had marked improvement of their disability on the Oswestry Disability Index (ODI) to a moderate 
or minimal impact on their daily function versus the control group. The authors concluded that, 
In  addition  to  superior  pain  relief,  10  kHz  spinal  cord  stimulation  provides  long-term 
improvements in quality of life and functionality for subjects with chronic low-back and leg pain. 
Similarly, a systematic review and meta-analysis performed by Head and colleagues evaluated a 
variety of spinal cord stimulation systems and device parameters for use in patients with chronic 
low back and leg pain. The authors concluded that data from level 1 randomized controlled trials 
have elevated the status of spinal cord stimulation to a safe and effective alternative for the 
treatment of neuropathic low back pain and leg pain. In this case, the patient has chronic low 
back pain that has been non-responsive to medication management, physical therapy, epidural 
steroid injections, cognitive therapy and intrathecal pain pump. Based on the level one evidence 
to support the usage of spinal cord stimulation therapy for patients with chronic low back and 
leg pain that is refractory to other forms of conservative care, the requested spinal cord 
stimulation is appropriate for treatment of this patients chronic low back pain. Therefore, the 
requested percutaneous implantation of neurostimulator electrode array, epidural, is medically 
necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is an eight-year-old male with a history of immune thrombocytopenia (ITP). Per the 
provider, the patient will not be undergoing major surgery for splenectomy at his age given the 
risk of infection when there are less invasive treatment alternatives available. The provider has 
recommended treatment with Promacta to increase platelets. The Health Insurer has denied the 
requested medication as not medically necessary. This denial is the subject of this appeal and 
determination. The physician reviewer found that based on the available medical records and 
current guidelines, Promacta is not supported as medically necessary for treatment of this patients 
diagnosis of ITP. At this time, there is an ongoing phase 3 trial, which is randomizing patients to 
medical treatment with IVIG or steroids versus Promacta, however this study is ongoing. Applying 
the guidelines from the American Society of Hematology (ASH), Promacta is indicated as second-
line therapy for patients who have poor response to steroids or IVIG or who cannot tolerate these 
treatments. Per the ASH guidelines, patients who have a high risk of bleeding due to age and 
activity should be treated with first-line treatments such as oral steroids to address his varying 
platelet count, which is often less than 20,000, and poses a risk of bleeding for this patient, who 
desires to participate in risky activities. The patient may be a candidate for treatment with Promacta 
in the future if his condition fails to improve with first-line therapies including steroids. Based on 
the available documentation, the requested Promacta 25 mg tablet is not medically necessary for 
treatment  of  this  patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer  
 
The patient is a 64-year-old male who presented to the emergency department on 11/7/22 with 
a sudden onset of abdominal pain and vomiting. The patient has requested reimbursement for 
inpatient hospital stay at Tri City Hospital from 11/9/22 through 11/12/22. The Health Insurer 
has denied this request and reported that the services at issue were not medically necessary for 
the treatment of this patient. The physician reviewer found that the submitted documentation 
supports the medical necessity of the services at issue. In this case, the patient presented to the 
hospital with abdominal pain and vomiting. Imaging showed possible obstruction and colitis, and 
evaluation was recommended and found colonic inflammation and ulceration. The records noted 
that imaging showed further possible dilation of the colon two days after presentation. At that 
time, due to the possibility of worsening obstruction, colitis, or toxic megacolon, discharge would 
not have been appropriate. In this clinical setting, given the possible severity of the patients 
condition, the services at issue were medically indicated. Therefore, inpatient hospital stay at Tri 
City Hospital from 11/9/22 through 11/12/22 was medically necessary for the treatment of this 
patient.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 1 
 
A 49-year-old male enrollee has requested authorization and coverage for 0424T insertion 
neurostimulator system for central sleep apnea. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees central 
sleep apnea. The physician reviewer found that in this case, the patient has severe central sleep 
apnea. Notes dated 6/18/22 reported an apnea-hypopnea index (AHI) of 35 with significant 
daytime  sleepiness.  The  patient  was  noted  as  being  a  highway  maintenance  worker,  an 
occupation posing high risk of injury to himself or others. The 0424T phrenic neurostimulator 
system is an implantable device that stimulates the diaphragm to contract, resulting in patients 
breathing, and is an option in selected patients with symptomatic central sleep apnea intolerant 
of CPAP or other standard therapies. While the device is approved by the U.S. Food and Drug 
Administration, (FDA), there may be a need for additional studies on cardiovascular outcomes 
and long-term safety in relation to other therapies for central sleep apnea. However, in this 
clinical setting, as the records indicate that the patient is unable to tolerate standard therapy 
with CPAP, biPAP, or ASV, the requested service is likely to be more beneficial for the patient 
than any remaining, available therapies. Therefore, 0424T insertion neurostimulator system for 
central sleep apnea is likely to be more beneficial for treatment of the patients condition than 
any available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 2 
 
A 49-year-old male enrollee has requested authorization and coverage for 0424T insertion 
neurostimulator system for central sleep apnea. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees central 
sleep apnea. The physician reviewer found that Ding and Zhang note that transvenous phrenic 
nerve stimulation is an effective and safe therapeutic approach that is approved by the FDA for 
the treatment of moderate to severe central apnea. In this case, notes dated 6/18/22 reported a 
sleep study dated 12/18/18 reported 27 obstructive apneas, 70 central apneas, zero mixed 
apneas, and 85 hypopneas. The patient has failed ASV and other PAP therapy modalities and has 
symptomatic central apnea. Given that the patient has failed first-line of treatment of central 
apnea with ASV and PAP therapy, phrenic nerve stimulation is likely to be more beneficial in this 
case than standard therapies. Therefore, 0424T insertion neurostimulator system for central 
sleep apnea is likely to be more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Insurer Denial Overturned

Summary Reviewer 3 
 
A 49-year-old male enrollee has requested authorization and coverage for 0424T insertion 
neurostimulator system for central sleep apnea. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees central 
sleep  apnea.  The  physician  reviewer  found  that  multiple  controlled  clinical  studies  have 
demonstrated the safety and efficacy of the Remede phrenic nerve stimulator system for the 
treatment of central sleep apnea.  The system is FDA approved for this indication. In this case, 
the patient has primarily central sleep apnea noted on formal sleep test, has not responded to  
CPAP, biPAP, or ASV, and is symptomatic with disturbed sleep and daytime fatigue. Therefore, 
0424T insertion neurostimulator system for central sleep apnea is 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 Reviewer  
 
The patient is a 14-year-old female who has been diagnosed with autism spectrum disorder. On 
10/05/21, the provider requested 16 hours per week 1:1 applied behavior analysis (ABA) therapy 
per week and 8 hours supervision per month. The physician reviewer found that the submitted 
documentation fails to demonstrate the medical necessity of the services at issue. Specifically, 
the intensity approved by the Health Insurer (12 hour per week 1:1 ABA therapy and 6 hours per 
month supervision) is the appropriate treatment frequency. The medical record included several 
treatment plans indicating the patient has made progress over their course of treatment with the 
provider over the last several years. Challenging behavior has reduced, and the number of 
targeted  goals  have  also  reduced  over  the  last  several  treatment  authorization  requests. 
However, the patient's Vineland scores have decreased over this same period of time. Even with 
this decrease over time, all scores on subdomains (communication, daily living, and socialization) 
are within or just beyond the threshold of one standard deviation from the mean. These score 
highlight that the patient is functioning within, or close to, the average range (in the identified 
subdomains) compared to same aged peers. While the patient still demonstrates a need for 
support, treatment intensity can be faded.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary  
The patient is a 52-year-old female with a history of Graves disease and post-COVID symptoms 
including fatigue, brain fog, and varying degrees of shortness of breath. The patient underwent 
flow cytometry on 2/23/23 as workup for her long COVID symptoms. The Health Insurer has 
denied the services at issue as not medically necessary for the evaluation of the patients medical 
condition. This denial is the subject of this appeal and determination. The physician reviewer found 
that the records provided for review reflect that this patient underwent flow cytometry on 2/23/23 
as workup for her post-COVID conditions. No laboratory test can definitively distinguish post-
COVID conditions from other conditions with similar symptomatologies but different etiologies. 
The use of flow cytometry to assess cell surface markers and cytokine expression in patients with 
long  COVID  is  being  investigated  in  research  settings to  elucidate  the  pathophysiology  of 
inflammation in the setting of long COVID. However, there are no existing clinical applications 
of flow cytometry results for patients with long COVID. Inflammatory markers are generally not 
recommended for the workup of patients with suspected or confirmed long COVID. Therefore, the 
laboratory services flow cytometry performed on 2/23/23 were not medically necessary for the 
evaluation of the patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer  
The patient is a 60-year-old male. The patient has requested reimbursement for magnetic 
resonance (e.g., proton) imaging (MRI), spinal canal and contents, cervical; without contrast 
material on 8/15/22. The physician reviewer found that at issue is whether the MRI (e.g., proton), 
spinal  canal  and  contents,  cervical;  without  contrast  material  on  8/15/22,  was  medically 
necessary for the evaluation of this patient. The submitted documentation does not support the 
medical necessity of the service at issue. The treatment for chronic musculoskeletal pain, 
including benign neck pain with or without radicular symptoms, includes patient education, self-
care, independent exercise, remaining active, basic topical thermal modalities for palliation, and 
common analgesics, if warranted, for palliation. Childress and colleagues note that in the initial 
evaluation and management of neck pain, diagnostic tools such as imaging have variable utility. 
Early MRI imaging is not known to improve outcomes in this clinical setting and may lead to an 
overemphasis in invasive procedures and surgery that are ultimately not clinically beneficial. In 
this case, the records did not document red flags in the patients history or examination such 
as symptoms or signs suspicious for infection, abscess, bleeding, or tumor, that would indicate 
advanced imaging of the cervical spine without an appropriate trial of conservative therapy. 
Notes dated 8/15/22 reported a normal neurological examination, and an examination of the 
cervical  spine  showed  normal  range  of  motion  with  tenderness  only  at  the  level  of  the 
musculature surrounding the neck and upper back, consistent with myofascial pain and possible 
radiculitis. The provider recommended physical therapy and did not note a plan for cervical spine 
MRI. In this case, given that the patients clinical history and examination did not suggest 
pathology that necessitated interventions beyond observation and conservative care, and as the 
records did not document a trial of appropriate conservative management prior to the imaging 
study in question, the service at issue was not medically indicated. Therefore, MRI (e.g., proton), 
spinal canal and contents, cervical; without contrast material on 8/15/22, was not medically 
necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary  
The patient is a 60-year-old female with a history of class 1 obesity complicated by dyslipidemia. The 
records available for review indicate that the patient had a body mass index (BMI) over 30 kg/m2 prior 
to beginning treatment with Wegovy. The physician reviewer found that the issue is whether the 
requested Wegovy solution auto-injector 0.25 mg/0.5 mL 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 1 obesity complicated by dyslipidemia. The records reflect 
that the patient has attempted treatment with diet management and exercise without significant 
benefit. Per the provider, the patient has contraindications or intolerances to several weight loss 
medications. Wegovy has been shown to effectively promote weight loss for patients in conjunction 
with diet and exercise. Furthermore, the patient has demonstrated prior weight loss success with 
Wegovy. All told, the requested Wegovy solution auto-injector 0.25 mg/0.5 mL is medically necessary 
for the treatment of this patient.