Brain: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation treatment. The utilization of proton beam in treating gliomas, such as oligodendroglioma, is an area of active investigation. Proton beam has unique properties compared to standard x-ray, or photon, therapy in its ability to deposit radiation dose. Often, fewer proton beams can be utilized to achieve a dose distribution similar to standard x-ray beam, potentially resulting in less radiation exposure to critical organs. Proton beam is currently utilized and strongly indicated in a setting where severe toxicities would result if normal tissue constraints cannot be met by standard x-ray beam. There is strong evidence suggesting decreased treatment related toxicity when proton beam is utilized for gliomas.

Physician 1: This case involves a 35-year-old male with a high-grade glioma status post two surgeries, chemotherapy, and radiation. The patient is currently stable, but carries a very guarded prognosis. His neurosurgeon and neuro-oncologist believe a magnetic resonance spectroscopy (MRS) is needed to assist in planning further treatment. The Health Plan has denied coverage for an MRS indicating there is insufficient peer-reviewed evidence demonstrating the accuracy of MRS is superior to alternative diagnostic modalities.MRS is now widely used for the treatment planning of gliomas. There is copious recent literature supporting its use in this clinical setting. This patient has a high-grade glioma; MRI alone is likely to be equivocal. Therefore, an MRS is medically appropriate and within the standard of care.

Where the denial was upheld

Physician 1: The patient is a 51-year-old man diagnosed with glioblastoma in July 2004. He was treated with surgery, radiation therapy, and chemotherapy. The patient underwent further surgery in January 2005 followed by treatment with interleukin-13 pseudomonas exotoxin. An MRI performed in September 2005 demonstrated progressive disease and it has been recommended that the patient be treated with CPT-11 and Avastin. The Health Plan has denied authorization for Avastin on the basis the therapy is considered investigational in this clinical setting.The included evidence includes two abstracts/papers that have been submitted for publication. One of these papers noted that in 21 patients treated with CPT-11 and Avastin, 9 had some sort of response. This was suggestive of an improved response to the combination when compared to CPT-11 alone.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergent services from through. The Health Plan has denied this request indicating that the requested services are not emergent services for treatment of the enrollee’s medical condition. A review of the records indicates a diagnosis of a stage IV glioblastoma multiforme (GBM) brain tumor for this enrollee. The enrollee presented with loss of speech, difficulty reading and writing, and loss of vision, and cognition was rapidly declining. The enrollee is reported to have had intraoperative brain mapping with partial resection surgery of a very large tumor, which was causing brain swelling and mass effect, and related services during the dates of services at issue. A magnetic resonance imaging (MRI), is reported to have shown several areas of tumor in the left parietal lobe.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for brain was denied, the published record says the denial is worth fighting.