Breast Cancer denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician #1: The patient is a 51-year-old woman diagnosed with breast cancer in July 2005. At that time she was found to have a 1.1cm poorly differentiated ductal cancer with negative nodes. The estrogen receptor was positive and HER-2/neu was negative. In an effort to aid in the decision-making process regarding the usefulness of adjuvant chemotherapy, her cancer was submitted for Oncotype DX analysis. On the basis of that test, she was found to have a relatively high risk of recurrence and, therefore, chemotherapy was recommended. The patient’s request for reimbursement was denied by the Health Plan based upon a determination that the use of the Oncotype DX assay is experimental/ investigational.Oncotype DX assay is a relatively new assay wherein 21 genes are analyzed in a breast cancer, allowing for the development of a prognostic score.

Physician 1: This patient is a 59-year-old female who was diagnosed with breast cancer in February 2006. She had a 1.4cm cancer with negative lymph nodes. She underwent radiation therapy with the Mammosite brachytherapy technique soon after the lumpectomy was performed and has submitted a request for reimbursement to the Health Plan. The Health Plan denied her request citing the investigational nature of the therapy.The Mammosite technique is one of a variety of newer approaches to the treatment of the residual breast cancer following lumpectomy. The conventional treatment is whole-breast radiation, which entails daily treatment for six to seven weeks. The Mammosite technique involves the insertion of a balloon into the biopsy cavity and then loading the areas with radiation needles over a five day period.

Where the denial was upheld

Physician 1: The patient is a young woman with breast cancer with a very high risk of relapse based on persistently positive lymph nodes after induction chemotherapy. She has had PET imaging as follow-up in 2002 and 2003. The patient wishes to undergo further PET imaging. She has no localizing symptoms or findings. Based upon the records provided, other imaging has not been performed recently. The Health Plan has denied coverage for the requested PET scan on the basis it is considered investigational in this clinical setting. PET scanning is not indicated as a screen for recurrent cancer in this setting. It is only questionably more sensitive and specific than other modalities. In addition, treatment would not be based on a PET scan alone (other imaging and biopsies would be needed).

Physician 1: The patient is a 63-year-old female first diagnosed with breast cancer in early 1999. At that time she underwent mastectomy, followed by adjuvant chemotherapy with Adriamycin and Cytoxan, then taxotere. She was then well for five years when she developed recurrence in a supraclavicular node, which was completely resected. No other metastatic disease was found, and she has been receiving further chemotherapy. It is proposed that she be treated with high dose chemotherapy and autologous stem cell rescue. The use of this treatment is the subject of this appeal. For many years, the use of high dose chemotherapy (HDC) with peripheral stem cell transplant (PSCT) has been a very controversial treatment in breast cancer. Primarily, it has been studied in two very separate situations.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving breast cancer, then check the rights and deadlines that apply to your plan.