Cervical denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 58-year-old female who had surgical treatment of her cervical cancer in August 2003 and has been followed by her gyn-oncologist who noted that follow-up exams have shown a firm area at the vaginal apex. On 12/13/04, the area was noted to be more nodular though still small. The patient’s provider is concerned that this change represents recurrent tumor. Therefore, the patient’s provider has recommended a FDG-PET scan to characterize its metabolic activity. If it is “cold” (low), tumor is most unlikely. If it is “hot” (high), this is quite specific for tumor in this setting. The Health Plan has denied coverage for a PET scan on the basis it is considered investigational in this setting. The use of PET scanning in this clinical setting is within the standard of current practice of oncology, gynecology, and nuclear medicine.

Nature of Statutory Criteria/Case Summary: The representative of the patient has requested reimbursement for air ambulance and ground ambulance transportation services for treatment of the enrollee’s stage III cervical cancer. Findings: The physician reviewer found that Air ambulance is considered medically necessary under certain circumstances. Emergency circumstances include when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport, when the time needed to transport the patient by land poses a threat to a patient’s survival, or when the proper equipment needed for the patient is not available on a land ambulance. Air ambulance may be appropriate to transport a patient from one facility to another if the patient requires a higher level of care than the sending facility can provide.

Where the denial was upheld

Findings: The physician reviewer found that a patient has requested authorization and coverage for an interleukin-23 (IL-23) inhibitor combined with the approved Keytruda.The records indicate that this patient presents with a history of cervical adenocarcinoma. The patient has been treated with external beam radiation therapy (EBRT), cisplatin, and intracavitary brachytherapy, as well as Keytruda. The patient has requested the addition of an IL-23 inhibitor to be taken in combination with Keytruda. However, there is a lack of support in the medical literature or guidelines for this combination in the treatment of this patient’s cervical adenocarcinoma. The U.S. Food and Drug Administration (FDA) has not approved IL-23 inhibitors for the treatment of patients with recurrent cervical cancer.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for fertility preservation services (stimulation and removal of her oocytes, inseminating the oocytes, and the cryopreservation of the embryo). Researchers found that fertility preservation in both female and male oncological patients is now possible and should be integrated as part of the oncological healthcare. In this case, the patient had negative margins from the initial excisional procedure. According to medical literature, the rates of residual AIS, recurrent AIS, and concomitant or subsequent invasive adenocarcinoma in this clinical setting are approximately 2.6%, 20%, and less than one percent, respectively.

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 cervical, then check the rights and deadlines that apply to your plan.