Cutaneous Melanoma denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a myPath melanoma assay.Findings: The physician reviewer found that The myPath melanoma assay is a gene expression profiling (GEP) test used to classify melanoma pathology specimens by risk of recurrence. As a prognostic test for cutaneous melanoma, it is considered investigative. However, it may be beneficial when used to classify atypical spitz or spitzoid tumors, helping to differentiate benign nevi from cutaneous melanoma, including atypical Spitz tumors. Swetter and colleagues state, “Diagnostic molecular techniques are still largely investigative and may be appropriate as ancillary tests in equivocal melanocytic neoplasms, but they are not recommended for routine diagnostic use in cutaneous melanoma.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test DecisionDX-Melanoma performed. Findings: The physician reviewer found that the patient is diagnosed with cutaneous melanoma on the mid-upper back. Histopathologically, the tumor was Clark level III and extended to the Breslow depth of 0.4 mm. The DecisionDX-Melanoma assay performed showed class 1 molecular signature, which is associated with a low risk of near term (within five years) metastatic disease. The patient requested reimbursement for the DecisionDX-Melanoma assay performed. The Health Plan denied reimbursement for the testing and noted that the services at issue were considered investigational for evaluation of the patient’s cutaneous melanoma. There is a lack of support in the medical literature for the services at issue in this clinical setting.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDX-Melanoma Class I investigational for the evaluation of the enrollee’s malignant melanoma. Findings: Three physician reviewers found that the patient was diagnosed with a cutaneous melanoma in the skin located in his epigastric region. At that time he was found to have an invasive melanoma, non-ulcerating, Clark Level II, Breslow thickness 0.35, and no mitoses were seen. The provider recommended tissue sampling in an effort to determine the patient’s prognosis. The patient’s tissue was sent for DecisionDX- Melanoma Class I assay and testing. The patient requested reimbursement for the testing. The Health Plan has denied reimbursement because the Health Plan deems the services at issue as experimental/investigational for the evaluation of this patient.

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