Endometrial Cancer denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensity modulated radiation therapy (IMRTfor treatment of the enrollee’s uterine cancer. .Findings: Three physician reviewers found that upon review of available data, IMRT is likely more beneficial in treating this patient’s endometrial cancer than standard therapy consisting of three-dimensional conformal radiotherapy (3DCRT). Chen and colleagues reported that the main areas where IMRT benefits patients is decreased gastrointestinal toxicity and decreased marrow toxicity. For marrow toxicity, a multi-institutional phase II trial showed that bone marrow toxicity could be decreased with the appropriate IMRT planning parameters (Klopp, et al). Based on this support, the requested IMRT has a substantial advantage over 3DCRT in the treatment of endometrial cancer.

Nature of Statutory Criteria/Case Summary: An enrollee has requested a panel of genetic hereditary cancer tests (MyRisk `Colaris` testing) for evaluation of her further risk of cancer. Findings: Two physician reviewers found that this patient has both breast and endometrial cancer and a strong family history of breast cancer. She has tested negative for BRCA and pathology shows a low likelihood of Lynch syndrome. Panel testing is supported by the National Comprehensive Cancer Network (NCCN) guidelines for patients such as in this case. There is also a role for multi-gene testing in individuals who have tested negative (indeterminate) for a single syndrome, but whose personal or family history remains strongly suggestive of an inherited susceptibility. All told, this patient is likely to benefit from the panel of genetic hereditary cancer tests with MyRisk.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for alternative surgical positioning, without laying the patient flat and without inverting the patient, during total hysterectomy with bilateral salpingo-oophorectomy surgery. Laparotomy, laparoscopic, and robotic hysterectomy are all surgical approaches for the removal of the uterus. Several factors should be considered in determining which approach to select, including the indication for the hysterectomy, the size and position of the uterus, the presence of other pelvic pathologies, patient factors, and surgeon expertise. Laparotomy involves a larger abdominal incision and is generally reserved for situations when laparoscopy is not feasible. Laparoscopic hysterectomy is minimally invasive and is associated with a shorter hospital stay, less postoperative pain, and faster recovery.

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for Foundation One gene testing for evaluation of the enrollee’s endometrial cancer. Findings: The physician reviewer found that Foundation One assay explores the mutations of an individual’s cancer cells. The hope is that the assay will identify a specific target which could inform the clinician as to what chemotherapeutic agent would be useful. Thus far, however, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have offered convincing evidence of the efficacy of this approach.

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