Esophagus denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee’s representative has requested reimbursement for intensity-modulated radiation therapy (IMRT) and special physician consultation. IMRT is often utilized to treat certain body sites when normal tissue dose constraints cannot be met by other radiation techniques. In the case of lung and pelvic area treatments, IMRT is helpful to spare adjacent critical organs. This is particularly important in patients who have been receiving chemotherapy as well. Toxicities such as radiation pneumonitis, esophagitis, and bowel perforation can cause significant complications leading to hospitalization. The National Comprehensive Cancer Network (NCCN) guidelines have outlined the importance of treating the primary target in a safe manner while respecting the established dose constraints of surrounding organs.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for FoundationOne CDx genomic testing. Adenocarcinoma of the esophagus that has metastasized carries a poor prognosis. Next-generation sequencing (NGS) offers the opportunity to assess numerous mutations simultaneously, along with other molecular events such as amplification, deletions, tumor mutation burden, and microsatellite instability (MSI) status. The U.S. Food and Drug Administration (FDA) approves the use of several targeted therapeutic agents, including trastuzumab, pembrolizumab/nivolumab, for the treatment of esophageal and esophagogastric junction cancers. The National Comprehensive Cancer Network (NCCN) guidelines for esophageal and esophagogastric junction cancers recommend the use of NGS for locally advanced esophageal cancer.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam radiation therapy (PBRT). The records provided for review document that this patient has a history of metastatic esophageal cancer with small pulmonary nodules and lesions in his spine and liver after treatment with chemotherapy. The patient’s provider has recommended palliative proton beam radiotherapy due to the presence of metastatic disease. As noted in the medical literature, during palliative radiotherapy for esophageal cancer or bone metastases, the standard of care includes treatment with photons. There is a lack of clinical data to suggest that proton beam radiotherapy is associated with improved outcomes or decreased toxicities compared to treatment with photons.

Nature of Statutory Criteria/ Case Summary: The enrollee requested coverage for Proton Beam Radiation Therapy for newly diagnosed moderately differentiated adenocarcinoma of the gastroesophageal junction. History included reflux esophagitis and Barrett’s esophagus. The enrollee indicated being in good health until he noticed having difficulty eating, with a sensation of food getting stuck, leading to substantial weight loss. PET/CT showed no metastatic disease and a mass in the distal esophagus. Medical oncology recommended treatment including concurrent chemotherapy with radiotherapy, followed by surgical resection. The enrollee presented to Radiation Oncology regarding the role of proton therapy in the treatment of his cancer. After discussion, the patient opted for the proton beam radiation therapy.

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