Glioblastoma denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is an 18-year-old young man first noted to have some numbness in his right arm in November 2005. It progressively worsened over the next few months, and by April 2006 he had right arm numbness and weakness along with neck pain. An MRI of the spine revealed a 3.9 x 1.2 x 1.4 cm enhancing lesion at C2 to C4. The lesion was partially excised in early May 2006. The final histopathologic diagnosis is glioblastoma (GBM). The June 2006 spine MRI shows no change in the size of the enhancing lesion (suggesting that less was removed than thought or that the tumor has grown back to its original size). The patient improved after the operation, but according to his mother, his neurologic symptoms (tingling and weakness) are returning. The patient’s providers have recommended Avastin and CPT-11 as initial therapy.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Intensity-modulated radiation therapy (IMRT) (30 units/visits).IMRT offers several significant advantages over standard 3-dimensional conformal radiation therapy (3D-CRT) for the treatment of glioblastoma. One of the primary benefits is improved target coverage. Studies have consistently shown that IMRT provides better coverage of the planning target volume (PTV) compared to 3D-CRT. This enhanced coverage allows for more precise delivery of the prescribed radiation dose to the tumor while minimizing exposure to surrounding healthy tissues.

Where the denial was upheld

Physician 1: The patient is a 51-year-old man diagnosed with glioblastoma in July 2004. He was treated with surgery, radiation therapy, and chemotherapy. The patient underwent further surgery in January 2005 followed by treatment with interleukin-13 pseudomonas exotoxin. An MRI performed in September 2005 demonstrated progressive disease and it has been recommended that the patient be treated with CPT-11 and Avastin. The Health Plan has denied authorization for Avastin on the basis the therapy is considered investigational in this clinical setting.The included evidence includes two abstracts/papers that have been submitted for publication. One of these papers noted that in 21 patients treated with CPT-11 and Avastin, 9 had some sort of response. This was suggestive of an improved response to the combination when compared to CPT-11 alone.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tibsovo. The use of next-generation sequencing (NGS) panel testing as a means of selecting anti-cancer therapy in advanced cancer has been progressing over the past few years and is an area of active research with ongoing studies. The concept of this approach is that all cancers are unique and that each cancer has a specific individual molecular driver which can be identified using this testing. Once identified, specific therapy can be given to the patient that directly treats their tumor. In this case, the patient was originally diagnosed with anaplastic astrocytoma. Notes dated 6/28/22 reported that the patient had a recurrence that was categorized as glioblastoma, World Health Organization (WHO) grade IV.

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