Glioblastoma Multiforme denials in California external review

What the reviewers wrote

Where the denial was overturned

The enrollee requested reimbursement for FoundationOne CDx comprehensive genomic profiling test. The enrollee has glioblastoma multiforme (GBM) and initially presented to her physician with a rapid, progressive neurologic decline over the course of four to five days. Diagnostics revealed a brain mass with intra-tumor hemorrhage. She underwent sub-total tumor resection. Pathology was significant for GBM. Her symptoms improved after surgery and the plan was for the initiation of chemo-radiation therapy. The neuro-oncologist determined additional testing of the tumor tissue was needed to discover any further genomic alterations. The FoundationOne CDx comprehensive genomic profiling test (CPT code 0037U) was performed.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Tempus xT assay gene panel. Findings: The physician reviewer found that Central nervous system tumors are classified by the World Health Organization (WHO) based on their proliferative potential, morphology, and molecular genetics and are conferred grades I through IV. Anaplastic astrocytoma (WHO grade III) and glioblastoma multiforme (WHO grade IV) are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. Glioblastoma multiforme is a fatal disease that is incurable. Chemotherapy may prolong survival but the gains are modest. Standard therapy is to resect the glioblastoma multiforme maximally followed by treatment with temozolomide. Median survival for patients is 12 months from the date of diagnosis.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergent services from through. The Health Plan has denied this request indicating that the requested services are not emergent services for treatment of the enrollee’s medical condition. A review of the records indicates a diagnosis of a stage IV glioblastoma multiforme (GBM) brain tumor for this enrollee. The enrollee presented with loss of speech, difficulty reading and writing, and loss of vision, and cognition was rapidly declining. The enrollee is reported to have had intraoperative brain mapping with partial resection surgery of a very large tumor, which was causing brain swelling and mass effect, and related services during the dates of services at issue. A magnetic resonance imaging (MRI), is reported to have shown several areas of tumor in the left parietal lobe.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing performed for evaluation of the enrollee’s glioblastoma multiforme. Findings: 2/3 of the physician reviewers found that the FoundationOne assay is a molecular assay that explores the mutations of an individual’s cancer cells. The hope of course is that the assay will identify a specific mutation or target which could guide the clinician as to which chemotherapeutic agent would be useful in treatment. However, at this time, there is a lack of convincing evidence that the assay adds to our decision making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the potential value of molecular profiling, none of which have been convincing as to the efficacy of these analyses.

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