Head Neck Throat denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospitalization services. In this case, the patient underwent total glossectomy and laryngectomy and received subsequent inpatient postoperative care. While major ablative procedures such as total glossectomy and laryngectomy are becoming less common in the treatment of primary head and neck malignancies, their role is still very important in the treatment of recurrent disease, which was the indication in this case. Recovery from such life altering surgery is inherently complex and universally requires inpatient admission for close monitoring and administration of requisite multi-disciplinary services. Head and neck cancer patients that undergo ablative surgery suffer physical detriments in the form of global de-conditioning and direct limitations in function at the surgical sites.

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for proton beam therapy. Proton beam has unique properties compared to standard x-ray, or photon, therapy in its ability to deposit radiation dose. Fewer proton beams can be utilized to achieve a dose distribution similar to a standard x-ray beam resulting in less radiation exposure to critical organs. Proton beam is currently utilized and strongly indicated in a setting where severe toxicities would result if normal tissue constraints cannot be met by standard radiation. There is also strong evidence demonstrating decreased acute treatment toxicity with proton beam therapy in head and neck radiation treatments.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for laboratory test [Oncology (oropharyngeal or anal), evaluation of 17 DNA biomarkers using droplet digital PCR (ddPCR), cell-free DNA, algorithm reported as a prognostic risk score for cancer recurrence]. The National Comprehensive Cancer Network (NCCN) guidelines indicate that the performance of various plasma cell-free HPV deoxyribonucleic acid (DNA) detection assays for a diagnosis of HPV-positive oropharyngeal cancer against a gold standard of E6/E7 messenger ribonucleic acid (mRNA) detection is unknown. Sensitivity and specificity against p16-immunohistochemistry (IHC) are approximately 90% and 94%, respectively.

The enrollee is requesting reimbursement for proton radiation beam therapy. The enrollee has squamous cell cancer of the left tonsil that has spread to his left neck lymph nodes. He initially presented to his primary care physician with swelling of the left neck. An ultrasound showed two enlarged submandibular lymph nodes suspicious for malignancy. A left neck lymph node biopsy showed keratinizing squamous cell carcinoma. A computed tomography (CT) scan of the neck showed heterogeneous enlarged lymph nodes in the jugulodigastric chain. It was determined his condition was likely occult oropharyngeal primary. The enrollee’s radiation oncologist notes that proton therapy may be used to reduce the dosage impact to uninvolved salivary glands, oral cavity, and other normal tissues, reducing short and/or long-term toxicity. The enrollee began proton radiation beam 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 head neck throat, then check the rights and deadlines that apply to your plan.