Hepatocellular Carcinoma denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 62-year-old man who was diagnosed with a hepatocellular carcinoma by MRI in April 2004 with extensive left portal vein involvement. The patient’s provider determined that surgery was not an option for the patient and systemic chemotherapy was of limited value. Non-surgical ablative therapy was also ruled out. The patient’s provider recommended transcatheter arterial chemoembolization (TACE). The Health Plan has denied coverage for TACE indicating it is considered experimental for treatment of the patient’s condition. Review of the submitted records indicates the patient has had two TACE treatments. The first was in May 2004 and the second was in June 2004. Follow-up MRI of the liver has shown diminution of the size of the left portal vein mass. The patient remains asymptomatic as to abdominal pain and distension, nausea and vomiting.

The patient is a 66-year-old man with cirrhosis and a single hepatocellular carcinoma of the left lobe of the liver. He has a history of severe portal hypertension secondary to his cirrhosis and has had esophageal variceal bleeding. The patient underwent two banding procedures for his esophageal varices without recurrent upper gastrointestinal bleeding. In November 2003, the patient was found to have two hepatic masses on CT scan. By report, a biopsy was performed that documented hepatocellular carcinoma. An MRI was performed on 2/4/04 that revealed only a single lesion in the left lateral segment, cirrhosis, and evidence of portal hypertension. There was no ascites noted.In March 2004, the patient’s surgeon recommended a transjugular intrahepatic portosystemic shunt (TIPS) procedure prior to surgical resection of the isolated hepatoma.

Where the denial was upheld

Physician 1: This patient is a 62-year-old male diagnosed with hepatocellular carcinoma in July 2004. The tumor was resected and no further treatment was provided at that time. The patient did well until November 2005 when he was found to have an abdominal nodule positive for recurrence. CT and PET scans revealed multiple lung metastases. He was treated with an investigational agent, which did not halt the progression of his disease. In April 2006 the patient began chemotherapy with cisplatin, 5-FU, interferon and Avastin. The patient’s request for reimbursement and prospective authorization for Avastin and interferon was denied by the Health Plan citing the experimental/investigational nature of the therapy.Overall chemotherapy has been of little benefit in metastatic hepatocellular carcinoma.

Physician 1: The patient is a 58-year-old male with a history of hepatocellular carcinoma. He underwent liver resection and three chemoembolization treatments. He was then evaluated for experimental chemotherapy and was found ineligible. The patient was seen by a surgeon and was found unresectable. A recent workup revealed progressive disease. It was then recommended the patient receive TheraSphere therapy. The Health Plan has denied authorization and coverage for the proposed therapy on the basis it is considered investigational.Review of the clinical evidence indicates recent CT and PET scans revealed bulky disease in both lobes of the liver and also some peritoneal implants. Though TheraSphere therapy has been recommended, it is not likely to have any effect on gross, bulky disease because it is a beta-omitting radiation treatment. Its depth of penetration is only a few millimeters.

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