Invasive Ductal Carcinoma: when insurers say no, reviewers often say yes

Where the denial was overturned

Physician 1: The patient is a 53-year-old woman diagnosed with infiltrating lobular carcinoma in July 2000 and subsequently diagnosed with ipsilateral invasive ductal cancer in January 2005. She was found to have a 1.4cm tumor with positive estrogen receptors and negative axillary nodes. The patient underwent an Oncotype DX assay and had a recurrence score of 17 which predicts an 11% chance of recurrence if the patient is not treated with chemotherapy. On that basis, the decision was made to forgo adjuvant chemotherapy.

Physician 1: The patient is a 43-year-old woman who recently was diagnosed with stage I breast cancer. She underwent a diagnostic breast biopsy in October 2004, which revealed a 6 mm intermediate grade (grade II) invasive ductal carcinoma (DCIS). The tumor is ER positive, PR positive, and Her2/neu 2+ (but FISH negative). She underwent a second excision for a positive DCIS margin as well as a sentinel lymph node biopsy in November 2004. This revealed additional DCIS, but with a narrowly negative margin. Two sentinel lymph nodes were excised, both are negative by routine histopathology as well as immunohistochemistry. A post-op MRI did not reveal any additional disease. The patient’s family history is important in that she is of Ashkenazi Jewish heritage.

Where the denial was upheld

Physician 1: The patient is a 45-year-old woman diagnosed with breast cancer in March 2005. At that time she was found to have a 7.1 cm invasive ductal carcinoma, and she was begun on aggressive chemotherapy with TAC. This ended in June 2005, at which time she had a mastectomy. At that surgery, it was determined that she had had an excellent response to the chemotherapy, with minimal cancer in the breast. Six nodes, however, were found to be positive. The patient had two further cycles of chemotherapy since the surgery, and it is now proposed that she be treated with high dose chemotherapy (HDC) with autologous stem cell transplant. Authorization and coverage for the proposed treatment has been denied by the Health Plan as investigational.The use of HDC in the various stages of breast cancer has been a very controversial topic for many years.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy for treatment of the enrollee’s Stage IIA invasive ductal carcinoma. Findings: All three physician reviewers found that the request for proton beam therapy is not likely to be more beneficial for treatment of the patient’s medical condition than any available standard therapy. There is a lack of peer-reviewed literature demonstrating that proton therapy affords a benefit over other standard available therapies such as photon therapy for breast cancer. While proton therapy will almost always appear superior to photon therapy dosimetrically due to its Bragg peak, this does not necessarily translate into a clinical benefit.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for invasive ductal carcinoma was denied, the published record says the denial is worth fighting.