Leukemia: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for skilled nursing services of a registered nurse in the home health or hospice setting-49 units (G0299).Findings: The physician reviewer found that incidence of childhood cancer in the United States is increased by 0.6%/year. The most common cancer type in childhood is leukemia. Advances in the treatment of childhood cancer have shown an improvement in prognosis in recent years. Therefore, the survivor rate of children with cancer has risen in the past decade. Children with cancer have many problems and symptoms related to disease and treatment. Therefore, planning and implementation of individualized family centered nursing interventions to improve health status in these children are important.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a special heart scan and laboratory test. With regard to the complete echocardiogram with Doppler flow, echocardiograms are reserved for high-risk patients after transplant. This patient is considered high risk due to a pre-existing reduced ejection fraction, graft versus host disease, and prior anthracycline chemotherapy. For such patients, a complete echocardiogram with Doppler is recommended at intervals including approximately 3 and 12 months post-transplant. The patient is approximately 12 months post-transplant.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication Iclusig (ponatinib) HCl tablet 15 mg for treatment of the enrollee’s B-cell acute lymphocytic leukemia (BCR-ABL), Philadelphia chromosome-positive. Findings: The physician reviwer found that the submitted documentation fails to demonstrate the medical necessity for the requested medication in this clinical setting. The decision to change therapy from Dasatinib to Iclusig (ponatinib) was based on the treating provider’s assessment that Dasatinib was a treatment failure (resistance). However, according to the records, this patient was actually responding well to Dasatinib and did not exhibit signs of resistance. The medical record noted that the BCR-ABL had gradually decreased from a 5.2 log to 0.09 log.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing. The World Health Organization (WHO) guidelines for the diagnosis of polycythemia vera require that a patient fulfill three major criteria or two major criteria and one minor criteria. According to the WHO guidelines, major criteria include (1) a hemoglobin level of more than 16.5 g/dL, or a hematocit level over 49%, or increased red cell mass, (2) a bone marrow biopsy showing hypercellularity for age with trilineage growth including prominent erythroid, granulocytic, and megakaryocytic proliferation with pleomorphic, mature megakaryocytes, and (3) the presence of JAK2 V617F or JAK2 exon 12 mutations. Minor criteria include a subnormal serum erythropoietin (EPO) level.

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 leukemia was denied, the published record says the denial is worth fighting.