Liver: when insurers say no, reviewers often say yes

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.

Physician 1: The patient is a 54-year-old female diagnosed with breast cancer in 2004, treated with mastectomy, chemotherapy, and localized radiation. At present, she has been diagnosed with isolated liver metastasis with documented growth despite chemotherapy. According to the submitted notes, the treating oncologist has identified one main lesion putting pressure on the nearby biliary ducts and recommended a consultation for consideration of stereotactic body radiosurgery. The Health Plan indicates stereotactic body radiosurgery is considered investigational and therefore, is not a covered benefit.Treatment options in cases such as this include clinical trial with Phase 1 chemotherapeutic drugs, ablative treatment (radiofrequency, cryotherapy, microwave, or high dose rate brachytherapy), chemoembolization, radiation therapy (conformal or stereotactic), or supportive care.

Where the denial was upheld

Physician 1: The patient is a 44-year-old premenopausal female. Shortly after the birth of her last child she experienced increasing weight loss, abdominal pain and increasing night sweats. Evaluation of her symptoms revealed Stage IV disease believed to be of gastrointestinal (GI) origin, though the exact primary was debatable. The patient sought treatment through her Health Plan and was advised that treatment was palliative in nature. The patient then sought treatment at the Burzynski clinic in May 2004. She was advised to consider a combination of agents approved for the treatment of GI primary, agents not FDA approved for the treatment of a GI malignancy (i.e., Herceptin), and nutritional supplements plus the utilization of sodium phenylbutyrate.The patient has experienced a questionable response, but has experienced significant thrombocytopenia.

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.

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