Lung: when insurers say no, reviewers often say yes

Where the denial was overturned

Physician 1: The patient is a 68-year-old female first diagnosed with bronchoalveolar carcinoma of the lung in August 2004. She was originally treated what Iressa, and then with Tarceva. In April 2006 she was found to have progressive disease and began chemotherapy with carboplatin and Taxol. The patient’s provider recommends that Avastin be added to this chemotherapy regimen. The Health Plan denied the requested authorization based on a determination that the therapy is experimental/investigational in this clinical setting.Avastin is a member of a relatively new class of drugs, which presumably interfere with tumor angiogenesis. It is similar in some ways to both Iressa and Tarceva. Avastin has been approved for use, in combination with chemotherapy, in colon cancer and is being actively studied in other cancers.

Physician 1: The patient is 60-year-old male with a complicated medical history who has been diagnosed with metastatic, stage IV, non-small cell adenocarcinoma of unknown primary origin. His chemotherapy regimen includes Taxotere and carboplatin. As available evidence suggests the lung may be the primary site of his cancer, his provider has recommended the addition of Avastin. The Health Plan has determined that the efficacy of Avastin is unproven in this clinical setting and therefore has denied coverage for the therapy. The use of Avastin in this setting is apparently based on the large, recently reported study cited above. Though it is only one study, it included 850 patients with good randomization between the group treated with chemotherapy alone versus the group treated with chemotherapy and Avastin.

Where the denial was upheld

Physician 1The patient is a 59-year-old man who had lung surgery in August 2002. At that time he had resection of his right lower lobe, revealing a poorly differentiated squamous cell cancer, 3cm in size, with negative nodes. In March 2003, the patient developed two areas of endobronchial recurrence. He then underwent chemotherapy with little response. An endobronchial biopsy in June 2003 again was positive. The patient was treated with external beam radiation therapy from June 2003 to July 2003. Repeat bronchoscopy in September 2003 showed persistence of one of the lesions and the patient was treated with local brachytherapy to this lesion.In December 2003, CT scan of the chest demonstrated two new pulmonary nodules, each about 1cm in size. One was at the right lung base and the other was in the superior segment of the right lower lobe.

Physician 1: This patient is a 62-year-old female who was diagnosed with a right upper lobe 5 cm mass in February 2004. First-line treatment was surgery. This was followed by adjuvant treatment consisting of chemotherapy, DDP and navelbine with radiation therapy. The patient experienced a relapse one year out and received second-line chemotherapy with gemcitabine and Taxotere. This was followed with Iressa and then Tarceva. The patient has requested authorization and coverage to add Avastin to her treatment plan. The Health Plan has denied this request indicating Avastin has not been shown to be effective for treatment of the patient’s condition.The Health Plan’s denial should be upheld. The data for the combination of therapies involved in this case are very sparse and are not based on randomized controlled trials.

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