Lung Cancer denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 53-year-old female with the diagnosis of two primary cancers, lung and ovarian. On 1/9/04, the patient had a percutaneous biopsy of a left supraclavicular mass, which showed a poorly differentiated squamous cell carcinoma, probably lung in origin. On 2/1/04, the patient underwent a total abdominal hysterectomy and a bilateral salpingo-oophorectomy (TAH-BSO), which revealed a serous cystadenocarcinoma, grade III. A positron emission tomography (PET) scan was performed on 2/24/04, which showed widespread metastatic disease involving left supraclavicular area, mediastinum, right lung, retroperitoneum, and pelvis. A CT scan was performed on 5/3/04 and was compared to the prior exam of 1/14/04. There had been the interval TAH-BSO and marked improvement in the pulmonary nodules and mediastinal and retroperitoneal adenopathy.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam therapy. The use of proton therapy is standard for certain body sites when normal tissue dose constraints cannot be met by other radiation techniques. In the case of lung cancer, proton therapy is recommended to spare areas of normal lung. Proton beam has unique properties compared to photon beam in its ability to deposit radiation dose. Oftentimes, fewer proton beams can be utilized to achieve a dose distribution similar to a standard photon beam, which potentially results in fewer areas of low scattered radiation dose. Normal tissue sparing is particularly important in lung cancer patients as they typically have less than average functional lung volume. Toxicities such as radiation pneumonitis and esophagitis can cause significant morbidities.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stereotactic body radiation therapy for treatment of the enrollee who has a history of lung cancer. Findings: The physician reviewer found that The requested services are not medically necessary for treatment of this patient’s medical condition. SBRT, delivering high fractional doses in 4-5 fractions, is an established approach for the treatment of discrete lesions from cancer. SBRT systems use fiducials, bony anatomy or external markers as a coordinate system to map the delivery of radiation to increase the precision and accuracy of radiation delivery. SBRT can be considered in select patients with oligometastatic bone metastases.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the FoundationOne test for evaluation of the enrollee’s left hilar mass. Findings: 2/3 of the physician reviewers found that Foundation One is a molecular assay that explores the mutations of an individual patient’s cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the Foundation One assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment.

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 lung cancer, then check the rights and deadlines that apply to your plan.