Lymphoma: when insurers say no, reviewers often say yes

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient is a 59-year-old female with a history of hyperlipidemia, anxiety, and hypothyroidism who presented with a chronic cough for four months. Findings: The physician reviewer found that A chest x-ray demonstrated bilateral large perihilar masses. A computed tomography (CT) scan of the patient’s chest/abdomen/pelvis was subsequently obtained on 9/9/20, which demonstrated a large heterogeneously enhancing anterior mediastinal mass, mediastinal and right internal thoracic chain adenopathy, interlobular septal thickening in the anterior portions of both upper lobes concerning for lymphangitic spread of tumor, and a large heterogeneously enhancing pelvic mass. The patient was referred to an oncologist given the high suspicion for cancer who subsequently ordered a biopsy as well as a PET scan for further work up.

Nature of Statutory Criteria/Case Summary: The provider noted that the patient initially underwent treatment with a complete response but has now relapsed with central nervous system (CNS) involvement. The patient was being treated with methotrexate and rituximab. The treatment plan included methotrexate in combination with temozolomide and rituximab. The patient underwent a left orchiectomy and treatment with cyclophosphamide and rituximab. The patient subsequently underwent right orchiectomy and treatment with intrathecal methotrexate. The patient has requested authorization and coverage for Temodar (temozolomide). The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Temodar (temozolomide) is medically necessary for the treatment of the patient’s medical condition.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy (36 Gy in 18 fractions). Proton beam radiation therapy is a specialized form of radiation therapy that utilizes protons to target and destroy cancer cells. While it can be highly effective for certain types of cancers, its use in extremity treatment is not routinely recommended. The primary goal of cancer treatment in the extremities is to achieve local control and preserve the function of the limb. Conventional radiation therapy techniques, such as intensity-modulated radiation therapy (IMRT) or three-dimensional (3D) conformal techniques can effectively achieve these objectives while minimizing the risk of complications.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy (PBRT) (CPT 77520 x 30), (CPT 77522 x 30), (CPT 77523 x 30), (CPT 77525 x 30) and (CPT 76498). Current evidence does not endorse the routine use of PBRT in the treatment of Hodgkin lymphoma. The standard treatment of Hodgkin lymphoma is with photon techniques utilizing intensity modulated radiation therapy and image guidance using breath hold techniques, which can minimize dose to the heart and lungs. There is insufficient data to suggest that PBRT would significantly improve the sparing of the spinal cord, heart, and/or lungs compared to standard photon techniques. In the majority of cases, IMRT is able to achieve an acceptable cardiac and lung dose.

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