Malignant Melanoma denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A female patient has requested reimbursement for the porcine xenograft wound treatment that was utilized during surgery. The Health Plan has denied this request and reported that the services at issue were investigational for the treatment of the enrollee, who was status post excision of malignant melanoma. A review of the record indicates that the enrollee was diagnosed with malignant melanoma of the right foot. Per the records, excision was performed. The provider noted that the graft was required due to the size of the surgical defect and tightness of the closure on this anatomical location. Per the provider, the surgical defect was partially closed, with the remainder of the defect filled with a porcine xenograft to facilitate secondary healing.

A 64-year-old female enrollee has requested authorization and coverage for whole body PET scan. Findings: Two physician reviewers found that this patient was diagnosed with malignant melanoma. The patient underwent resection of the lesion on her back in addition to a left axillary lymph node biopsy. The patient had a negative MRI of the brain and PET scan. A CT scan of the lower extremities showed multiple subcutaneous densities. The patient underwent a second biopsy of lesions on her back which showed malignant melanoma in situ. Re-staging PET scans have been requested every four to six months. The patient has requested authorization for a whole body PET scan. The National Comprehensive Cancer Network (NCCN) guidelines advocate for the use of PET studies every 6 to 12 months for the first 5 years after treatment for melanoma.

Where the denial was upheld

Physician 1: This patient is a 51-year-old male diagnosed with malignant melanoma of the scalp in June 2002, treated surgically. In July 2003 he was found to have involvement of the lymph nodes in his neck, which were resected. This was followed by one year of interferon therapy. In May 2005 the patient was found to have involvement of his spleen and left hilar area; he was treated with biochemotherapy, including Temodar, platinol vinblastine, interleukin-2 (IL-2), and interferon. There was no response. He was then treated with an experimental agent, MDX-010, with again, no response. He next was treated with chemotherapy including carboplatinum, Taxol, and sorafenib, again with progression of disease.It is now proposed that the patient be treated with high dose IL-2 along with taurolidine. This treatment is the subject of a clinical trial in Dublin, Ireland.

Nature of Statutory Criteria/ Case Summary: The enrollee requested reimbursement for DecisionDx-Melanoma test. The enrollee was diagnosed with malignant melanoma of the right mid upper back. He was seen for evaluation of moles on his trunk that had been present for years. He has a family history of melanoma. An irregular brown macule was noted on his right mid-upper back and a shave biopsy was done. Findings: The physician reviewer found that the dermatopathology report showed malignant melanoma, superficial spreading type, arising in association with a nevus,without ulceration, peripheral margins involved. A complete excision of the lesion was performed. The pathology report showed dysplastic nevus with free margins. The DecisionDx-Melanoma test result was Class 1 Sub-class: 1A, which is associated with a low risk of recurrence within five years.

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 malignant melanoma, then check the rights and deadlines that apply to your plan.