Malignant Tumor denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Comprehensive genomic profiling test (FoundationOne CDx). As noted in the medical literature, the standard of care for patients with metastatic colon cancer includes testing for KRAS, NRAS, BRAF, HER2, and microsatellite instability (MSI). Per the National Comprehensive Cancer Network (NCCN) guidelines, this testing can be performed individually or as part of next-generation sequencing, which has the ability to detect actionable mutations. The American Society of Clinical Oncology (ASCO) recommends genetic testing on colon cancer tumors. Next-generation sequencing offers the advantage of identifying markers known to have targeted therapy as well as potential clinical trials. Given this patient’s metastatic disease, comprehensive molecular profiling was appropriate.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. Medical literature reports that irritant contact dermatitis is often caused by cumulative exposure to weak irritants, accounting for 80% of all cases of contact dermatitis, and may co-exist with atopic dermatitis and allergic contact dermatitis, with pruritus classically reported by these patients. Researchers note that systemic contact dermatitis refers to a skin condition where an individual who is cutaneously sensitized to an allergen will subsequently react to that same allergen or a cross reacting allergen via a different route. Per the authors, current treatment options include topical steroids and oral antihistamines for symptom relief and dietary avoidance to causative foods or metals. In this case, the patient presented with a pruritic rash.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for re-admission to inpatient skilled nursing facility level of care. Admission to a skilled nursing facility is appropriate for patients with conditions requiring observation, treatment plan evaluation, physician updating orders, and constantly available skilled nursing services. Skilled nursing services may include wound management, tracheostomy care, bowel and bladder training, tube feeding, and administering intravenous (IV) medications or medications that cannot be self-administered safely. Skilled nursing observation may include regularly monitoring vital signs, skin in the setting of wounds, and intake and output.

Findings: The physician reviewer found that an enrollee with a diagnosis of locally advanced invasive ductal carcinoma (IDC) of the left breast and nodal metastasis has requested reimbursement for the Guardant Reveal genomic blood test. The records indicate that this patient with breast cancer has a high risk of recurrence due to her nodal disease and hormone receptor negativity on pathology. Thus, close surveillance is warranted. However, there is a lack of data in the clinical medical literature and National Comprehensive Cancer Network (NCCN) guidelines to support a role for plasma-based circulating tumor cell (CTC) assays, such as the Guardant Reveal, for use during routine surveillance. Per the NCCN guidelines, the clinical use of CTC or circulating tumor DNA (ctDNA) in metastatic breast cancer is not yet included in disease assessment and monitoring.

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