Meningioma denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that The patient has requested authorization and coverage for open magnetic resonance imaging (MRI) of the brain. One of the major impediments to successful MRI scanning is claustrophobia. Claustrophobic patients may feel frightened and experience feelings of suffocation and confinement in relatively tight spaces like the bore of an MRI scanner. Nguyen and colleagues report that claustrophobia, other anxiety reactions, excessive motion, and other unanticipated patient events in MRI may delay or preclude diagnostic-quality imaging. The authors further note that open configured MRI systems may facilitate interventional procedures and/or increase patient comfort. An open MRI may decrease anxiety and improve acceptability in claustrophobic patients compared with a closed bore MRI.

A 63-year-old female enrollee has requested NovoTTF treatment for treatment of her meningioma. Findings: Two physician reviewers found that meningiomas are brain tumors arising from the dura mater of the brain. They are typically slow growing and amenable to resection if pathologically classified as Grade I. However, Grade II and Grade III meningiomas have higher proliferative rates and are usually only partially resected. In 2011, the U.S. Food and Drug Administration approved the NovoTTF-100A device to deliver alternating electrical fields to treat recurrent glioblastoma multiforme (GBM). The approval was based on a randomized clinical study where 237 patients were treated with either NovoTTF versus best standard of care chemotherapy (including bevacizumab) (Stupp et al). There is also a case report of a long term survivor with recurrent GBM treated with NovoTTF (Villano et al).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy (including CPT code 77525 x 35 proton beam radiation therapy; CPT G6002 x 35 Dailey stereoscopic; CPT 77301 x 1 IMRT plan; CPT 77300 x 10 MU calculations; CPT 77336 x 7 complex treatment device; CPT 77427 x 7 physician treatment management; CPT 31575 x 1 laryngoscopy; CPT 77263 x 1 physician clinical planner; CPT 77470 x 1 special treatment procedure; CPT 77334 x 2 custom immobilization; CPT 77370 x 1 physics consult; and CPT 70553 x 1 magnetic resonance imaging (MRI) brain with and without contrast).Findings: The physician reviewer found that meningiomas, standard treatment options are surgery, conventionally fractionated radiation or stereotactic radiosurgery.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for proton beam radiation therapy (PBRT). Proton therapy, while offering precise targeting capabilities that minimize damage to surrounding brain tissues, may not present a clear advantage over standard treatments for patients with meningiomas according to current national guidelines and available evidence. Health authorities typically recommend surgery and/or photon-based radiotherapy, such as intensity-modulated radiation therapy (IMRT), as the standard care for meningiomas, especially when considering the treatment of benign or low-grade tumors. The precision of proton therapy is theoretically beneficial for reducing side effects by sparing healthy tissue adjacent to the tumor.

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