Metastatic Breast Cancer denials in California external review
In the California DMHC record, independent physician reviewers decided 82 published external-review cases involving metastatic breast cancerand overturned the plan’s denial in 50%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for metastatic breast cancer
| Treatment | Decisions | Overturned |
|---|---|---|
| Avastin | 13 | 23.1% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 51 | 45.1% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 31 | 58.1% |
What the reviewers wrote
Where the denial was overturned
Physician 1This patient is a 53-year-old female who has breast cancer metastatic to her lungs. She is status post multiple chemotherapeutic regimens. She is currently stable. She has requested authorization for positron emission tomography (PET) scanning to monitor her clinical situation. The Health Plan has denied the patient’s request on the basis that PET scanning is considered investigational for this indication.The patient has metastatic breast cancer, status post resection and has undergone multiple courses of chemotherapy. She requires careful follow-up for evidence of recurrence. Multiple modalities exist including PET and CT scans. PET scanning has been approved by the Food and Drug Administration for use in cases of breast cancer. Given that the patient has been utilizing PET scanning to follow recurrence/response, she should remain with the current modality.
Physician 1: The patient is a 47-year-old female who was first diagnosed with breast cancer in 1998. She was initially treated with adjuvant chemotherapy including Adriamycin, Cytoxan, and Taxol. This was followed by five years of tamoxifen. In 2004 the patient was found to have bone metastases and was treated with other hormonal therapies. In April 2006 she was found to have progressive disease in bone, and liver and her oncologist recommended treatment with Taxol and Avastin. The provider’s request for authorization was denied as the Health Plan has deemed the therapy experimental/ investigational in this clinical context.Avastin is within a class of new drugs that presumably inhibit angiogenesis. It has been approved for use in combination with chemotherapy in several types of cancer. There is essentially only one applicable study in metastatic breast cancer.
Where the denial was upheld
Physician 1: The patient is a 49-year-old woman who received Taxane-based neoadjuvant therapy prior to mastectomy (pathologic and clinical response not provided) in 2003 and relapsed with lung metastasis six months later. Her lung was resected and she then received “adjuvant” chemotherapy with another taxane-based three-drug combination regimen. The patient had a second lung recurrence two months after her last dose of chemotherapy. She has now been started on a four-drug combination regimen that includes Avastin, Xeloda, Abraxane and Tarceva.
Physician 1: This patient is a 57-year-old female apparently first diagnosed with breast cancer in 1989 and treated with surgery, radiation, and chemotherapy of unknown types. In 2000, she had a local recurrence and was treated with mastectomy and hormonal therapy. In 2003, she was found to have bone metastases. Additional chemotherapy of unknown type was given. The patient was seen in June 2005 by another oncologist who noted that she was stable on a combination of two chemotherapy drugs, Abraxane and Xeloda. The extent of her disease and its responsiveness to the combination therapy are unclear.It has been recommended that Avastin be added to her current regimen. This has been denied by the Health Plan as investigational.The patient is a 57-year-old woman with reported bone-only metastatic breast cancer.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 metastatic breast cancer, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY