Non-small Cell Lung Cancer denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensity modulated radiation therapy (IMRT). IMRT is standardly utilized to treat certain body sites when normal tissue dose constraints cannot be met by other radiation techniques. In the case of lung cancer, IMRT is commonly utilized to spare areas of normal lung. This is particularly important in patients who have chronic obstructive pulmonary disease (COPD), as is the case with this patient. Toxicities such as radiation pneumonitis and esophagitis can cause significant morbidity leading to hospitalization. There is strong evidence in the literature demonstrating a correlation between normal lung sparing and the rates of treatment-related complications.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 gene testing for evaluation of the enrollee’s non-small cell lung cancer (NSCLC). Findings: Two of the physician reviewer found that genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients and thus to facilitate prompt treatment or protocol inclusion. The National Comprehensive Cancer Network (NCCN) guidelines indicate that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.

Where the denial was upheld

Physician 1The patient is a 59-year-old man who had lung surgery in August 2002. At that time he had resection of his right lower lobe, revealing a poorly differentiated squamous cell cancer, 3cm in size, with negative nodes. In March 2003, the patient developed two areas of endobronchial recurrence. He then underwent chemotherapy with little response. An endobronchial biopsy in June 2003 again was positive. The patient was treated with external beam radiation therapy from June 2003 to July 2003. Repeat bronchoscopy in September 2003 showed persistence of one of the lesions and the patient was treated with local brachytherapy to this lesion.In December 2003, CT scan of the chest demonstrated two new pulmonary nodules, each about 1cm in size. One was at the right lung base and the other was in the superior segment of the right lower lobe.

Physician 1: This patient is a 62-year-old female who was diagnosed with a right upper lobe 5 cm mass in February 2004. First-line treatment was surgery. This was followed by adjuvant treatment consisting of chemotherapy, DDP and navelbine with radiation therapy. The patient experienced a relapse one year out and received second-line chemotherapy with gemcitabine and Taxotere. This was followed with Iressa and then Tarceva. The patient has requested authorization and coverage to add Avastin to her treatment plan. The Health Plan has denied this request indicating Avastin has not been shown to be effective for treatment of the patient’s condition.The Health Plan’s denial should be upheld. The data for the combination of therapies involved in this case are very sparse and are not based on randomized controlled trials.

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 non-small cell lung cancer, then check the rights and deadlines that apply to your plan.