Ovarian Cancer denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 53-year-old female with the diagnosis of two primary cancers, lung and ovarian. On 1/9/04, the patient had a percutaneous biopsy of a left supraclavicular mass, which showed a poorly differentiated squamous cell carcinoma, probably lung in origin. On 2/1/04, the patient underwent a total abdominal hysterectomy and a bilateral salpingo-oophorectomy (TAH-BSO), which revealed a serous cystadenocarcinoma, grade III. A positron emission tomography (PET) scan was performed on 2/24/04, which showed widespread metastatic disease involving left supraclavicular area, mediastinum, right lung, retroperitoneum, and pelvis. A CT scan was performed on 5/3/04 and was compared to the prior exam of 1/14/04. There had been the interval TAH-BSO and marked improvement in the pulmonary nodules and mediastinal and retroperitoneal adenopathy.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing services, Tempus XT 648 gene panel. Cancer research guidelines on ovarian cancer notes that the investigation of germline and/or somatic BRCA1 and BRCA2 status helps inform upfront therapies including maintenance regimens. Even in the absence of BRCA1 and BRCA2 mutations, comprehensive genomic profiling may reveal homologous recombination deficiency status, as denoted by specific genomic profiles, that may provide information on the magnitude of benefit of poly adenosine diphosphate-ribose polymerase (PARP) inhibitor therapy.

Where the denial was upheld

Physician 1The patient is a 56-year-old woman who underwent surgery for ovarian cancer, stage III-B in 2002. She then underwent six cycles of carboplatinum-taxol. She was well until January 2004 when a rising CA-125 was noted. The patient was then apparently treated with cisplatin-cytoxan and subsequently underwent secondary cytoreductive surgery. She now apparently has progressive disease.It has been noted the results of a chemosensitivity assay suggest resistance to many of the further chemotherapy drugs that might be tried in this situation. It has now been proposed that the patient be treated with Avastin.

Physician 1: The patient is a 59-year-old female diagnosed with ovarian cancer in October 2003. She was initially treated with cytoreductive surgery and chemotherapy. She was found to have recurrent disease and underwent splenectomy in October 2004. The patient has had additional chemotherapy since that time, but as of January 2006 she has been found to have progressive and strongly symptomatic disease. The patient’s clinician has requested authorization for intra-peritoneal hyperthermic chemotherapy. The Health Plan has denied authorization citing the investigational nature of the procedure in the treatment of recurrent ovarian cancer.Intra-peritoneal chemotherapy for ovarian cancer has been studied for many 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 ovarian cancer, then check the rights and deadlines that apply to your plan.