Prostate Cancer: when insurers say no, reviewers often say yes

Where the denial was overturned

Physician 1The patient is a 62-year-old male who has recurrent prostate cancer with a PSA of zero currently. In addition, the record indicates the patient is status post prostatectomy. The patient underwent a Prostascint scan on 11/6/03 at the direction of his oncologist. He is requesting authorization and coverage for the Prostascint scan.In this patient the Prostascint scan performed on 11/6/03 detected metastatic prostate adenocarcinoma in two areas, the prostatic fossa and left iliac node region, which were not identified on the CT scan performed on 10/29/03 or the bone scan performed on 11/6/03. While the prostatic fossa was already noted to be abnormal on digital rectal examination, the left iliac lymph node region abnormality was not otherwise identified.

Physician 1: The patient is a 61-year-old male diagnosed with a low-grade adenocarcinoma of the prostate in July 1998. At that time, he elected to undergo watchful waiting. More recently, his PSA rose to 7.4 in June 2005. Repeat biopsy revealed a Gleason score of 3+2=5/10, three of eleven core biopsies were positive. Physical examination was consistent with a clinical stage T2a. According to the radiation oncologist consult note, options regarding definitive treatment were discussed and the patient “appears to favor treatment with prostate brachytherapy.” The records are unclear as to why the patient did not undergo a brachytherapy implant, but rather, received IMRT fractionated radiotherapy to the prostate. He was treated with the IMRT technique to the prostate with 6 MV photons, utilizing IGRT techniques to deliver a tumor dose of 7560 cGy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Prostate genomic testing. Findings: The physician reviewer found that current medical literature, the service at issue was not likely to have been more beneficial for the evaluation of this patient than standard risk stratification, for example, risk stratification under the National Comprehensive Cancer Network (NCCN). The Oncotype DX Prostate cancer assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS), with a lower GPS score meaning a more favorable biology and less aggressive disease.

Physician 1The patient is a 59-year-old male who received brachytherapy for prostate adenocarcinoma in October 1998. PSA levels have fluctuated from 1.0 in December 1999 to 5.0 in July 2004. The patient has recently been experiencing poor bladder emptying. A CT scan of the abdomen and pelvis performed in August 2004 revealed small prostate with seed implants, no enlarged lymph nodes, fatty liver, small right renal cyst, small right renal stone, and mild left pelviectasis vs. small parapelvic cysts. A bone scan revealed no evidence of metastatic disease. The patient wishes to undergo cryosurgery. The Health Plan has denied authorization and coverage for cryosurgery on the basis it is considered investigational.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for prostate cancer was denied, the published record says the denial is worth fighting.