Prostate Adenocarcinoma denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Findings: The physician reviewer found that The patient has requested authorization and coverage for proton beam therapy, transperineal placement of a hydrogel spacer, special medical radiation physics consultation, special treatment procedure, and/or guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed. On review of the current peer-reviewed medical literature and guidelines, the requested proton beam radiation therapy is not supported as medically necessary for treatment of this patient. The records provided for review document that this patient was appropriately referred to undergo a course of definitive radiation treatment for this favorable intermediate risk prostate cancer per National Comprehensive Cancer Network (NCCN) guidelines.

Where the denial was upheld

The patient is a 57-year-old male diagnosed with prostate cancer. He had medical problems including diabetes mellitus, hypertension, and hypercholesterolemia, and was not experiencing erections or engaging in sexual activity.PSA was elevated at 13.7 in February 2006, and unilateral prostate induration was palpable on digital rectal examination. Ultrasound-guided prostate biopsy performed in April 2006 revealed a Gleason grade of 4+3 adenocarcinoma of the prostate involving 30% of the biopsy specimen from the left side and 5% of the biopsy specimen from the right. Prior to treatment the patient was diagnosed with a Gleason grade total 7, clinical stage T2c adenocarcinoma of the prostate.In April 2006 alternatives for treatment were discussed with the patient including radical surgery, external radiation, and brachytherapy, and a bone scan was ordered.

Physician 1The patient is a 60-year-old man with a PSA of 4.7 who had a Gleason score of 3+3=6 prostate carcinoma on prostate biopsy performed in June 2004. This was present in cores at the right mid-apex and lateral areas, and the left apex and lateral areas. This is an extensive prostatic adenocarcinoma and should be viewed more as a T2b lesion than a T1c lesion. The chance of the carcinoma being organ confined is probably closer to 50% than 80%. The patient has medical problems including diabetes mellitus, hypertension, and hypercholesterolemia. He wishes to undergo cryosurgery. The Health Plan had denied authorization for cryosurgery on the basis it is considered investigational.This patient has a mid-grade prostate adenocarcinoma, which is bilateral in extent. He wishes to undergo cryosurgery.

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