Renal denials in California external review
In the California DMHC record, independent physician reviewers decided 29 published external-review cases involving renaland overturned the plan’s denial in 41.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for renal
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. | 20 | 50% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 9 | 22.2% |
What the reviewers wrote
Where the denial was overturned
A 69-year-old male has requested coverage for a positron emission tomography (PET) scan for evaluation of his renal cancer. Findings: Three physician reviewers found that the patient has undergone right nephrectomy for renal cell cancer. Prior magnetic resonance imaging (MRI) and computed tomography (CT) scans showed liver metastases which have shrunken over time with treatment. The patient has a solitary kidney with impaired function. Laboratory testing reveals that his serum creatinine level is 1.6 and glomerular filtration rate (GFR) is 43. Previous imaging with positron emission tomography/computed tomography (PET/CT) demonstrated that the liver lesions are PET avid, thus his provider has recommended repeat PET/CT to evaluate the remaining liver lesions as well as other sites for potential treatment with radiofrequency ablation (RFA).
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryosurgical ablation. Per the current high quality peer-reviewed medical literature, cryotherapy is an acceptable standard of care therapeutic modality for management of small renal cell carcinomas. Multiple studies with follow-up data exceeding five years strongly support the long-term oncologic efficacy of cryotherapy for renal cell carcinomas measuring under 3 cm. Moreover, the National Comprehensive Cancer Network (NCCN) guidelines for management of renal cell carcinoma supports the use of ablative therapies, such as cryotherapy, for management of clinical stage T1 kidney cancers.
Where the denial was upheld
Physician 1The patient is a 55-year-old man with a history of renal cell carcinoma who underwent nephrectomy in March 2002. Prior to that time he had been diagnosed with acute myelogenous leukemia (AML), which went into remission in 2001 with chemotherapy. He has not had a relapse of his acute leukemia. In May 2003, the patient was found to have multiple lung metastases from his renal cell carcinoma. As of June 2004 these appeared to have increased in size.The patient has a fully HLA-matched sibling who has already donated allogeneic stem cells. It has been proposed that the patient be treated with non-myeloablative allogeneic stem cell transplant. The goals of this therapy would be to control his metastatic renal cell carcinoma, and presumably to provide further treatment of his AML.
The patient is a 48-year-old male who was diagnosed with metastatic renal cell cancer in January 2005. He was initially diagnosed following VATS and lung biopsy for a left pleural effusion, at which time he also underwent talc pleurodesis. His primary was identified as the right kidney and he underwent a right nephrectomy in March 2005. He was treated with systemic therapy for his metastatic disease with IL-2 and interferon, which was changed to Avastin and interferon in August 2005. The patient had a PET scan in September 2005 demonstrating uptake of the left lung, ribs, posterior neck and soft tissue adjacent to the maxilla. Treatment was then switched to sorafinib with the persistence of metastatic, though stable, disease. By report, his last PET scan revealed only a single mass in the left lung that demonstrated FDG uptake.
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 renal, 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