Renal Cell Carcinoma denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for a computed tomography (CT) scan of the chest and/or CT scan of the abdomen and pelvis. Radiologic imaging is the most useful type of surveillance status post treatment for known RCC as most cases of disease recurrence or progression occur in asymptomatic patients. According to the American College of Radiology (ACR), the criteria for post-treatment follow-up and active surveillance of patients with clinically localized RCC includes surveillance imaging recommended at three, six, and 12 months post-operatively, and every six-24 months for five years. Contrast-enhanced CT of the abdomen and pelvis is a sensitive examination for the detection of recurrence in the nephrectomy bed and other sites of metastatic disease.

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 37-year-old woman first diagnosed with renal cell carcinoma in January 2001. At that time she underwent nephrectomy. She was then well until mid-2003 when she developed left groin pain. Evaluation in September 2003 revealed a solitary lytic bone metastasis in her left superior pubic ramus. This was resected and the patient was treated with radiation therapy following surgery. As yet, the patient has not experienced any further recurrence or evidence of metastasis. Because of the patient’s high risk of further recurrence, the patient’s provider has proposed that the patient undergo nonmyeloablative allergenic transplant if an HLA-matched sibling can be found.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT)-guided ablation microwave renal right procedure for treatment of the enrollee, who presented with right renal tumor. Findings: Two of the three physician reviewers found that the patient was evaluated for abdominal pain by contrast enhanced computed tomography (CT) scan. This scan revealed a small enhancing right renal mass approximately 13 mm. The lesion was highly suspicious for small renal neoplasm. After discussion with her provider, the patient elected to proceed with ablative therapy. The patient requested reimbursement for the CT-guided ablation microwave renal right procedure. The Health Plan denied the reimbursement. Per the Health Plan, the services at issue were investigational for treatment of this patient’s medical condition.

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 cell carcinoma, then check the rights and deadlines that apply to your plan.