Triple Negative Breast Cancer denials in California external review
In the California DMHC record, independent physician reviewers decided 13 published external-review cases involving triple negative breast cancerand overturned the plan’s denial in 76.9%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 8 | 75% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 5 | 80% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne CDx comprehensive genomic profiling test. This patient has triple negative breast cancer that was advanced in presentation and is now metastatic. The records indicate that she is treatment-naïve and can expect a response from chemotherapy. The patient reportedly refused treatment with chemotherapy. Decisions regarding chemotherapy should consider patient preference, goals of treatment, the presence of toxicities from previous therapies, and the availability of alternative treatment options. In order to provide these options to this patient, the provider recommended mutational testing with FoundationOne CDx.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) for attenuation, skull base to mid-thigh, and/or PET with CT for attenuation, skull base to mid-thigh. According to the American College of Radiology (ACR) criteria for monitoring response to neoadjuvant systemic therapy for breast cancer in a patient with known breast cancer and clinical suspicion for metastatic disease, PET/CT scan is considered usually appropriate. As noted by the ACR, for the purposes of staging and monitoring treatment response, PET/CT detects 50-100% of distant metastasis, with a specificity of 50-97%. In addition, multiple studies have demonstrated that PET/CT is particularly useful in the ongoing assessment of patients with triple negative breast cancer.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for combination therapy using Opdivo (nivolumab) and Yervoy (ipilimumab). The U.S. Food and Drug Administration (FDA) has not approved Opdivo and Yervoy for the treatment of patients with triple negative breast cancer and this regimen is not supported by major drug compendia or the medical literature. Currently, the regimen of Opdivo and Yervoy is the subject of ongoing clinical trials. The current NCCN guidelines and peer-reviewed medical literature support treatment of metaplastic breast cancers similarly to other invasive breast cancers. Current data support therapies such as a PARP inhibitor, pembrolizumab, or Sacituzumab.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan. Findings: The physician reviewer found that The records provided for review document that this patient was diagnosed with triple negative breast cancer in 2014 with recurrence in 2018. A PET scan showed activity in a left thyroid nodule measuring 1.4 cm stable compared to prior and possibly reactive right axillary lymph nodes. Bilateral breast MRI noted changes of mastectomy and subpectoral implant reconstruction without evidence of adenopathy and the imaged bones, intrathoracic soft tissues, and intraabdominal soft tissues were unremarkable. Based on the available records, there is no current indication for a PET scan.
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 triple negative breast cancer, 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