Uterine denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for a positron emission tomography (PET) scan for evaluation of the enrollee’s newly diagnosed leiomyosarcoma. Findings: Two physician reviewers found that patients who have underwent routine hysterectomy with the incidental finding of uterine sarcoma such as in this case, the National Comprehensive Cancer Network (NCCN) recommend that those patients have CT scans of the chest, abdomen, pelvis or abdominal/pelvic magnetic resonance imaging (MRI) and chest CT to evaluate for metastases. For patients who have had their tumors morcellated such as in this case, the NCCN indicate that pelvic MRI should be considered. The NCCN further states that PET/CT scanning should be considered for ambiguous findings.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensity modulated radiation therapy (IMRTfor treatment of the enrollee’s uterine cancer. .Findings: Three physician reviewers found that upon review of available data, IMRT is likely more beneficial in treating this patient’s endometrial cancer than standard therapy consisting of three-dimensional conformal radiotherapy (3DCRT). Chen and colleagues reported that the main areas where IMRT benefits patients is decreased gastrointestinal toxicity and decreased marrow toxicity. For marrow toxicity, a multi-institutional phase II trial showed that bone marrow toxicity could be decreased with the appropriate IMRT planning parameters (Klopp, et al). Based on this support, the requested IMRT has a substantial advantage over 3DCRT in the treatment of endometrial cancer.

Where the denial was upheld

A 54-year-old female has requested proton beam therapy for treatment of her pulmonary and spinal metastases secondary to progressive uterine leiomyosarcoma. Findings: The physician reviewer found that a proton is the charged nucleus of a hydrogen atom (hydrogen atom minus an electron). Charged particles (such as protons and carbon) can be used to deliver therapeutic radiation. “Standard radiation” is delivered with a linear accelerators (LINAC), which deliver photon therapy (akin to high energy light), whereas protons (and other charged particles) are generated from a cyclotron.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene test for treatment of the enrollee's uterine leiomyosarcoma. Findings: Three physician reviewers found that currently, therapy and achieved outcomes for metastatic uterine leiomyosarcoma are not based on panel testing. To demonstrate the clinical utility of panel genetic testing, such as FoundationOne, prospective randomized clinical trials are needed to compare the strategy of targeted treatment based on panel results with standard of care and currently there is a lack of such trials. The available literature as to its clinical utility consists of a small number of uncontrolled studies, and nonrandomized controlled trials that use imperfect comparators. As such, this evidence is not sufficient to make any conclusions as to its efficacy in this clinical setting.

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