Avastin denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is an 18-year-old young man first noted to have some numbness in his right arm in November 2005. It progressively worsened over the next few months, and by April 2006 he had right arm numbness and weakness along with neck pain. An MRI of the spine revealed a 3.9 x 1.2 x 1.4 cm enhancing lesion at C2 to C4. The lesion was partially excised in early May 2006. The final histopathologic diagnosis is glioblastoma (GBM). The June 2006 spine MRI shows no change in the size of the enhancing lesion (suggesting that less was removed than thought or that the tumor has grown back to its original size). The patient improved after the operation, but according to his mother, his neurologic symptoms (tingling and weakness) are returning. The patient’s providers have recommended Avastin and CPT-11 as initial therapy.

Physician 1: The patient is a 56-year-old woman with recurrent breast cancer, Stage IV with inflammatory histopathology. She is appealing denial of coverage for therapy with Avastin in combination with paclitaxel (Taxol). At issue is whether immunotherapy with Avastin is likely to be more beneficial than any available standard therapy.The data addressing the role of Avastin in breast cancer is encouraging yet incomplete. It is clear from single institution and cooperative group trials that Avastin, in combination with chemotherapy, has important activity in advanced breast cancer. However, the timing and combinations that best exploit this activity in the breast cancer treatment algorithm remains to be determined.

Where the denial was upheld

Physician 1: This patient is a 62-year-old female who was diagnosed with a right upper lobe 5 cm mass in February 2004. First-line treatment was surgery. This was followed by adjuvant treatment consisting of chemotherapy, DDP and navelbine with radiation therapy. The patient experienced a relapse one year out and received second-line chemotherapy with gemcitabine and Taxotere. This was followed with Iressa and then Tarceva. The patient has requested authorization and coverage to add Avastin to her treatment plan. The Health Plan has denied this request indicating Avastin has not been shown to be effective for treatment of the patient’s condition.The Health Plan’s denial should be upheld. The data for the combination of therapies involved in this case are very sparse and are not based on randomized controlled trials.

Physician 1: This patient is a 62-year-old male diagnosed with hepatocellular carcinoma in July 2004. The tumor was resected and no further treatment was provided at that time. The patient did well until November 2005 when he was found to have an abdominal nodule positive for recurrence. CT and PET scans revealed multiple lung metastases. He was treated with an investigational agent, which did not halt the progression of his disease. In April 2006 the patient began chemotherapy with cisplatin, 5-FU, interferon and Avastin. The patient’s request for reimbursement and prospective authorization for Avastin and interferon was denied by the Health Plan citing the experimental/investigational nature of the therapy.Overall chemotherapy has been of little benefit in metastatic hepatocellular carcinoma.

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