Brca Testing denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 58-year-old female with a history of multiple cancers. In 1991, she was diagnosed with breast cancer and underwent bilateral mastectomies followed by chemotherapy. In 1993, she underwent hysterectomy and bilateral oophorectomy for a mucinous adenocarcinoma of the ovary. This was followed by intravenous as well as intraperitoneal chemotherapy. In 1996, she was found to have melanoma in situ of her back, which was widely excised. In May 2004, she was found to have cancer in the head of the pancreas, which was not resectable. Notes indicate the patient has a maternal great aunt with breast cancer and a maternal cousin with breast cancer.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (BRCA testing) Findings: The physician reviewer found that this patient is a candidate for risk assessment and genetic testing. The patient is of Ashkenazi ancestry and has a first degree relative with cancer. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, pancreatic and gastric cancers (Tai, et al; Ferrone, et al). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. Given this patient’s indication for testing, the gene test (BRCA testing) was likely to have been more beneficial for evaluation of this patient’s medical condition than standard available testing.

Where the denial was upheld

A 60-year-old female enrollee has requested BRCA testing for evaluation of her family history of cancer. Findings: Two physician reviewers found that the medical records note that she does not have a personal history of cancer. The patient’s father was diagnosed with prostate cancer at 80 years of age, and her mother was diagnosed with breast cancer at 78 years of age. Additionally, her grandfather was diagnosed with colon cancer in his 80s, a cousin was diagnosed with rectal cancer at age 62, and an aunt was diagnosed with breast cancer in her 60s. BRCA mutations are associated with a high incidence of both breast and ovarian cancer. Information regarding whether a patient is BRCA positive can have several implications with regards to patient management. As to breast cancer, patients may consider more intense screening or bilateral mastectomies.

This patient is a 32-year-old female who is currently pregnant and has not been diagnosed with cancer. However, the patient’s mother was recently diagnosed with ovarian cancer and the mother’s sister died of breast cancer and her age at diagnosis is unknown. The patient’s mother’s mother died of cervical/uterine cancer and her mother’s brother may have colon cancer, but this has not been confirmed. Due to her family history, the patient is requesting authorization for BRCA testing to detect a genetic susceptibility to cancer. The Health Plan denied her request for authorization citing a lack of medical necessity.BRCA testing detects certain gene mutations that significantly increase the risk of ovarian and/or breast cancer. These mutations are usually detected in families wherein there are a number of young women with breast cancer and/or ovarian cancer; overall these are rare findings.

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