Cancer Care denials in California external review
In the California DMHC record, independent physician reviewers decided 1,625 published external-review cases involving cancer care and overturned the plan’s denial in 43.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By denial reason
| Denial reason | Decisions | Overturned |
|---|---|---|
| experimental / investigational | 897 | 41.4% |
| medical necessity | 719 | 46.6% |
Within this category
| Subcategory | Decisions | Overturned |
|---|---|---|
| Proton Beam | 315 | 34% |
| Other | 292 | 48.6% |
| Chemotherapy | 224 | 42.4% |
| Radiation Oncology | 150 | 38.7% |
| Radiation Therapy | 147 | 58.5% |
| Cancer Rx | 145 | 46.2% |
| Investigational Tx | 145 | 44.1% |
| Surgery | 127 | 44.9% |
| OON/ Acad Ctr Ref | 33 | 42.4% |
| Clin Trial (I) | 19 | 26.3% |
| Clin Trial (II - IV) | 18 | 50% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 897 | 41.4% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 719 | 46.6% |
Urgent Care Expedited reviews, decided in days rather than weeks. | 9 | 22.2% |
What the reviewers wrote
Where the denial was overturned
Physician 1: The patient is a 53-year-old woman diagnosed with infiltrating lobular carcinoma in July 2000 and subsequently diagnosed with ipsilateral invasive ductal cancer in January 2005. She was found to have a 1.4cm tumor with positive estrogen receptors and negative axillary nodes. The patient underwent an Oncotype DX assay and had a recurrence score of 17 which predicts an 11% chance of recurrence if the patient is not treated with chemotherapy. On that basis, the decision was made to forgo adjuvant chemotherapy.
Physician 1: The patient is a 47-year-old male diagnosed with a high-grade pleomorphic sarcoma of the left supraclavicular fossa. The recommendation of the treating oncologist was for a dose of 60 Gy delivered in 30 fractions to the left supraclavicular area. A post-treatment note from April 2005 indicated the PET and CT scan revealed no solid evidence of recurrence, however, a note dated July 2006 indicated a locally recurrent high-grade pleomorphic sarcoma interposed between the left scapula, clavicle and chest wall, occurring two years after neoadjuvant chemotherapy, surgical resection and post-operative radiation therapy. According to the radiation oncologist, the superior aspect of the patient’s recurrence was clearly within his prior radiation therapy portal, with the inferior aspect of it appearing to extend beneath the inferior margin on the portal.
Where the denial was upheld
Physician 1The patient is a 51-year-old woman who was diagnosed with left breast cancer in December 2003. At that time she was found to have a 1.3cm invasive ductal carcinoma with two positive nodes, one of which apparently was palpable to the surgeon. She has been treated with adjuvant chemotherapy including Adriamycin, Cytoxan, and Taxotere. Since her surgery was a segmental mastectomy, she now requires radiation therapy to the breast.The patient has been seen by radiation therapy who discussed the technique of whole breast radiation, including possible toxicities. It has been proposed the patient receive radiation only to the area of the tumor, using intensity-modulated radiation therapy (IMRT).It is standard and advisable for women who undergo less than a mastectomy to undergo radiation therapy to the breast.
Physician 1: The patient is a 63-year-old female first diagnosed with breast cancer in early 1999. At that time she underwent mastectomy, followed by adjuvant chemotherapy with Adriamycin and Cytoxan, then taxotere. She was then well for five years when she developed recurrence in a supraclavicular node, which was completely resected. No other metastatic disease was found, and she has been receiving further chemotherapy. It is proposed that she be treated with high dose chemotherapy and autologous stem cell rescue. The use of this treatment is the subject of this appeal. For many years, the use of high dose chemotherapy (HDC) with peripheral stem cell transplant (PSCT) has been a very controversial treatment in breast cancer. Primarily, it has been studied in two very separate situations.
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 category of care 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 cancer care, 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