Chemotherapy 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 1The patient is a 57-year-old male with well-controlled HIV who is on highly active antiretroviral therapy. The patient has acute myeloid leukemia (AML) and possible antecedent MDS. He is now being considered for consolidation of first remission with a peripheral stem cell transplant. The Health Plan has denied authorization and coverage for the requested therapy on the basis it is considered experimental.Further data regarding this patient’s AML, AHD, and cytogenetics is needed to help define where he falls in the National Comprehensive Cancer Network guidelines. The decision to pursue treatment should rest on those data and not on his HIV positivity. As such, cytogenetic results and additional hematologic data should be obtained. Unless the patient’s HIV is poorly controlled, his HIV status does not preclude stem cell transplantation.

Where the denial was upheld

Physician #1: The patient is a 53-year-old woman with ovarian cancer. She had her initial surgery in September 2004, with the findings of Stage III papillary serous ovarian cancer. She had extensive peritoneal and omental seeding as well as positive lymph nodes. She was apparently treated with chemotherapy and underwent second-look surgery in March 2005. It appears she was free of cancer at that time.Since that time she has had a rising CA-125 and a recent PET scan has demonstrated new areas of uptake consistent with recurrent cancer. She has been started on Doxil chemotherapy and has requested authorization and coverage for intraperitoneal chemotherapy. At issue is whether the requested therapy is likely to be more beneficial for treatment of the patient’s condition than any available standard therapy.Intraperitoneal chemotherapy for ovarian cancer has been studied for many years.

Physician 1: This patient is a 42-year-old male with a previous diagnosis of myoepithelial sarcoma of the paranasal sinus. He has apparently been treated with surgery, radiation, and multiple chemotherapeutic agents including Cisplatin, Ifosfamide, Taxol, Carboplatinum, Adriamycin, and Temodar. He has also been treated with Cyberknife radiotherapy. The patient’s tumor was found positive for the epithelial growth factor (EGF) receptor and it is proposed that he be treated with Erbitux. The provider’s request for authorization of Erbitux was denied by the Health Plan citing the experimental nature of the therapy.Erbitux is one of a new class of drugs that inhibits the EGF receptors on a cancer cell and presumably interferes with angiogenesis. Erbitux has been approved by the FDA for use, along with chemotherapy, in the treatment of colon cancer.

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