Cryoablation denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for special cold therapy cryoablation. Findings: The physician reviewer found that This patient’s records document that she is being treated for neoplasm of bone. The provider noted that the patient presented with a right talus bone lesion. X-rays of the right ankle showed a bone lesion in her right talus. The patient’s physical examination revealed right ankle with medial swelling, tenderness to palpation at the medial ankle, and limited range of motion due to stiffness and pain. The patient’s provider has recommended treatment with cryoablation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cryoablation of the metastatic tumor at the right chest wall. In a peer-reviewed medical literature reported on percutaneous ablation of musculoskeletal metastases. The authors noted that this treatment modality “may result in significant pain palliation, prevention of morbidity from skeletal-related events, and local tumor control.” The authors concluded that “this minimally invasive approach has unique advantages compared with surgery or radiation therapy.” In addition, `many studies have shown that percutaneous ablation of a painful bone metastasis can significantly and sustainably reduce symptoms.” Thus, the literature does support the use of cryoablation for bone metastasis for the purpose of palliating bone pain and local tumor control.

Where the denial was upheld

Physician 1: The patient is a 79-year-old man who had an elevated PSA of 12. On 1/14/05, he underwent a prostate biopsy. Of six core biopsies, only the one from the left apex was involved with a Gleason score of 3+3 with 50% involvement. The patient was placed on hormone ablative therapy by his urologist. On 3/11/05, the patient’s PSA dropped to 3.8. A repeat PSA on 3/14/05 was 2.2. With this good response, the patient’s urologist recommended the patient undergo cryoablation. The Health Plan has denied coverage for cryoablation on the basis it is considered investigational for treatment of prostate cancer.Based on Partin’s Tables, the patient has 62% chance of having the cancer limited to his prostate.

Findings: The physician reviewer found that: Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cryoablation of ductal carcinoma in situ (DCIS) of the left breast. The records indicate that this patient presented with a history of DCIS of the left breast. The provider noted that the patient underwent treatment with cryoablation. DCIS is considered a precancerous lesion that predisposes a patient toward invasive breast cancer. Cancer center guidelines report that the normal therapeutic algorithm for DCIS is total mastectomy with or without sentinel lymph node biopsy, followed by reconstruction. Alternatively, the patient may undergo breast conserving surgery without any lymph node assessment followed by whole breast radiation therapy. The guidelines do not deviate from these recommendations.

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