Decision Dx-melanoma denials in California external review
In the California DMHC record, independent physician reviewers decided 51 published external-review cases involving Decision Dx-melanomaand overturned the plan’s denial in 2%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Melanoma | 33 | 3% |
| Cutaneous Melanoma | 12 | 0% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene test. In this patient’s case, the records document melanoma, 1.5 mm Breslow thickness. On pathology, the specimen showed areas of regression and lymphovascular invasion, which both can be features of higher risk of metastasis. In this setting, the National Comprehensive Cancer Network recommends offering sentinel lymph node biopsy. Younger age and lymphovascular invasion are positive predictors of positive sentinel lymph node testing. Per the records, this patient has both a positive and negative predictor of positive sentinel lymph node biopsy. DecisionDx-Melanoma testing can be useful in certain instances where more information and data are needed.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a DecisionDX-Melanoma test. For a thin melanoma, pathologic stage pT1a, the standard treatment involves wide excision of the lesional site with appropriate margins. In this case, a dermatopathology report from a specimen described the clinicopathologic features of the initial tumor as a thickness 0.3 mm depth, without ulceration, a mitotic index of zero, and without significant regression, which is otherwise a low risk tumor. The DecisionDX-Melanoma gene expression profiling (GEP) test resulted in a class 1a score. Under the National Comprehensive Cancer Network (NCCN) guidelines, standard treatment in this clinical setting would be re-excision with appropriate margins.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test DecisionDX-Melanoma performed. Findings: The physician reviewer found that the patient is diagnosed with cutaneous melanoma on the mid-upper back. Histopathologically, the tumor was Clark level III and extended to the Breslow depth of 0.4 mm. The DecisionDX-Melanoma assay performed showed class 1 molecular signature, which is associated with a low risk of near term (within five years) metastatic disease. The patient requested reimbursement for the DecisionDX-Melanoma assay performed. The Health Plan denied reimbursement for the testing and noted that the services at issue were considered investigational for evaluation of the patient’s cutaneous melanoma. There is a lack of support in the medical literature for the services at issue in this clinical setting.
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 treatment 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 Decision Dx-melanoma, 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