Decision Dx-melanoma denials: what the review data shows
Independent reviewers have decided 51 published cases where an insurer denied Decision Dx-melanoma — and they overturned the insurer 2% of the time. A denial for Decision Dx-melanoma is a starting position, not a final answer.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Melanoma | 33 | 3% |
| Cutaneous Melanoma | 12 | 0% |
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 outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Decision Dx-melanomawhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY