Genetic Testing denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollee’s eye cancer. Findings: Two physician reviewers found that the patient was diagnosed as having choroidal melanoma based on a fine needle aspirate. The specimen was submitted to pathology and for genetic testing to determine the risk of metastasis. The patient requested reimbursement for gene testing but the Health Plan has denied the patient’s request for reimbursement. Per the Health Plan, the services at issue were investigational for the evaluation of this of this patient. There is sufficient scientific evidence that genetic testing of the uveal melanoma tumor can stratify the tumors into high and low risk for systemic metastasis. Gene tests provide reliable information for providers as they determine a treatment course for their patients.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (CPT 81450). Findings: Two of the three physician reviewers found that chronic lymphocytic leukemia is characterized as an indolent leukemia, but a patient’s individual clinical course is not predictable. It is impacted by stage at presentation and certain biomarkers. Among these, mutations in TP53, NOTCH1, BIRC3, and SF3B1 have been shown to be helpful to categorize patients into prognostic groups. Thus, mutational analysis has been adopted by many oncologists at the time of chronic lymphocytic leukemia diagnosis. In addition to this indication, mutational analysis may also be needed in the case of treatment resistance.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for evaluation the enrollee’s major depressive disorder and post-traumatic stress disorder (PTSD). Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The medical literature lacks well-designed and adequately powered studies illustrating consistent and reproducible results that provide clinically useful information pertaining to genomic testing and its relationship to specific pharmacologic interventions. In this case, the patient tried many medications and had frequent medicine changes. However, there is a lack of documentation demonstrating the specific type and duration of psychotherapies provided, which are standard therapies that often outperform psychotropic medication.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing for evaluation of the enrollee’s melanoma. Findings: The 3 physician reviewers found that the physician reviewer found there is a lack of support for the services at issue in this patient’s case. In this clinical setting, the standard of care is wide excision to obtain clear tumor margins. Long-term follow-up would include annual skin examinations, history and physical examination every six to twelve months for five years, then annually as clinically indicated, as well as imaging as indicated to investigate specific signs or symptoms. The National Comprehensive Cancer Network guidelines state that routine/baseline testing of primary melanomas is not recommended before or after sentinel node biopsy outside of a clinical study.

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