Intensity Modulated Radiation Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 47-year-old male diagnosed with a high-grade pleomorphic sarcoma of the left supraclavicular fossa. The recommendation of the treating oncologist was for a dose of 60 Gy delivered in 30 fractions to the left supraclavicular area. A post-treatment note from April 2005 indicated the PET and CT scan revealed no solid evidence of recurrence, however, a note dated July 2006 indicated a locally recurrent high-grade pleomorphic sarcoma interposed between the left scapula, clavicle and chest wall, occurring two years after neoadjuvant chemotherapy, surgical resection and post-operative radiation therapy. According to the radiation oncologist, the superior aspect of the patient’s recurrence was clearly within his prior radiation therapy portal, with the inferior aspect of it appearing to extend beneath the inferior margin on the portal.

Physician 1: The patient is a 64-year-old male who was diagnosed with a well-differentiated adenocarcinoma of the pancreas on 7/22/04. The mass was in the head of the pancreas measuring 2.5cm in diameter and had encased the superior mesenteric artery. Following evaluations, the patient was given chemotherapy followed by conventional radiology as a step towards a definitive surgery. Since November 2004, the patient has been evaluated by various cancer centers and has been found to have a surgically unresectable tumor. It has been recommended the patient undergo intensity-modulated radiation therapy (IMRT) as a step towards a definitive approach. The Health Plan has denied authorization and coverage for IMRT on the basis it is considered experimental. It is well known and accepted that cancer of the pancreas carries a reputation of poor prognosis.

Where the denial was upheld

Physician 1The patient is a 51-year-old woman who was diagnosed with left breast cancer in December 2003. At that time she was found to have a 1.3cm invasive ductal carcinoma with two positive nodes, one of which apparently was palpable to the surgeon. She has been treated with adjuvant chemotherapy including Adriamycin, Cytoxan, and Taxotere. Since her surgery was a segmental mastectomy, she now requires radiation therapy to the breast.The patient has been seen by radiation therapy who discussed the technique of whole breast radiation, including possible toxicities. It has been proposed the patient receive radiation only to the area of the tumor, using intensity-modulated radiation therapy (IMRT).It is standard and advisable for women who undergo less than a mastectomy to undergo radiation therapy to the breast.

Physician 1: The patient is a 60-year-old man who underwent a Whipple’s procedure for a well-differentiated pancreatic cancer stage T3, N1, M0 in March 2005. The tumor extended into the peripancreatic fat and all gross tumor was removed. The 3.5 cm tumor was associated with the involvement of 8 of 13 lymph nodes. The patient next underwent chemotherapy, which was completed at the end of November 2005. He is now ready for radiation therapy and there is a dispute on the method: intensity modulated radiation therapy (IMRT) versus conventional radiation therapy. The Health Plan has denied authorization and coverage for IMRT based upon their determination that it is an investigational therapy in the treatment of pancreatic cancer.The patient has a defined chance of local recurrence because of the extension of the cancer into the peripancreatic fat and the lymph node involvement.

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 Intensity Modulated Radiation Therapy, then check the rights and deadlines that apply to your plan.