Intra-operative Radiation Therapy denials in California external review
In the California DMHC record, independent physician reviewers decided 32 published external-review cases involving Intra-operative Radiation Therapyand overturned the plan’s denial in 31.3%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Breast Cancer | 19 | 21.1% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 29 | 31% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 3 | 33.3% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy (IORT) (CPT 77469 and 77424). Accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. The National Comprehensive Cancer Network (NCCN) supports the use of APBI use in well selected patients with breast cancer. Based on the records provided for review, this patient meets the criteria for APBI set forth by the NCCN given her age over 50 years, tumor less than 2 cm, no lymphovascular involvement, and estrogen receptor (ER) positive tumor. Surgical margins of at least 2 mm and negative lymph nodes are also criteria and are confirmed at the time of surgery.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right breast lumpectomy intraoperative radiation therapy (IORT) (CPT 77424 and 77469). Findings: The physician reviewer found that recent National Comprehensive Cancer Network (NCCN) guidelines endorse the use of IORT in the treatment of well-selected patients with breast cancer. Moreover, phase 3 studies have shown equivalent outcomes in patients who undergo standard radiation therapy and IORT.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intraoperative radiation therapy. At issue is whether intraoperative radiation therapy (IORT) is likely to be more beneficial for this patient’s therapy compared to other standard forms of adjuvant radiation therapy following lumpectomy. It is considered standard therapy for patients to undergo adjuvant radiation therapy after a lumpectomy as part of their treatment program. Most commonly, this radiation therapy is given post-surgery over the course of one to several weeks using a variety of treatment modalities such as external beam or interstitial brachytherapy. The American Brachytherapy Society notes that there are established consensus guidelines which establish suitable patients for IORT as well as established dosing regimens.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Intra-operative radiation therapy (IORT).At issue is whether IORT is likely to be more beneficial for this patient’s therapy compared to other standard forms of adjuvant radiation therapy following lumpectomy. It is considered standard therapy for patients to undergo adjuvant radiation therapy after a lumpectomy as part of their treatment program. Most commonly, this radiation therapy is given post-surgery over the course of one to several weeks using a variety of treatment modalities such as external beam or interstitial brachytherapy. Studies show that there are established consensus guidelines which establish suitable patients for IORT as well as established dosing regimens.
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 Intra-operative Radiation Therapy, 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