Invest Tx Protocol denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 56-year-old man who was diagnosed with myelodysplastic syndrome (MDS) in 1992. His specific form of MDS is refractory sideroblastic anemia. Over the years he has been on a variety of treatments, including Neupogen to stimulate his white blood cell count, and Epogen, to increase his hemoglobin. It appears that the patient’s hemoglobin has not been responding well to his current treatment and he has been on thalidomide for an unknown period of time. He requests continuation of thalidomide therapy. The Health Plan has denied the request on the basis that thalidomide is considered experimental for treatment of the patient’s medical condition.MDS encompasses a wide range of subtypes, but all are characterized by a bone marrow that is not functioning normally, such that one or the other of the formed elements of the blood is deficient.

Physician 1The patient is a 58-year-old woman with a history of fibromyalgia with associated chronic fatigue syndrome and depression since the early 1990’s. The patient has been prescribed many medications including Trazadone, Nortriptyline, Flexeril, Celexa, Zoloft, Ultram, Voltaren, etodolac, and Neurontin. Treatment with these medications provided the patient with significant pain relief but resulted in minimal increase in her energy level. Since initiating Provigil in June 2003 the patient has noted marked improvement in her energy level and quality of life. She has also been able to stop use of Neurontin while taking Provigil. The patient has requested authorization and coverage for continued treatment with Provigil.

Where the denial was upheld

Physician 1This is a patient with apparent left-sided chronic ulcerative colitis who has continued symptoms despite topical and systemic therapy with mesalamine preparations. She is said to have been unresponsive to corticosteroids in the past; however, a review of the medical records provided documents no use of prednisone or other corticosteroids since at least the fall of 2003. Imuran was started in September 2003. The treatment notes from December 2003 indicate the patient was in remission and away from steroids. The patient was no longer on Imuran when she presented with a flare-up of her disease in March 2004, which may be an indication the patient will respond to immunomodulator therapy if maintained on the drug. The treatment notes suggest the patient might have had trouble with nausea while on Imuran but this is not clearly documented.

Physician 1: This patient is a 62-year-old female who was diagnosed with a right upper lobe 5 cm mass in February 2004. First-line treatment was surgery. This was followed by adjuvant treatment consisting of chemotherapy, DDP and navelbine with radiation therapy. The patient experienced a relapse one year out and received second-line chemotherapy with gemcitabine and Taxotere. This was followed with Iressa and then Tarceva. The patient has requested authorization and coverage to add Avastin to her treatment plan. The Health Plan has denied this request indicating Avastin has not been shown to be effective for treatment of the patient’s condition.The Health Plan’s denial should be upheld. The data for the combination of therapies involved in this case are very sparse and are not based on randomized controlled trials.

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 Invest Tx Protocol, then check the rights and deadlines that apply to your plan.