Optune denials in California external review
In the California DMHC record, independent physician reviewers decided 17 published external-review cases involving Optuneand overturned the plan’s denial in 94.1%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Optune denials
| Category | Decisions | Overturned |
|---|---|---|
| Glioblastoma | 8 | 87.5% |
| Glioblastoma Multiforme | 8 | 100% |
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. | 10 | 100% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 7 | 85.7% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: A 58-year-old male enrollee has requested authorization and coverage for Optune treatment for treatment of the enrollee’s glioblastoma multiforme. Findings: The physician reviewer found that Central nervous system tumors are classified by the World Health Organization based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV. Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. Chemotherapy prolongs survival, but the gains are modest. The standard of care is to resect the glioblastoma multiforme maximally followed by treatment with temozolomide. Most glioblastoma multiforme tumors recur, and then the treatment options are limited. This patient has exhausted these options.
Nature of Statutory Criteria/Case Summary: An enrollee has requested Optune treatment for treatment of the enrollee’s glioblastoma. Findings: Three physician reviewers found that the Central nervous system (CNS) tumors are classified by the World Health Organization (WHO) based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV (Louis, et al; Kleihues, et al). Glioblastoma multiforme is a high grade tumor that is best treated with resection, radiation therapy, and chemotherapy. The standard of care is to resect the glioblastoma maximally followed by treatment with temozolomide. The U.S. Food and Drug Administration (FDA) approved Optune (formerly NovoTTF-100A) to deliver alternating electrical fields to treat recurrent glioblastoma.
Where the denial was upheld
An enrollee has requested authorization and coverage for continuing treatment with the Optune device and the medication Avastin.The patient has exhausted all treatment options involving surgical resection followed by radiation therapy with concurrent and adjuvant temozolomide. The submitted documentation includes two assessments from physicians caring for the patient that attest to his poor performance status, which would correspond with a grade of 4 on the ECOG Performance Status scale. The patient’s tumor is advanced, and the requested Optune device is not curative.
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 Optune, 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