Radiation Therapy denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiation therapy to the adrenal glands. Historically, the management of metastatic tumors has been focused on systemic therapies such as chemotherapy. The advent of newer molecular sequencing techniques and targeted therapies has allowed clinicians to provide very tailored systemic therapies to metastatic cancer patients. Patients who respond well to these targeted systemic therapies may demonstrate good disease response throughout most of their body. However, it is still common for certain localized metastatic tumor deposits to continue to grow despite good overall disease control in the rest of the body.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for any or all of the additional components of the requested image-guided superficial radiation therapy services [therapeutic radiology treatment planning; therapeutic radiology simulation-aided field setting, simple; therapeutic radiology simulation-aided field setting, intermediate; treatment devices, design and construction, complex; medical radiation physics, dosimetry, treatment devices, and special services; radiation treatment management; and ultrasonic guidance for placement of radiation therapy fields] in addition to the authorized services [radiation treatment delivery, superficial and/or orthovoltage, per day; therapeutic radiology simulation aided field setting, and basic radiation dosimetry calculation].

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.

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