Selective Internal Radiation Therapy denials: what the review data shows

Where the denial was overturned

A 42-year-old female has requested selective internal radiation therapy (SIRT) for treatment of her breast cancer. Findings: Two physician reviewers found that the patient has a history of left breast infiltrating ductal carcinoma. At the time of her original diagnosis five years ago, she underwent mastectomy with chemotherapy. Her chemotherapy included agents Abraxane, Xeloda, and Navalbine. Despite this treatment, the patient has developed extensive hepatic disease including multiple confluent metastatic foci causing enlargement of her liver. A computed tomography (CT) scan performed one year ago and subsequent positron emission tomography/computed tomography (PET/CT) both confirmed the presence of this extensive disease. The patient also reportedly has skeletal metastases but is currently experiencing her primary symptomatology from the bulky liver disease.

A 63-year-old female enrollee has requested selective internal radiation therapy (radioembolization) for treatment of her metastatic breast cancer. Findings: Three physician reviewers found that in this patient’s case, the requested services are likely to be of greater benefit than other treatment options. The use of selective internal radiation therapy has been tested in various contexts, both as a general strategy for local control of malignant disease of the liver, and also in more specific neoplastic contexts defined by tissues of origin. In the latter category, for example, the treatment of neuroendocrine tumors in the liver is well supported. Although the use of this modality for treatment of liver tumors from metastatic breast cancer is less defined, there is clinical data supporting the safety and efficacy of this approach.

Where the denial was upheld

A 61-year-old male enrollee has requested coverage for selective internal radiation therapy (SIRT) radioembolization of metastatic liver tumors for treatment of his pancreatic adenocarcinoma with liver metastases. Findings: Two physician reviewers found that the patient has a past history of prostate cancer and was found to have multiple liver metastases several years ago. Biopsy demonstrated a signet ring adenocarcinoma with most likely a pancreatic primary. The patient was started on chemotherapy with Gemzar/Xeloda/Tarceva which was continued through three years when progression of disease was noted. He was then switched to Abraxane/Vandetanib and subsequently to FOLFOX with progression of disease. Most recently, the patient had re-staging of disease, with further evidence of progression. Pathology review found either stomach, pancreatic or biliary duct primary.

The representative of a 59-year-old male has requested Selective Internal Radiation Therapy (SIRT) for treatment of liver metastases from colon cancer. Findings: The physician reviewer found that this patient has had a partial hepatectomy and has exhausted chemotherapy choices. The radiofrequency approach was also attempted for hepatic tumor ablation. A stent was placed to relieve his biliary obstruction, and this was also unsuccessful. His options appear to have been nearly exhausted. The hepatic metastases are growing, and he now has an osseous metastasis in the right femur. His bilirubin and creatinine are increasing. A request has been made for SIRT. SIRT is not indicated in patients with advancing disease. It appears that this patient does not qualify for this therapy.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Selective Internal Radiation Therapywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.