Surgery denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1: The patient is a 54-year-old female diagnosed with breast cancer in 2004, treated with mastectomy, chemotherapy, and localized radiation. At present, she has been diagnosed with isolated liver metastasis with documented growth despite chemotherapy. According to the submitted notes, the treating oncologist has identified one main lesion putting pressure on the nearby biliary ducts and recommended a consultation for consideration of stereotactic body radiosurgery. The Health Plan indicates stereotactic body radiosurgery is considered investigational and therefore, is not a covered benefit.Treatment options in cases such as this include clinical trial with Phase 1 chemotherapeutic drugs, ablative treatment (radiofrequency, cryotherapy, microwave, or high dose rate brachytherapy), chemoembolization, radiation therapy (conformal or stereotactic), or supportive care.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prophylactic lymphovenous bypass surgery. Researchers state, “In the United States, breast cancer is the most common cause of lymphedema owing to its prevalence. It is estimated that 20% to 50% of patients who undergo complete axillary lymph node dissection (ALND) for breast cancer go on to develop lymphedema. The variability in rate is due, at least in part, to differences in the diagnostic criteria and the length of follow-up. The advent of sentinel lymph node biopsy has decreased the need for ALND and reduced the rate of lymphedema to 5% to 7%.” The authors further note, “Lymphovenous bypass (LVB) procedures are also being used prophylactically in patients undergoing lymph node dissection, and outcomes are promising.

Where the denial was upheld

Physician 1The patient is a 59-year-old male who received brachytherapy for prostate adenocarcinoma in October 1998. PSA levels have fluctuated from 1.0 in December 1999 to 5.0 in July 2004. The patient has recently been experiencing poor bladder emptying. A CT scan of the abdomen and pelvis performed in August 2004 revealed small prostate with seed implants, no enlarged lymph nodes, fatty liver, small right renal cyst, small right renal stone, and mild left pelviectasis vs. small parapelvic cysts. A bone scan revealed no evidence of metastatic disease. The patient wishes to undergo cryosurgery. The Health Plan has denied authorization and coverage for cryosurgery on the basis it is considered investigational.

The patient is a 57-year-old male diagnosed with prostate cancer. He had medical problems including diabetes mellitus, hypertension, and hypercholesterolemia, and was not experiencing erections or engaging in sexual activity.PSA was elevated at 13.7 in February 2006, and unilateral prostate induration was palpable on digital rectal examination. Ultrasound-guided prostate biopsy performed in April 2006 revealed a Gleason grade of 4+3 adenocarcinoma of the prostate involving 30% of the biopsy specimen from the left side and 5% of the biopsy specimen from the right. Prior to treatment the patient was diagnosed with a Gleason grade total 7, clinical stage T2c adenocarcinoma of the prostate.In April 2006 alternatives for treatment were discussed with the patient including radical surgery, external radiation, and brachytherapy, and a bone scan was ordered.

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