Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Non-small-cell lung carcinoma
Treatment: current procedural terminology (CPT) code: 0242U: targeted genomic sequence analysis panel, solid organ neoplasm, cell free circulating deoxyribonucleic acid (DNA) analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements

The insurer denied coverage for current procedural terminology (CPT) code: 0242U: targeted genomic sequence analysis panel, solid organ neoplasm, cell free circulating deoxyribonucleic acid (DNA) analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements.
The denial is overturned.

This case involves a male with a history of non-small lung carcinoma, drug abuse, atrial fibrillation, coronary artery disease, chronic obstructive pulmonary disease, dyslipidemia, hyperparathyroidism, hypertension, peripheral vascular disease, and prostate cancer. The patient presented for an oncologist visit secondary to non-small cell lung carcinoma. The patient was diagnosed with squamous cell carcinoma of the right middle lobe of the lung years ago. The patient was started on radiation treatment on the second week. He concurrently utilized paclitaxel. He completed concurrent chemotherapy and radiation. He was initiated on consolidation chemotherapy with carboplatin and paclitaxel. He received his first cycle. Following the treatment, he was hospitalized with pneumonia. He had a follow-up Positron emission tomography (PET) scan. He was considered to have progressive disease and was started on Keytruda. He had a complicated course with multiple admissions. His treatment was interrupted due to poor functional status. A computed tomography (CT) scan completed showed a mass-like opacity in the right hilar region that measured 8.78 x 5.7 centimeters (cm). There were numerous additional nodules throughout the right lower lobe. There was a new mass in the right upper lobe that measured 16 mm (millimeter). A CT scan showed a right middle lobe necrotic mass that measured 5.1 x 3.69 cm. There was mild progression in the multifocal right lower lobe interstitial and alveolar opacities and atelectasis. He had been discharged from the hospital and recommended to go on hospice. Options of management included palliative care hospice, rechallenge with immunotherapy, and further work-up for targeted mutations. A Guardant 360 deoxyribonucleic acid (DNA) panel was ordered.  

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome with the requested testing. The NCCN (National Comprehensive Cancer Network) Guidelines note that molecular diagnostic studies and non-small cell lung cancer can lead to targeted treatment therapies and avoidance of therapy that is unlikely to provide clinical benefit. The Food and Drug Administration (FDA) notes that Guardant360 is used to help providers decide if patients with non-small cell lung cancer are eligible for treatment with Osimertinib.  

The requested panel has final approval from the appropriate regulatory bodies for the patient's diagnosis. The FDA notes that Guardant360 is recommended to help providers decide if patients with non-small cell lung cancer are eligible for treatment with Osimertinib.  

The patient is a good candidate for the CPT code 0242U. 

There are no adverse risks over standard treatment/services. Per the FDA, there are no known reasons to not utilize the testing. It has been found to be safe and effective for the patient's diagnosis.  

The requested service is likely to be more beneficial than any other standard treatments/ procedures.

The carrier's denial of current procedural terminology (CPT) code: 0242U: targeted genomic sequence analysis panel, solid organ neoplasm, cell free circulating deoxyribonucleic acid (DNA) analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements should be overturned.