Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician #1:  This patient is a 53-year-old female apparently treated with chemotherapy in the past for ovarian cancer. She has recently been found to have progressive disease, as evidenced by a rising CA-125 and positive PET scan. The patient was started on Doxil intravenous chemotherapy, but is requesting authorization for treatment with intraperitoneal hyperthermic chemotherapy. The Health Plan denied the request based on a determination that the procedure is experimental/investigational for the treatment of ovarian cancer.Intraperitoneal chemotherapy for the treatment of ovarian cancer has been studied for many years. Although the data has not been consistent, a recent review of the published, randomized studies did indicate that intraperitoneal chemotherapy, in combination with intravenous chemotherapy, might prolong survival. However, this outcome has only been demonstrated when such therapy is used as the primary chemotherapeutic treatment for ovarian cancer. There is no convincing data demonstrating that intraperitoneal chemotherapy is superior to intravenous chemotherapy alone in the treatment of advanced, recurrent, previously treated ovarian cancer. There is interest in hyperthermic intraperitoneal chemotherapy, but there are no randomized studies to suggest that this approach would offer any added benefit. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician #2:  The patient is a 53-year-old female with metastatic ovarian cancer.  The record is limited as to her past medical history, but she is currently being treated with Doxil. The patient has explored the option of treatment with intraperitoneal hyperthermic chemotherapy and submitted a request for authorization to her Health Plan.  The Health Plan considers this an investigational procedure and authorization was denied.There is a Level I clinical study that demonstrates stage IV ovarian cancer can be appropriately treated with surgery to reduce the tumor burden and intraperitoneal chemotherapy with or without systemic chemotherapy.  There is no evidence yet to support the premise that hyperthermic therapy in combination with surgery and intraperitoneal chemotherapy is a superior treatment approach. Further randomized, prospective, controlled clinical trials are needed before hyperthermic therapy can be considered the standard of care.  Such trials are currently underway under the auspices of the National Cancer Institute.  Based upon the information set forth above, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician #3:  The patient is a 53-year-old female with recurrent ovarian cancer.  The details of her previous treatment regimens were not provided, nor was the pathology report.  Nonetheless, her oncologist indicates she has a rising CA-125 and metastatic activity was visible on a recent PET scan.  It appears the patient has researched alternative treatments, and wishes to undergo intraperitoneal hyperthermic chemotherapy. The Health Plan has denied authorization and coverage for this procedure on the basis that it has not been shown to be efficacious in the treatment of recurrent ovarian cancer.Intraperitoneal chemotherapy has a role in the treatment of optimally debunked, stage III ovarian cancer and possibly in some cases of recurrent ovarian cancer. However, the published data on hyperthermic intraperitoneal chemotherapy is limited, and deals primarily with gastrointestinal cancers. There is no data that supports this treatment approach as standard therapy for recurrent ovarian cancer. Based on the currently available data, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.