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

Physician 1:  The patient is a 61-year-old man diagnosed with right lung cancer. He underwent right pneumectomy in April 2004. It was a moderately differentiated squamous cell cancer. Subsequently, he was found to have left lung lesions and lesions in the left lobe of the liver. Chemotherapy was given with mixed results. In December 2005 the first chemoembolization results were uncertain. In April 2006 the patient had a second chemoembolization with no significant impact. Subsequently, the patients provider recommended SIR-Spheres treatment. The Health Plan has determined that the requested therapy is not medically necessary. SIR-Spheres therapy has shown a significant improvement in the control of hepatic lesions from a colon primary. Given the poor prognosis with lung cancer most centers provide only palliative therapies. This patient has lesions in the lung, which are not under any more control than those in the liver. Furthermore, there is no mention of pain symptoms associated with the hepatic lesions. In the absence of documented symptoms, any form of therapy is counterproductive. Therefore, I have determined that the requested therapy 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 61-year-old man diagnosed with lung cancer in 2004. The patient underwent pneumectomy. The patient then developed metastatic disease to the opposite lung and liver. The patient was treated with multiple courses of chemotherapy and chemoembolization of the liver. The patient has progressive metastatic disease in the liver that is unresponsive to chemotherapy and chemoembolization. There is no indication in the submitted records that the patient is experiencing pain. The patient was recommended to receive SIR-Spheres treatment. At issue is whether SIR-Spheres therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapyThis is a patient with lung cancer and metastatic disease to the liver that is unresponsive to chemotherapy and chemoembolization. Unfortunately, the use of SIR-Spheres treatment is not likely to be of benefit in this clinical setting. There is no evidence SIR-Spheres therapy is useful in patients with metastatic lung cancer to the liver who are not experiencing pain. Therefore, I have determined that the requested therapy 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 61-year-old male diagnosed with squamous cell carcinoma of the right lung in 2004, treated surgically. Follow-up exam noted metastatic disease to the left lung as well as to the liver. Since then, the patient has undergone multiple treatments including chemoembolization and systemic chemotherapy. Resection was deemed not feasible and consideration for SIR-Spheres treatment was suggested if the patients lesions were amenable to such therapy. The Health Plan has denied coverage for SIR-Spheres treatment on the basis that it is considered experimental for patients such as this patient.Treatment options for patients with unresectable liver metastases include ablation with radiofrequency, alcohol, cryotherapy, microwave or high dose radiation. Other options include chemoembolization, chemotherapy plus radiation in a clinical trial or systemic or intra-arterial chemotherapy in a clinical trial.  In this case a number of these options have been delivered, however, the rationale for exclusion of the other options is not mentioned in any of the submitted notes. Given the lack of evidence demonstrating that all therapies have been exhausted, as well as the absence of documentation indicating the patient is an appropriate candidate for SIR-Spheres therapy, I have determined that the requested therapy 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.