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 who previously had been diagnosed with non-small cell lung carcinoma as well as coronary artery disease, atrial fibrillation, chronic obstructive pulmonary disease, hypertension, prostate cancer, and peripheral vascular disease. The documentation indicated he was seen for a transition of care. The documentation indicated the patient was initially diagnosed with lung cancer years ago. He did initiate radiation and was started on concurrent paclitaxel he completed concurrent chemotherapy and radiation in the first week. A CT (computed tomography) scan performed showed decreasing size of dominant right middle lobe nodule as well as a decrease in size of right hilar adenopathy. There was a new nodule to the left upper lobe with an additional nodule noted. He was initiated on consolidation chemotherapy. Following the treatment, he was hospitalized as he developed symptoms of pneumonia. He then had a complicated course with multiple admissions. A CT scan performed did show a mass-like opacity to the right hilar region with numerous additional nodules throughout the right lower lobe. There was a new mass in the right upper lobe measuring 16 mm (millimeters) and additional right upper lobe lateral mass measuring 2.6 cm (centimeters). The documentation indicated he was recommended he move closer to family and be placed on hospice. The recommendation was also made per physician to undergo the DNA panel in question.

The scientific evidence in peer reviewed literature does support a result of improvement in health outcomes. Per NCCN (National Comprehensive Cancer Network) guidelines, Non-Small cell Lung carcinoma, molecular diagnostic studies in non-small cell lung cancer allow for discovery of alterations to identify potentially efficacious targeted therapies as well as avoidance of therapy unlikely to provide clinical benefit.

The performing of the molecular and biomarker analysis, as noted above is the mechanism to determine if the tumor has actionable mutations. In other words, this will provide the treating physician with the knowledge of the existence of any mutations that have specific targeted therapy that can be delivered. If mutations exist, then the appropriate therapy can be provided. This therapy is generally less toxic than general chemotherapy thus, it will be safer and more effective for the patient. If no actionable mutations are found, then the treating physician can use appropriate chemotherapy or immunotherapy as he deems appropriate with the knowledge that there are no specific targeted therapies that could be used instead. The molecular analysis will allow for the treating physician to provide the most efficacious and safe therapy for the patient. 

The requested service is likely to be more beneficial than any of the standard treatments/ procedures for this patient.

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.