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

Physician 1: The patient is 60-year-old male with a complicated medical history who has been diagnosed with metastatic, stage IV, non-small cell adenocarcinoma of unknown primary origin. His chemotherapy regimen includes Taxotere and carboplatin. As available evidence suggests the lung may be the primary site of his cancer, his provider has recommended the addition of Avastin. The Health Plan has determined that the efficacy of Avastin is unproven in this clinical setting and therefore has denied coverage for the therapy.  The use of Avastin in this setting is apparently based on the large, recently reported study cited above. Though it is only one study, it included 850 patients with good randomization between the group treated with chemotherapy alone versus the group treated with chemotherapy and Avastin. In male patients with adenocarcinoma, the group who received the Avastin had a higher response rate and improved length of survival. Accordingly, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 60-year-old male with recently diagnosed Stage IV adenocarcinoma of unknown primary  CUP.  His provider has recommended chemotherapy with Taxotere and carboplatin with the addition of Avastin.  The patients request for authorization of Avastin was denied by the Health Plan citing the experimental/investigational nature of the therapy.FDA approval of Avastin (bevacizumab) for non-small cell lung cancer therapy is based on the survival benefit demonstrated in a large multi-institutional study. Although the diagnosis and treatment of patients with CUP is vexing for the oncology specialist, the preponderance of the data in this particular case implicates a lung primary cancer. Avastin is an FDA approved, standard, survival-enhancing therapy that should be made available for this patient who has a clinical picture consistent with adenocarcinoma from a lung primary.  In fact, that is the treatment perspective of his oncologist and Avastin therapy would constitute the best standard of care. Therefore, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: This patient is a 60-year-old male with adenocarcinoma of unknown primary.  After consideration of various radiographic studies, it is believed to be a lung cancer. The patient is currently undergoing chemotherapy with carboplatin and Taxotere and his provider would like to include Avastin in his treatment regimen. The Health Plan denied the providers request for authorization asserting there is insufficient data supporting the efficacy of Avastin therapy for patients such as this one.When treating patients with an unknown primary, the principle adhered to by most oncologists is to treat what you think you can treat.  As such, the most likely first degree is that of lung cancer, and the best treatment must be directed by that supposition.Recent data indicates there is a survival advantage associated with the utilization of Avastin in combination with carboplatin and Taxotere for patients with lung cancer.  Based on the principle noted above, I have determined that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.