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

Nature of Statutory Criteria/Case Summary: A 43-year-old female enrollee has requested authorization and coverage for VistaSeq hereditary cancer panel for evaluation the enrollees breast cancer. Findings:  The physician reviewer found that The identification of a pathogenic germline mutation in certain genes can have a significant impact on the care of a patient. The genes that have been identified at this point have associated clinical syndromes. These syndromes help describe the risk of certain medical diagnoses and cancers. Identification of patients with pathogenic germline mutations in these genes can result in improved surveillance care, preventative health measures, and prophylactic interventions that can decrease ones risk of cancer and/or permit detection of cancer at early stages which are still amenable to curative therapy. VistaSeq is a multi-gene panel that evaluates 27 genes associated with inherited susceptibility for malignancy. There have been multiple genes associated with young onset breast cancer they include: BRCA1/2, ATM, CHEK2, PALB2, PTEN, p53, CDH1. Since there are a number genes that can be associated with a risk for developing breast cancer, multi-gene panel testing with next generation sequencing is the optimal means to evaluate patients who fulfill the above criteria. In conclusion, multi-gene panels, like that offered by VistaSeq, is an effective and efficient way to assess a patients risk of carrying a germline mutation and the results could have a significant impact on the patients medical management.  For the reasons provided, VistaSeq hereditary cancer panel is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.