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

Physician 1The patient is a 59-year-old man who had lung surgery in August 2002. At that time he had resection of his right lower lobe, revealing a poorly differentiated squamous cell cancer, 3cm in size, with negative nodes. In March 2003, the patient developed two areas of endobronchial recurrence. He then underwent chemotherapy with little response. An endobronchial biopsy in June 2003 again was positive. The patient was treated with external beam radiation therapy from June 2003 to July 2003. Repeat bronchoscopy in September 2003 showed persistence of one of the lesions and the patient was treated with local brachytherapy to this lesion.In December 2003, CT scan of the chest demonstrated two new pulmonary nodules, each about 1cm in size. One was at the right lung base and the other was in the superior segment of the right lower lobe. Biopsies of the endobronchial lesions in February 2004 and April 2004 were positive for recurrent cancer. The patients provider has recommended that the pulmonary nodules be treated with radiofrequency ablation (RFA). The Health Plan has denied authorization and coverage for RFA on the basis that it is considered experimental.The patient was diagnosed with lung cancer in mid 2002. He had endobronchial recurrences in 2003 that were treated with radiation and now apparently has experienced endobronchial recurrences again. In addition, the patient has two new metastatic lung nodules distant from the endobronchial recurrences.RFA is a technique being actively investigated as an alternative to surgery and/or radiation for the control of localized areas of cancer. It has been used palliatively for pain control, and is being explored in a variety of situations. There is no indication that RFA will offer this patient any significant benefit in terms of survival, especially since the two peripheral nodules are not the patients only sites of disease. Even if the recent endobronchial recurrences were not present, it is unlikely that the two nodules are the patients only areas of cancer. Thus, though it is possible that RFA could be used to eradicate these two nodules, it is very unlikely that such a procedure would have any impact on the patients overall course or survival. In addition, there are potential complications from RFA in the lung. Furthermore, if removal of these two nodules is critical, they can be removed surgically. There is no evidence that RFA in this situation is likely to result in significant clinical benefit. 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 2The patient is a 59-year-old man who underwent a right lower lobectomy for a poorly differentiated non-small cell cancer in August 2002. In January 2003, a CT of the chest was negative but bronchoscopy revealed a recurrence of the tumor. YAG laser opened the airway, and was followed by external beam radiation therapy to 6600 cGy and brachytherapy. This treatment was completed in July 2003. Meanwhile, a CT scan in June 2003 revealed two new lesions on the right side, one in the lung base, and one in the superior of the right lower lobe of 1cm in diameter.Additionally, a 1cm mass posterior to the trachea at the level of aortic arch and between the trachea and esophagus was described. The patients provider has recommended radiofrequency ablation (RFA) of the lesions. The patient has exhausted all options with chemotherapy and radiation therapy. The patients condition is not curable by any method. At this point there is no indication to treat for palliation because no symptoms have been produced by the patients metastases. RFA for the treatment of future symptoms carries potential complications including pneumothorax and fistula from the tracheo-esophageal mass. Furthermore, RFA is likely to cause the patient to develop symptoms as a result of the therapy. However, since all other therapy has been exhausted, RFA remains the only treatment available to the patient. Therefore, I have determined that the requested procedure 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 3The patient is a 59-year-old man who was diagnosed with non-small cell lung cancer (NSCLC) of the right lower lobe in February 2002. He underwent lobe resection and mediastinal lymph node sampling for what ultimately was found to be a T1N0 NSCLC. He developed recurrent cancer in March 2003 and underwent external beam radiation therapy as well as brachytherapy to a residual endobronchial lesion in November 2003. The submitted records note that first and second line systemic chemotherapy was administered. On a CT scan in early 2004, the patient was found to have two small nodules in his right lung as well as a larger paratracheal mass, but without sites of additional disease.A recent bronchoscopy noted a persistent and enlarging tracheal mass that has undergone YAG laser treatment as well as stent placement. There is also a pathology report from April 2004 that reveals squamous cell carcinoma of the bronchus. The patient apparently has at least four sites of disease: trachea, right bronchus (or bronchial tree) and two pulmonary parenchymal lesions. The first two sites of disease are being palliated with stenting and YAG laser treatment, while the latter two sites of disease appear to be asymptomatic. A request has been made for radiofrequency ablation (RFA) treatment of the two pulmonary parenchymal lesions.The patient has recurrent NSCLC with current sites of active disease consisting of a tracheal lesion, a separate endobronchial lesion and two pulmonary parenchymal lesions. He is undergoing palliative treatment for the tracheal and endobronchial lesions, but the pulmonary lesions appear to be asymptomatic. There is no indication of any planned cytotoxic therapy, and the patient cannot undergo further radiation therapy given the previous treatment. RFA of metastatic or unresectable cancers of the pulmonary parenchyma (either primary or metastatic) has been reported. There are reports of the side effects as well as early reports of the success for local disease control. However, there is no data that would support the treatment of metastatic NSCLC beyond the two front-line chemotherapy regimens. In addition, as the lesions are currently asymptomatic, there is no evidence that treatment of these metastatic sites will improve the patients survival when the ongoing treatment of the symptomatic lesions is palliative, at best.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 sta