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

This patient a 60-year-old woman with a history of nasopharyngeal carcinoma first diagnosed when she was 15 years of age. She was treated with external beam radiotherapy. The patient had a remission of her cancer. She developed cervical schwannoma and sarcoma of the scalp in 1995, which was probably radiation induced. The patient presented with worsening difficulty with swallowing. An MRI of the brain was ordered in early 2002 and she was first diagnosed with advanced meningioma of foramen magnum in late 2002. A repeat MRI in May 2003 showed some progression. Another MRI performed in January 2004 showed the growth had increased by 33%. The patient was referred to a provider who recommended the patient participate in a clinical trial involving Avastin. The Health Plan has denied authorization and coverage for the requested therapy on the basis that it is considered experimental for treatment of the patients condition.The patient has a meningioma in a very strategic location. Thus, surgical intervention has serious possible consequences. Strategic radiation either by linear accelerator or gamma knife is generally a very viable option for deep-seated meningioma. However, because of the patients previous external beam radiotherapy, further radiation treatment can cause serious side effects. In the absence of surgical or radiation alternatives, it has been proposed that the patient participate in a phase I clinical trial involving Avastin. Avastin has been approved for treatment of metastatic colorectal cancer. To date, there is no data supporting the efficacy of Avastin in the treatment of meningioma. Thus, there is no evidence that the proposed trial will be of any benefit to the patient. 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.The patient is a 60-year-old female with a progressive foramen magnum meningioma, likely due to previous high dose radiation. She has requested authorization and coverage for participation in a clinical trial with Avastin. The Health Plan has denied the patients request on the basis that the requested therapy is considered investigational for treatment of meningioma.Analysis and Findings:Avastin has never been tested in any form of tumor involving the central nervous system. The proposed trial is a phase I trial where the primary goal is to determine the safety and tolerability of the proposed agent. Furthermore, the proposed trial involves primary brain tumors (glioma) rather than meningioma, which is the patients condition. There is no evidence that Avastin will be useful for treatment of the patients meningioma. 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.The patient is a 60-year-old woman with a foramen magnum meningioma. The standard of care for meningiomas is surgery or combined modality surgery plus radiation. Due to the patients prior history of nasopharyngeal carcinoma and subsequent radiation therapy, she is not a candidate for further radiation. Because of local involvement by the tumor of a vertebral artery, as well as the size and position of the tumor, the projected post-surgical neurological sequelae could include loss of ability to swallow and possible stroke with neuromotor disabilities. It has been recommended that the patient participate in a phase I trial of Avastin, for which the patient now seeks coverage. The Health Plan has denied authorization for the requested therapy on the basis that it is considered experimental for treatment of the patients diagnosis.Analysis and Findings:The standard of care in this case would involve an effort to debulk the tumor. Newer techniques (as compared to conventional surgical techniques) include radiosurgery, which may yet be an option for this patient. Further, there is no evidence that Avastin will be beneficial for this patient. 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.