Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 60-year-old woman who was diagnosed with a mucinous adenocarcinoma of the appendix in July 2002. She underwent a right hemicolectomy with no evidence of metastasis to the regional mesenteric lymph node basin. The patient received adjuvant chemotherapy of 5-FU/leucovorin. She was noted to have a mildly increased CEA in 2003 and a CT scan demonstrated a complex cystic mass in her pelvis, suspicious for recurrent disease. An in-plan provider then treated her in November 2003 by surgical debulking that included resection of three feet of small bowel, a low anterior resection, hysterectomy, bilateral salpingo-oophorectomy, omenectomy and peritonectomy of the paricolic gutters. She received intraperitoneal hyperthermic chemotherapy of mitomycin C. Her CEA level returned to normal, and in June 2004 she underwent closure of her ileostomy. At that time, however, three nodules consistent with recurrent disease on the serosa of the small bowel were excised.In January 2005, a CT scan of the abdomen and pelvis demonstrated recurrent peritoneal adenomucinosis. The patient remained asymptomatic and was therefore observed without treatment. Her CEA tumor marker has steadily risen during 2005 and repeated CT scans in July 2005 and October 2005 have demonstrated increasing peritoneal adenomucinosis as well as an enlarging right lower lung nodule, measuring 1.2 cm on the last CT scan. The patient has consulted several providers who recommend surgical debulking of her disease; some have also supported concurrent administration of intraperitoneal hyperthermic chemotherapy. The Health Plan has authorized the surgical debulking procedure, but has denied the request for intraperitoneal hyperthermic chemotherapy on the basis that its benefits have not been demonstrated.The patient is a 60-year-old woman with recurrent peritoneal adenomucinosis (or psuedomyxoma peritonei) having originally been diagnosed with a mucinous adenocarcinoma of the appendix in July 2002. The use of intraperitoneal hyperthermic chemotherapy in pseudomyxoma peritonei remains controversial. The data that supports this has come primarily from one physician; no randomized clinical trial has been performed that demonstrates the benefit of this approach. Review of the available data indicates patient selection has likely biased the outcomes that have been obtained, as patients with favorable outcomes (appendiceal primary, low grade histology, absence of ascities) are likely to do well independent of the use of intraperitoneal hyperthermic chemotherapy. Furthermore, there is no data on the effectiveness of treating patients with more than one round of therapy. Moreover, the requesting provider states that the chemotherapy he will likely use is melphalan (the first treatment used mitomycin C) and there is no data at all on the use of intraperitoneal hyperthermic melphalan in the treatment of pseudomyxoma peritonei.The patient is currently asymptomatic and the disease is slow growing (recurrent disease first detected in January 2005). The risk of treatment with intraperitoneal hyperthermic chemotherapy and surgical debulking outweighs any potential benefit, as this approach has an established mortality of 2-12%. Given the lack of available data to support the benefit of intraperitoneal hyperthermic chemotherapy (specifically melphalan) in a patient already treated with surgical debulking and intraperitoneal hyperthermic chemotherapy (mitomycin C), I have determined that the requested chemotherapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.