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

Physician 1:  The patient is a 68-year-old female first diagnosed with bronchoalveolar carcinoma of the lung in August 2004. She was originally treated what Iressa, and then with Tarceva. In April 2006 she was found to have progressive disease and began chemotherapy with carboplatin and Taxol. The patients provider recommends that Avastin be added to this chemotherapy regimen.  The Health Plan denied the requested authorization based on a determination that the therapy is experimental/investigational in this clinical setting.Avastin is a member of a relatively new class of drugs, which presumably interfere with tumor angiogenesis. It is similar in some ways to both Iressa and Tarceva. Avastin has been approved for use, in combination with chemotherapy, in colon cancer and is being actively studied in other cancers. A recently reported trial in non-small lung cancer did demonstrate some mild prolongation of survival in these patients when Avastin was added to their chemotherapy. However, in this study the treatment was used as first line treatment, not in patients already treated with drugs such as Iressa and Tarceva. Additionally, it is not clear that the advantage of adding Avastin was realized in patients with the particular histologic type of lung cancer (bronchoalveolar). There is as yet, no known clinical benefit with the use of Avastin in this setting.For these reasons, 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.Physician 2:  The patient is a 68-year-old female with stage IV non-small cell cancer of the lung (NSCLC) and multi-focal lung disease. She is currently treated with carboplatin and Taxol. Her provider has recommended the addition of Avastin to her regimen. The Health Plan has classified this approach as experimental/investigational for the treatment of lung cancer and has denied coverage for the therapy.  There is evidence for a survival advantage when Avastin is included as a component of chemo-immunotherapy for patients with Stage IV lung cancer.  The efficacy of Avastin has always been balanced with the possibility of the blood dyscrasia associated with its use and the increased risk of bleeding.  For an eligible, well-informed patient that meets the criteria for treatment, such as in the clinical scenario under consideration, adding Avastin is likely to result in a clinical benefit greater than that provided with her present therapeutic regimen.  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:  The patient is a 68-year-old woman with lung cancer.  She was diagnosed in August 2004 and initially treated with Iressa, then Tarceva.  The patient began treatment with carboplatin and Taxol following an April 2006 chest CT that showed left lung metastases. The patients provider has recommended the addition of Avastin to her treatment regimen. The Health Plan has determined that the use of Avastin remains unproven for the treatment of lung cancer and therefore has denied authorization and coverage for the therapy.  The patient has a history of lung cancer and has been treated with EGFR blockage. The 2004 Johnson study and the recent alert published by the National Cancer Institute both note an improvement in survival with the incorporation of Avastin.  As such, the addition of Avastin to the patients treatment plan is medically appropriate.  Based upon currently available data, 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.