Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Ovarian Cancer
Treatment: Pharmacy/Prescription Drugs/ Lynparza

The health plan denied the requested medication, Lynparza. 
The health plan's determination is overturned.

The patient is a female. She was seen in the office. This note states that the patient has a history of recurrent ovarian cancer status post Doxil/Avastin for recurrence and is now on Avastin maintenance. It goes on to state that the patient was placed on Lynparza prior to her recurrence, however it recurred during maintenance. The plan stated was to continue with a total of 12 cycles of Avastin. The patient's problem list includes the fact that she is breast cancer antigen (BRCA) 1-positive. Additionally, there is a computed tomography (CT) showing a new periportal lymph node compatible with recurrence of disease.
She was previously seen at which time it was noted that the patient was treated with Doxil/Avastin after undergoing a secondary debulking. She completed Doxil/Avastin, after which she was being treated with Avastin and Zejula (in context of the rest of the materials this is felt to be likely an error, with the physician meaning to indicate the patient to be on Lynparza rather than Zejula). The patient was noted to have a cancer screening blood (CA-125) level that was rising at that point. She was noted to have completed cycle #19 of Bevacizumab.
A note from radiation oncology again states the patient has a BRCA1 mutation. This note states that the patient underwent initial surgery in  followed by Carboplatin/Paclitaxel. The patient underwent surgery for removal of a pelvic recurrence and received Carboplatin/Doxil/Bevacizumab. Then Bevacizumab starting through present.
At issue is the medical necessity of the requested medication, Lynparza.

The health plan's adverse benefit determination of medical necessity is overturned, in whole.
 
After consideration of the available documentation, it does not appear the health plan's determination of medical necessity would be aligned with standard of care of most gynecology oncologists in this matter. Lynparza does appear to be medically necessary for this patient given the documentation available.
It is noted that there are some inconsistencies in the documentation. However, after consideration of all available materials, it appears that this patient was using Bevacizumab with Lynparza and has experienced an extraordinarily long disease-free interval after completion of Doxil/Avastin. The records indicate that the patient has been on and requested medication for over a year and has just recently been found to have radiologic evidence of disease. Given the long interval of being radiologically disease-free, it is likely that this therapy which the patient is currently being treated with is providing some benefit in terms of slowed progression of disease.
This patient has recurrent ovarian cancer and essentially has no hope of cure. Therefore, all treatment is essentially palliative, meaning the intent is to slow progression and/or relieve symptoms. This patient has no symptoms currently and has had a long disease-free interval. It does appear that she is receiving palliative benefit to this. Therefore, as she has no hope of cure, this tolerable regimen that appears to be slowing progression is the best possible outcome that could occur, and it is recommended that she be allowed to continue using it until it is intolerable or until she has rapid progression of disease.
As discussed above, in this setting all treatment is palliative (i.e., this patient has no hope of long-term cure). Given that the regimen is tolerable and has provided a very slow progression/recurrence of disease, it appears to be providing palliative benefit and she should be allowed to continue it.