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

Physician 1: The patient is a 58-year old woman experiencing progressive respiratory difficulty resulting from chemo-refractory, bilateral, bronchoalveolar cell carcinoma. The patient underwent a right upper lobe and right middle lobe lobectomy in 2002. The tumor recurred about a year later in both lungs. The cancer has progressed despite treatment with Iressa and then with Tarceva. The results of recent tests including a spirogram, coronary arteriogram, PET scan, CT scan and mediastinoscopy biopsies are described and are consistent with extensive bronchoalveolar cell carcinoma despite bilobectomy and chemotherapy.The patients provider has recommended the patient undergo lung transplantation. The Health Plan has denied coverage for the proposed procedure on the basis that it is an experimental treatment for bronchoalveolar cell carcinoma.Lung transplantation for patients with bronchoalveolar cell carcinoma has been reported and is included as part of the documents for review. The numbers reported are small. The reported survival rate is low and is lower in those who, as in this patient, have more extensive disease. Lung transplantation for bronchoalveolar cell cancer is experimental at the present time. The patient is not enrolled in a clinical trial.  Systemic chemotherapy remains a therapeutic option in this patient. I have determined that lung transplantation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2: The patient has been diagnosed with alveolar carcinoma and was treated with bilobectomy in 2002. She experienced bilateral lung recurrence of bronchoalveolar carcinoma of the lung and has not responded to appropriate medical therapy. A PET scan is positive in both lungs only. The patients respiratory function has deteriorated and she requires home oxygen. The patients provider indicates the patient is an appropriate candidate for bilateral lung transplantation. The Health Plan has denied coverage for the recommended procedure indicating it is considered experimental for patients such as this patient.The patient has requested bilateral lung transplant for treatment of recurrent bronchoalveolar carcinoma. The patient had progression of disease despite appropriate medical therapy. Studies of PET and CT scans suggest the disease is limited to the patients lungs. All of the submitted papers show only a limited number of patients in a research setting. Results of transplant were worse for advanced stages (survival was less than 25% in one study and 39% and 14% in another study). Given these results, the proposed procedure remains experimental and cannot be recommended at this time. 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 3: This is a 58-year-old woman with bronchoalveolar cell carcinoma, status post right upper middle lobectomy with pulmonary recurrence. The patient and her provider have requested authorization for a lung transplantation procedure. The Health Plan has denied this request on the basis that lung transplantation is considered experimental for treatment of bronchoalveolar cell carcinoma.Based upon review of the relevant literature, chemotherapy is likely to provide the patient with only a 10-20% response rate. One of the submitted articles shows the five-year recurrence free survival rate in 69 patients with transplant was 35% and patient survival was 37%. Additionally, in the Paloyan, et. al article, the issue of cardiopulmonary bypass is suggested by the authors to be beneficial rather than deleterious. Lung transplantation offers the best chance of survival in this clinical setting. 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.