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

Physician 1: The patient is a 64-year-old man with cutaneous melanoma metastatic to skin (resected), and the brain (treated with gamma-knife). An MRI performed in April 2005 revealed a recurrence to the brain. It is not known what treatment the patient is receiving for the brain recurrence. There has also been a recurrence in the lung, which is asymptomatic. The patient has a history of bladder cancer with no evidence of disease as of March 2005. He has been offered surgical clearance of the lung metastases and is interested in microwave ablation of all of his pulmonary lesions.The published literature does not provide information on the safety or efficacy of microwave ablation for lung metastases. In patients such as this patient with widespread metastatic disease there is no proven survival benefit to removing multiple lung nodules even by the traditional surgical method. Though this patient has done better than predicted with his brain metastases, these are still the most active and threatening sites of disease. Furthermore, the patients lungs are asymptomatic and there is an overall unfavorable risk/benefit ratio for any of three ablative methods proposed. 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.Physician 2: This patient is a 64-year-old man with a history of grade III bladder cancer diagnosed and treated in January 1996. In addition, the patient has had cerebellar metastasis, which was treated by radiosurgery. In May 2003, a CT scan showed three lesions in both lungs. In May 2005, a CT scan showed the lesions had enlarged. A needle biopsy of the left lung mass shows metastatic melanoma. The Health Plan physicians have recommended a surgical approach to the left-sided lesion and radiofrequency ablation for the remaining lesions. The patient wishes to undergo microwave ablation. Both microwave and radiofrequency are high frequency electromagnetic waves. They both produce heat as the destructive energy by which the tumor is killed. There is no evidence in the peer-reviewed literature demonstrating microwave ablation is superior to radiofrequency ablation. Given the similar efficacy of the two methods, there is no evidence the requested therapy will result in a better clinical outcome for this patient. The treatment offered by the Heath Plan is medically reasonable and appropriate. 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.Physician 3: The patient is a 64-year-old man with a history of melanoma diagnosed in 1996 who now has recurrent disease involving the lungs, brain and skin of the flank. The metastatic disease (pulmonary) was diagnosed in 2003. No therapy has been directed at the pulmonary metastases, though the brain metastasis has been treated with gamma knife surgery and the flank skin lesion was excised. Most recent imaging documents progression of metastatic disease. The CT of the chest performed in April 2005 was compared to that of January 2005. The most recent scan demonstrates enlargement of the pulmonary lesions of the right upper lobe (1.9 cm), left upper lobe (3.4 cm) and right lower lobe (1.2 cm), all of which are hypermetabolic on PET scanning consistent with metastatic disease. The left upper lobe lesion is adjacent to the aortic arch, which may limit therapy with radiofrequency ablation. In addition, a brain MRI done in April 2005 demonstrated the stable cerebellar lesion that was treated with gamma knife surgery as well as two new metastases in the anterior left parietal lobe and left occipital lobe.The patient remains asymptomatic and has not received any systemic therapy. Request has been made for microwave ablation of the three pulmonary metastases. The Health Plan has denied this request indicating the efficacy of the requested therapy has not been established.The patient was seen by a thoracic surgeon who felt that the lesions were amenable to surgical resection. In the treatment of metastatic melanoma, there may be some benefit from aggressively treating isolated or stable metastases; treatment of these pulmonary metastases must be carefully measured against the progressive brain disease seen most recently on the brain MRI. Surgical resection of metastases in the treatment of melanoma remains the standard and whether non-resectional/ablation techniques provide the same benefit is unknown. Whether microwave ablation is effective in the treatment of pulmonary metastases is completely unknown as there have been no studies evaluating survival or local control. Surgical resection is considered the preferred treatment in cases such as this case.Based upon the information set forth above, 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.