Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1The patient is a 49-year-old female who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy and debulking of tumor in July 2002 for ovarian cancer. In September 2002, the patient developed right upper quadrant abdominal pain. CT scan revealed two lesions in the right lobe of the liver. Biopsy was positive for metastases. Taxol and carboplatin resolved the metastases and a CT scan performed in March 2003 showed no residual tumor. In September 2003, the patients CA-125 began to rise and metastases were confirmed as recurrence in the liver. Gemzar was initiated and a consultation regarding radiofrequency ablation (RFA) was sought. In February 2004, the patients CA-125 increased to 304 from 182. The patient had discontinued chemotherapy due to toxicity. A CT of the abdomen in February 2004 revealed a 3cm mass in the liver. In April 2004, a CT of abdomen revealed a 7.2 x 4.1cm mass in the liver in the right post lobe and a 3 x 2.8cm mass in the right anterior lobe.The patient has an incurable situation with her metastatic ovarian cancer. She had been on chemotherapy to control her hepatic metastases with high toxicity (the patient discontinued chemotherapy). One of the patients metastases has increased in size from 3cm in diameter on 2/20/04 to 7.2cm on 4/14/04. Her initial tolerance to chemotherapy was good and the response to the tumor extraordinary.RFA has been approved by Medicare as an effective therapy for hepatic metastases. Given the size of the larger tumor on 4/14/04, surgery for the resection of the metastases is still the gold standard and should be pursued. If surgical resection is not possible, the patient should be placed on chemotherapy for one to two months in order to try to reduce the size of the larger mass. After chemotherapy, RFA would be indicated to destroy the two masses.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 at this time. The Health Plans denial should be upheld at this time. Surgical resection of the masses should be pursued. If surgical resection is ruled out, then RFA should be authorized after one to two months of chemotherapy.Physician 2The patient is a 49-year-old woman with a recurrent ovarian cancer who has requested treatment of two hepatic metastases by radiofrequency ablation (RFA). The patient was diagnosed in July 2002 and underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy and maximal tumor debulking. Two hepatic metastases were identified in September 2002, which were apparently confirmed by biopsy. The patient was treated with systemic Taxol and carboplatin with resolution of these lesions on CT scan. Her tumor marker of CA-125 remained normal until September 2003, when it began to rise. A repeat CT scan revealed recurrence of one of the hepatic metastases. She was treated with gemcitabine with stabilization of the hepatic lesion by radiologic evaluation.The patient has been evaluated by a provider who indicates that laparoscopic RFA is feasible. The patient has also been seen by another provider who requested a repeat CT scan of the liver as well as a PET scan. The results of these scans demonstrate two hepatic metastases both within the right lobe of the liver. Although these results were not available to the provider at the time of his evaluation, he stated that a right hepatic lobectomy would be recommended if the multiple lesions could be removed with this approach.The patient has requested authorization for RFA because of the potentially shorter recovery time and the need to continue to work. The Health Plan has denied the patients request on the basis that RFA is considered investigational.The patient has hepatic metastases from ovarian cancer. She has been treated with maximal surgical debulking (two years ago), Taxol/carboplatin and gemcitabine chemotherapy. By radiologic imaging, the patient has two isolated hepatic metastases limited to the right lobe of her liver. She has no underlying liver dysfunction. There is currently no data available that demonstrates the long-term curative role of RFA for any hepatic tumor (either primary or secondary). There are many reports that describe its use, including both short-term complication and short-term follow-up for local recurrence. This is especially true for hepatic metastases from less common primary sites, such as ovarian cancer. However, since the CT scan suggests that the lesions would be resectable with a right hepatic lobectomy, this would be the preferred treatment choice since there are data that support the survival benefit. Although the patient is requesting RFA for issues related to recovery, there is no data that has demonstrated equivalence or superiority to resection for the treatment of hepatic metastases. Based upon the information set forth, 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 3The patient is a 49-year-old female who was diagnosed with ovarian cancer in July 2002 and underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy and debulking. In September 2002, a CT scan revealed two lesions in the right lobe of the liver, which were subsequently determined to be metastases. Taxol and carboplatin were initiated. In March 2003, a CT scan showed no residual tumor. In September 2003, metastases were confirmed as recurrence in the liver. Gemzar was initiated. The patient discontinued chemotherapy due to toxicity. In February 2004, a CT scan revealed a 3cm mass in the liver. In April 2004, a CT scan of the abdomen revealed a 7.2 x 4.1cm mass in the liver in the right post lobe and a 3 x 2.8cm mass in the right anterior lobe.The patient has requested authorization for radiofrequency ablation (RFA) of the metastases due to the shorter recovery period associated with this procedure. The Health Plan has denied the patients request indicating that RFA is considered investigational.The patients early failure of chemotherapy points to platin-refractory disease, which suggests advantage to surgical intervention over additional chemotherapy. The patient has no ascites, peritoneal implants, or pleural effusion to indicate other tumor sites that would negatively impact survival advantage to re-operation. The patient is young and should be able to tolerate surgical intervention. The patient is seeking RFA as opposed to a major laparotomy. Though RFA is widely used in the treatment of colon cancer with hepatic metastasis, it is not as common in cases where the underlying disease is ovarian cancer. In the case of this patient, RFA may avoid major laparotomy with partial hepatectomy.