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201907-118851

2019

United Healthcare Ins. Co. of NY

Indemnity

Cancer

Cancer Screening

Experimental/Investigational

Upheld

Case Summary

This is a patient with a melanoma to the right back, Breslow .9 mm. There is no ulceration, no regression, the mitotic index is 0. This is a review for coverage of the decision DX melanoma assay. The requested service is not more likely to be beneficial than any standard treatment.

There is insufficient evidence to determine how gene expression profiling may be used to guide clinical decisions related to the diagnosis and treatment of cutaneous melanoma. Specifically, it is not known how or whether decisions concerning treatment and surveillance are improved over the current standard of care, and it is unknown whether health outcomes are improved as a result of those decisions. Further, the clinical practice guidelines from the NCCN recommend against routine prognostic testing for low versus high metastatic risk outside of a clinical trial. The standard prognostic indicators for melanoma include age, gender, Breslow thickness, ulceration, and mitotic rate. Gene expression profiling has not been shown to have independent prognostic value within the context of the other known prognostic factors for melanoma. It's independent prognostic value has not been confirmed in a large population of patients with average to low risk disease. Therefore the use of decision DX melanoma gene expression profile test is considered investigational/experimental. The health plan determination is upheld in whole.

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