Diagnosis: Breast Cancer
Treatment: Out-of-Network (OON) - Lab Blood Test (Liquid Biopsy)

The insurer denied the Out-of-Network (OON) - Lab Blood Test (Liquid Biopsy). The denial is upheld.

The patient in this case is a female diagnosed with breast cancer. Guardant 360 testing was performed.

No, the proposed treatment was not medically necessary.

Guardant 360 is a next generation sequencing assay that is done to look for genomic alterations in circulating cell free deoxyribonucleic acid (DNA). This test includes many different genes. It is done to try to find potentially effective treatment options. There is currently no evidence based on the results of any prospective clinical trial that has shown use of broad molecular profiling can improve overall health outcomes. This test is not recommended as a standard test known to improve overall health outcomes by National Comprehensive Network (NCCN) guidelines. Therefore, this test has not been shown to improve overall health outcomes and it should not be considered medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.