
202305-163426
2023
Empire Healthchoice Assurance Inc.
PPO
Cancer
Durable Medical Equipment (DME) (including Wearable Defibrilllators)
Medical necessity
Overturned
Case Summary
Cancer
Durable Medical Equipment (DME) (including Wearable Defibrillators)
Diagnosis: Glioblastoma Multiform
Treatment: Electric Tumor Treatment Filed
The insurer denied the request for Electric Tumor Treatment Field.
The health plan's determination is overturned.
The patient is a male with glioblastoma multiform. The patient has been treated by resection humor, chemotherapy including Temozolamide and Avastatin, and radiation. Continued treatment with tumor treating fields is the subject of this review.
The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested health service/treatment of Electric tumor treatment field is medically necessary. The patient has glioblastoma multiform. This is a primary brain cancer that generally results in death within five years. There are no known cures. All engines are in that slowing the progression of the disease and delaying death.
Electric Tumor Treating Fields (TTFields) have been shown to be safe and effective to slow the progression of the disease. Approval in the United States, Europe, and elsewhere was based on results of a clinical trial that randomly assigned 237 patients with recurrent glioblastoma to TTFields or clinician's choice chemotherapy. The majority of patients were enrolled at the time of second or greater recurrence and approximately 20 percent had received prior Bevacizumab. Median progression-free and overall survival were similar in those treated with TTFields versus chemotherapy. The objective response rate was nonsignificantly higher in patients treated with TTFields compared with chemotherapy. Consensus-based guidelines published by the National Comprehensive Cancer Network (NCCN) include alternating electric field therapy as a treatment option for patients with recurrent glioblastoma based on the trial data.
Trial also favors the use of TTFields as an up-front therapy rather than for recurrent glioblastoma. After a median follow-up of 40 months in surviving patients, those assigned to the TTFields device had improved progression-free survival compared with those assigned to Temozolomide alone for initial diagnosis of glioblastoma.
The use of electric tumor treating fields is medically necessary for this patient with a serious medical condition. The service has been shown to be beneficial in both patients who are newly diagnosed with this primary brain tumor and for those with brain tumor recurrence.
The health plan's determination of medical necessity is overturned in whole.