Insurance Coverage for Redo Thoracotomy in Germany!

[Fictional]

Learned today from our case manager at Premera Blue Cross that our insurance denial for Dr Rolle's latest surgery is overturned by outside review.

This will help us a lot. I am posting our letter of appeal (our request for coverage was denied when we asked for pre-authorization of the surgery) below. As with the previous, feel free to use it and share it with any who might find it helpful organizing their insurance denials. Unfortunately patients with rare cancers unfairly have many procedures denied (because the insurance companies have no clear policy?)- and ASPS is no exception. Because of some identifying information and the people involved, please do not post it on the Internet. We also included copies of all the papers mentioned in the appeal.

Premera Blue Cross' policy is to respond within 30 days - this was very quick...got an answer back in 2 weeks! We are also hoping that authorization of redo thoracotomy would clear us should she need additional redo's. On the letter of denial, there was an address to request reasons for the denial. We sent this in - and really there were no reasons listed for the denial, just that the thoracotomy was a "non-standard' procedure.

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Premera Blue Cross
Attention Member Appeal
PO Box 91102
Seattle WA 98111-9202

Member Name: *** *** Subscriber:
Group: Ref. No:

Service: Laser resection of lung metastases

Neil Kaneshiro, MD MHA
Asst Medical Director

Dear Dr. Kaneshiro:

We are writing to appeal Premera's denial of reimbursement for charges sustained during our **-year-old daughter ***'s recent (2/16/09-3/06/09) hospitalization for laser resection of left lung metastases.

Your letter of March 23, you stated that Premera's decision to deny reimbursement is based on lack of available evidence that repeat metastasectomy for recurrent pulmonary metastases provides benefits that outweigh the surgical risks. (Note: Since Premera has previously covered charges for ***'s right metastasectomy that used this same laser resection technique, we will assume that the act that this surgical technique was also used in her present procedure is not at issue in Premera's current denial, and will focus our comments on whether repeat thoracotomy is considered standard therapy for recurrent pulmonary metastases.)

There is actually a clear consensus on the literature supporting the benefits both for prolonged survival and for potential cure with redo thoracotomy for many types of cancers, and particularly for soft tissue sarcomas such as ***'s Alveolar Soft Part Sarcoma (ASPS). We will focus on the literature regarding such sarcomas. In the following paragraphs we will cite 3 papers dealing with repeat thoracotomy for soft tissue sarcomas in general, and one paper and one abstract dealing with repeat thoracotomy in ASPS in particular. There are even more papers we could cite supporting this position. We have enclosed copies of all of these references for your review.

The first paper we will cite is Rehders, et al., (2007), Benefit of Surgical Treatment of Lung Metastasis in Soft Tissue Sarcoma. These authors specifically addressed the value of repeat thoracotomy for patients with recurrent pulmonary metastases from soft tissue sarcomas. Their conclusion was as follows: "Comparing the survival data in these patients [i.e., those who underwent repeat thoracotomy] with the remaining patients [i.e. those with recurrent pulmonary metastases who did not receive repeat thoracotomy], we found that the patients who underwent a repeat operation had a significantly better prognosis (p=.002)... We conclude from these results that repeat resection, if technically feasible, could be a means of achieving long-term survival and should be recommended in patients with recurrence of pulmonary lesions.” Furthermore, in their study 6 of the 13 sarcoma patients who survived for more than 5 years had undergone repeat thoracotomy for recurrent pulmonary metastases. The following figure is taken from their paper, and displays the survival data for those with recurrent pulmonary metastases after thoracotomy who underwent repeat thoracotomy versus those who did not.


(Figure from paper)

“Figure 3. Kaplan-Meier overall survival curves according to repeat surgery because of recurrent pulmonary metastasis. Survival was significantly longer in patients who underwent repeat surgery (P=.002 long-rank test)."

Concerning the issue of surgical benefits versus risk, these authors concluded that: “This policy [i.e., “It seems worthwhile to operate on every patient with lung metastasis unless serious comorbidity or technically unresectable metastatic disease is present”] is underlined by the low complication rate of surgical treatment. In our study, there was no perioperative mortality and no major postoperative morbidity that required reoperation.”

The second paper we will cite is Liebl et al, (2007), Value of Repeat Resection for Survival in Pulmonary Metastases from Soft Tissue Sarcoma. These authors write as follows: “Out of the 29 patients [of the 42 they studied] who suffered from recurrent metastases, 19 underwent at least one repeat resection. In univariate analysis, patients with repeat resections...showed a median survival of 64 months compared to 19 months in all patients with a single resection (p=.0074), which is significantly longer.” They also found that repeat resections for recurrent disease was an independent prognostic factor in multivariate analysis. From this data they concluded that, “It is possible to control disease in patients with recurrent disease for an extended period with repeated pulmonary resection...Long-term survival is possible after resection of pulmonary metastases from soft tissue sarcoma...[and] repeat resection in resectable recurrent disease can lead to long-term survival...Given the continued paucity of meaningful therapeutic alternatives, surgical excision, especially of pulmonary metastases, is currently the only curative option for patients with metastatic disease and should remain the treatment of choice, regardless of age, disease-free interval, the extent of the disease, or the necessary extent of the resection.” Their bottom line: “Patients with repeat resections due to recurrent metastasis show a significantly better prognosis than those with only one resection.”

The third paper we will cite is Chen, et al., (2008), Significance of tumor recurrence before pulmonary metastasis in pulmonary metastasectomy for soft tissue sarcoma. These authors wrote of their operative experience that, “Furthermore, more than 70% of the patients presented recurrences of the tumor even after the pulmonary metastasectomies, which was compatible with the data shown by Downy...According to the frequency of recurrence after pulmonary metastasectomy, relative ineffectiveness of chemotherapy, and the better prognosis of the patients with repeat resection in our study, it would be strongly recommended that pulmonary metastasectomy be performed aggressively and repetitively.” Their bottom line, “Furthermore, patients with repeat metastasectomy for recurrent pulmonary metastasis also presented a significantly longer survival.”

In each of the above studies the authors noted a survival advantage after repeat metastasectomy for those with more indolent disease. ASPS, which is ***'s tumor type, is one of the most indolent of all soft tissue sarcomas, so the case for recurrent metastasectomy is particularly strong in her case.

Because ASPS comprises fewer than 1% of all soft tissue sarcomas, the literature dealing specifically with ASPS is smaller than that which deals with soft tissue sarcomas in general. However, there are two studies supporting recurrent pulmonary metastasectomy for patients with ASPS. The first is Kayton et al., (2006), Clinical presentation, treatment, and outcome of alveolar soft part sarcoma in children, adolescents, and young adults from Memorial Sloan Kettering Hospital. This paper was a retrospective review of 20 patients below the age of 25 with ASPS. In this group 60% (12) had lung metastases, and 9 of the 12 underwent metastasectomy. Between them, these 9 patients had a total of 31 metastasectomies, with a median of 3 and a range from 1 to 8. Overall survival rate among these 9 patients was 78% (7 of 9), with a median follow-up since diagnosis of 136 months (range 21-354 months). Although the numbers are smaller than in the previously cited studies, it is clear from these data that multiple metastasectomies are at least compatible with long-term survival.

The second study was presented as a poster at the 2001 CTOS meeting by Swannie, et al., describing the 16 year retrospective experience with 19 ASPS patients at Royal Marsden Hospital. Of the 19 patients studied, 73% (14/19) developed pulmonary metastases, and of these 9 underwent pulmonary metastasectomy. 4 showed prolonged disease free survival (average follow-up 68.1 months, range 21.8-222.6), and the authors concluded that, There is currently no effective systemic treatment [for ASPS] but resection of pulmonary metastases may be curative and should be pursued aggressively even if repeated metastasectomies are required."

Relating these studies to ***'s case in particular, we can see that her tumors are of the relatively indolent ASPS type, that her primary tumor was removed in January 2008 with negative margins, that her only known sites of metastases have been in the lungs, and that all of the lung lesions that have so far appeared have been resectable by the use of the laser surgical technique used by Dr. Axel Rolle (though several of the deeper lesions have been unresectable by conventional stapling techniques). To reiterate, laser resection was performed for both her right metastasectomy last August and for her repeat left metastasectomy this February because it was the only surgical technique capable of removing her central or deep metastases with negative margins while sparing healthy lung tissue (see enclosed data from our previous successful appeal supporting laser metastasectomy). ***'s surgical course and recovery after both procedures have confirmed the utility and the low morbidity of this approach. Pulmonary Function Testing prior to this surgery revealed a less than 8% decline in Total Lung Capacity after her prior laser thoracotomy, despite the resection with clean margins of 32 nodules. From a surgical standpoint, her current procedure was also a success. All palpable disease (13 nodules) was removed with negative margins, with the removal of very little lung parenchyma. After this procedure *** required no supplemental oxygen at any time. She was fully ambulatory within two days, and was back in school full-time and engaging in normal physical activities within two weeks.

These are the data that we, as both ***'s parents and as physicians, reviewed in making our treatment choice for ***. We are sure that once you have reviewed the data as we have you will conclude that the repeat thoracotomy for metastasectomy currently under appeal was clearly indicated as standard therapy, and that its benefits clearly outweighed the risks. We therefore sincerely request that Premera reconsider its decision to deny coverage for ***'s most recent pulmonary metastasectomy. The surgery resulted in successful clearance of all visible disease in the left lung, it is the only possible option available for saving her life and inducing a long term remission. We would be happy to provide additional documentation upon request. In addition, we authorize any representatives of Premera to contact any of her physicians and surgeons.

Thank you for your time and consideration,

*** MD MA and *** MD

Enclosures:

Rehders, et al., (2007), Benefit of Surgical Treatment of Lung Metastasis in Soft Tissue Sarcoma, Arch Surg 142: 70-75.

Liebl et al, (2007), Value of Repeat Resection for Survival in Pulmonary Metastases from Soft Tissue Sarcoma, Anticancer Research 27: 2897-2902.

Chen, et al., (2008), Significance of tumor recurrence before pulmonary metastasis in pulmonary metastasectomy for soft tissue sarcoma, Eur. J Surgery Sep: 1-6.

Kayton et al., (2006), Clinical presentation, treatment, and outcome of alveolar soft part sarcoma in children, adolescents, and young adults, J Ped Surg 41:187-193.

Swannie, et al., (2001) Alveolar soft part sarcoma in adults: analysis of clinical features and treatment outcome in 19 cases. CTOS Poster.

[Amanda]

Hello 'F'
This is wonderful news!!!
Thank you, for posting the information and i am sure it will help many people that may have to fight with the insurance companies.
I hope that you and your family had a great bunny day!

Amanda R