Cancer treatment: 53% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2026 · Medical necessity · age 41–50 Injections · Cancer The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the medication regimen consisting of Opdivo administered every 3 weeks in combination with Yervoy administered every 6 weeks.According to…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the medication regimen consisting of Opdivo administered every 3 weeks in combination with Yervoy administered every 6 weeks.According to National Comprehensive Cancer Network guidelines, immunotherapy is recommended primarily for tumors demonstrating microsatellite instability-high or deficient mismatch repair status. In patients with proficient mismatch repair or microsatellite stable rectal cancer, standard neoadjuvant treatment options include chemoradiation and combination chemotherapy regimens such as CAPEOX, FOLFOX, or FOLFIRINOX.In this case, the patient’s tumor is proficient mismatch repair/microsatellite stable. Opdivo and Yervoy are not approved by the U.S. Food and Drug Administration for this indication, and current medical literature does not establish clear benefit for this regimen in the neoadjuvant treatment of proficient mismatch repair/microsatellite stable rectal cancer. Published clinical trial data evaluating neoadjuvant ipilimumab and nivolumab in rectal cancer did not demonstrate significant improvement in complete response rates compared with standard chemoradiation.Given these findings, neoadjuvant treatment with Opdivo administered every 3 weeks in combination with Yervoy administered every 6 weeks is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the medication regimen at issue was not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46721

2. Overturned 2026 · Medical necessity · age 31–40 Cancer drugs · Malfor/Deform/Abnor The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Alunbrig (brigatinib). According to the medical records, the patient has neurofibromatosis type 2 with progressive central…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Alunbrig (brigatinib). According to the medical records, the patient has neurofibromatosis type 2 with progressive central nervous system tumors and has experienced disease progression despite multiple prior therapies directed at meningiomas and schwannomas. The patient also has contraindications to additional local therapies.Current medical literature supports the use of brigatinib in patients with neurofibromatosis type 2-associated tumors. Given the patient’s progressive disease and limited treatment alternatives, the requested Alunbrig (brigatinib) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certification in hematology and medical oncology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46450

3. Overturned 2026 · Experimental or investigational · age 51–64 Cancer surgery · Cancer The physician reviewer found that a patient has requested authorization and coverage for laser interstitial thermal therapy (LITT) and stereotactic biopsy, aspiration, or excision of an intracranial lesion. This patient has advanced head and neck cancer that…

   The physician reviewer found that a patient has requested authorization and coverage for laser interstitial thermal therapy (LITT) and stereotactic biopsy, aspiration, or excision of an intracranial lesion. This patient has advanced head and neck cancer that has progressed on radiation therapy and chemotherapy. It has invaded critical areas of the brain that are not amenable to surgical resection. Thus, a limited locoregional approach and biopsy, aspiration, or excision of an intracranial lesion is indicated based on National Comprehensive Cancer Network (NCCN) guidelines. The alternative is to recommend supportive care and hospice. However, the patient is young and has a good performance status. The patient has already been evaluated by radiation oncology and neurosurgery, and they have recommended laser interstitial thermal therapy and biopsy of the tumor. This is a standard approach towards unresectable central nervous system (CNS) lesions and is more appropriate for the patient than standard therapy. All told, LITT and stereotactic biopsy, aspiration, or excision of an intracranial lesion are likely to be more beneficial for the treatment of the patient’s condition than any available standard therapy. Findings: Three of the three reviewers found that the services are likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Final Result: The reviewers determined that the services are likely to be more beneficial for the treatment of the patient's medical condition than any available standard therapy. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: Reviewer 1 is board-certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Reviewer 2 is board-certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Reviewer 3 is board-certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. The reviewers are experts in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case EI26-46381

4. Upheld 2025 · Medical necessity · age 41–50 Cancer drugs · Cancer The physician reviewer found that a patient has requested authorization and coverage for KEYTRUDA® (pembrolizumab). Per the National Comprehensive Cancer Network (NCCN) guidelines, checkpoint inhibitors/immunotherapy, such as pembrolizumab, is recommended for…

   The physician reviewer found that a patient has requested authorization and coverage for KEYTRUDA® (pembrolizumab). Per the National Comprehensive Cancer Network (NCCN) guidelines, checkpoint inhibitors/immunotherapy, such as pembrolizumab, is recommended for patients with deficient mismatch repair (dMMR)/microsatellite instability (MSI)-high or polymerase epsilon (POLE)/polymerase delta 1 (POLD1) mutation phenotype with ultra-hypermutated (e.g., tumor mutational burden (TMB) greater than 50 mut/Mb) colon cancer (non-metastatic). This patient is MSI-stable, TMB intermediate, and does not have any of these other markers. The use of immunotherapy for colon cancer is not based on programmed death-ligand 1 (PD-L1) testing. PD-L1 expression alone does not predict benefit in microsatellite stable (MSS) colorectal cancer. Immunotherapy is ineffective in MSS tumors due to low TMB and minimal immune infiltration. Standard chemotherapy with or without targeted therapy remains the standard treatment. Given these findings, the requested KEYTRUDA® (pembrolizumab) is not necessary to protect life, prevent significant illness or significant disability, or alleviate severe pain through the diagnosis or treatment of disease, illness, or injury. In addition, the requested KEYTRUDA® (pembrolizumab) is not necessary to achieve age-appropriate growth and development, and attain, maintain, or regain functional capacity. Therefore, the requested KEYTRUDA® (pembrolizumab) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46353

5. Overturned 2025 · Medical necessity · age 51–64 Cancer drugs · Cancer The physician reviewer found that a patient has requested authorization and coverage for Orgovyx. Per the medical records, the patient has node-positive recurrent prostate cancer. The U.S. Food and Drug Administration (FDA) approves the use of Orgovyx…

   The physician reviewer found that a patient has requested authorization and coverage for Orgovyx. Per the medical records, the patient has node-positive recurrent prostate cancer. The U.S. Food and Drug Administration (FDA) approves the use of Orgovyx (relugolix) for the treatment of advanced prostate cancer. The National Comprehensive Cancer Network guidelines for the management of prostate cancer support its use in node-positive disease. In this clinical setting, given that current medical literature supports the use of Orgovyx for the treatment of node-positive recurrent prostate cancer, Orgovyx is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in internal medicine with subspecialty certifications in hematology and medical oncology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46326

6. Overturned 2025 · Medical necessity · age 65+ Hi-Int focused ultrasnd (HIFU) · Cancer The physician reviewer found that a patient has requested authorization and coverage for high-intensity focused ultrasound. According to leading expert guidelines, high-intensity focused ultrasound may be considered in select, appropriately informed patients…

   The physician reviewer found that a patient has requested authorization and coverage for high-intensity focused ultrasound. According to leading expert guidelines, high-intensity focused ultrasound may be considered in select, appropriately informed patients. Based on these guidelines as well as other studies, high-intensity focused ultrasound is now a standard treatment option for certain types of prostate cancer and can help patients avoid the complications of prostatectomy. In this case, the patient has a history of prostate cancer without evidence of extraprostatic extension or invasion into adjacent pelvic structures. The literature supports the use of high-intensity focused ultrasound in this clinical scenario. All told, the requested high-intensity focused ultrasound is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in urology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46301

7. Overturned 2025 · Medical necessity · age 51–64 Cancer drugs · Cancer The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bortezomib. T-cell acute lymphoblastic leukemia (T-ALL) is initially treated with chemotherapy to induce remission. Hyper-CVAD…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bortezomib. T-cell acute lymphoblastic leukemia (T-ALL) is initially treated with chemotherapy to induce remission. Hyper-CVAD is one of the most common induction regimens used in adults, but regimens have varied to involve agents from pediatric clinical trials since these regimens are associated with better outcomes, even in adults. The National Comprehensive Cancer Network (NCCN) guidelines on ALL recommend either pediatric regimens or hyper-CVAD for induction therapy. Ultimately, adult patients will need to proceed onto an allogeneic stem cell transplant for definitive cure, and minimal residual disease (MRD) present after induction therapy will be a critical prognostic factor. Furthermore, in treating adults with pediatric-inspired regimens, it is common practice to make modifications to suit the patient and achieve the best MRD. The addition of bortezomib has been demonstrated to show a survival advantage compared to a regimen without bortezomib. There is also data supporting its use in adult patients as part of the hyper-CVAD regimen. Given these findings, the requested bortezomib is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in medical oncology with subspecialty certification in hematology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46214

8. Upheld 2025 · Medical necessity · age 65+ Cancer drugs · Cancer The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a combination medication treatment of enfortumab vedotin with pembrolizumab.Neoadjuvant treatment with enfortumab vedotin and…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a combination medication treatment of enfortumab vedotin with pembrolizumab.Neoadjuvant treatment with enfortumab vedotin and pembrolizumab is not medically necessary for the treatment of this patient’s muscle-invasive bladder cancer. This combination is not recommended in the neoadjuvant setting, including in patients who are ineligible for cisplatin. The U.S. Food and Drug Administration approval of enfortumab vedotin with pembrolizumab does not extend to this clinical scenario. The combination remains under investigation in ongoing clinical trials, including KEYNOTE-B15/EV-304, and is not established as standard of care in this setting. Alternative options, including immunotherapy or clinical trial enrollment, may be considered.Therefore, the requested combination treatment of enfortumab vedotin with pembrolizumab is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in hematology with subspecialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and is knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46188

9. Overturned 2025 · Medical necessity · age 51–64 Proton beam therapy · Cancer The physician reviewer found that a patient has requested authorization and coverage for proton beam radiation therapy and/or placement of a perirectal hydrogel spacer. Proton beam has unique properties compared to standard photon or X-ray beam in its ability…

   The physician reviewer found that a patient has requested authorization and coverage for proton beam radiation therapy and/or placement of a perirectal hydrogel spacer. Proton beam has unique properties compared to standard photon or X-ray beam in its ability to deposit radiation dose. Oftentimes, fewer proton beams can be utilized to achieve a dose distribution that is similar to standard photon beam. This potentially results in fewer areas of low scattered radiation dose when using proton beams. Studies have not demonstrated a significant difference in overall survival nor normal tissue toxicities over photon beam when treating prostate cancer. These data question the utility of proton beam radiation for prostate cancer, particularly in localized disease. Per leading expert guidelines, proton therapy is currently utilized and strongly indicated in settings where severe toxicities would result if normal tissue constraints cannot be met by photon beam, such as in cases of unusual anatomy or re-irradiation of adjacent tissues. However, this is not the case for this patient. Though the patient is appropriately recommended a course of radiation therapy as a treatment modality for intermediate risk prostate cancer, proton beam therapy is not medically necessary as the radiation treatment modality. All told, the requested proton beam radiation therapy is not medically necessary for the treatment of this patient.With respect to the requested placement of a perirectal hydrogel spacer, a major concern during radiation therapy to the prostate is rectal toxicity due to exposure of the adjacent rectal wall. One method of reducing rectal toxicity is to create additional space and distance within the perirectum, which is the space between the prostate and the rectum. Absorbable hydrogel spacers have been created for this purpose. There is strong evidence demonstrating decreased rectal toxicity when hydrogel spacers are used in the setting of external beam radiation treatment to the prostate. One study showed decreased bowel toxicity and less decline in both urinary and bowel quality of life when a hydrogel spacer was utilized during prostate radiotherapy. A systematic review similarly demonstrated reduced late gastrointestinal and genitourinary toxicities. Additionally, the placement of a hydrogel spacer has been shown to lower the V70 parameter and thus decrease the risk of both acute and late rectal toxicity. Patients have also self-reported excellent quality of life after prostate radiotherapy with placement of a hydrogel spacer. For these reasons, the requested placement of a perirectal hydrogel spacer is medically necessary for the treatment of this patient.Therefore, the requested proton beam radiation therapy is not medically necessary for the treatment of this patient. However, the requested placement of a perirectal hydrogel spacer is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested placement of a perirectal hydrogel spacer is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be partially overturned. Credentials/Qualifications: The reviewer is board-certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46083

10. Upheld 2025 · Medical necessity · age 41–50 Cancer drugs · Cancer The physician reviewer found that a patient has requested authorization and coverage for an interleukin-23 (IL-23) inhibitor combined with the approved Keytruda.The records indicate that this patient presents with a history of cervical adenocarcinoma. The…

    The physician reviewer found that a patient has requested authorization and coverage for an interleukin-23 (IL-23) inhibitor combined with the approved Keytruda.The records indicate that this patient presents with a history of cervical adenocarcinoma. The patient has been treated with external beam radiation therapy (EBRT), cisplatin, and intracavitary brachytherapy, as well as Keytruda. The patient has requested the addition of an IL-23 inhibitor to be taken in combination with Keytruda. However, there is a lack of support in the medical literature or guidelines for this combination in the treatment of this patient’s cervical adenocarcinoma. The U.S. Food and Drug Administration (FDA) has not approved IL-23 inhibitors for the treatment of patients with recurrent cervical cancer. In addition, there is a paucity of clinical evidence supporting the use of an IL-23 inhibitor in combination with Keytruda in this patient’s clinical setting. The current recommendation is treatment with Keytruda plus chemotherapy, with or without bevacizumab, for PD-L1-positive tumors, and Keytruda monotherapy for PD-L1-positive tumors after chemotherapy. Another study reported that Keytruda “monotherapy demonstrated durable antitumor activity and manageable safety in patients with advanced cervical cancer.” The authors noted that based on clinical trial results, the FDA granted accelerated approval of Keytruda for patients with advanced PD-L1-positive cervical cancer who experienced progression during or after chemotherapy. Overall, IL-23 inhibitors are not included in guidelines or trials for cervical cancer, and the data suggest that their use should be limited to clinical trials. Therefore, the requested IL-23 inhibitor, combined with the approved Keytruda, is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in hematology with subspecialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-46073

11. Upheld 2025 · Medical necessity · age 51–64 Proton beam therapy · Cancer The physician reviewer found that a patient has requested authorization and coverage for proton beam radiation therapy. The patient was appropriately recommended a course of radiation therapy as a treatment modality for intermediate risk prostate cancer, per…

    The physician reviewer found that a patient has requested authorization and coverage for proton beam radiation therapy. The patient was appropriately recommended a course of radiation therapy as a treatment modality for intermediate risk prostate cancer, per National Comprehensive Cancer Network (NCCN) guidelines. Radiation therapy itself is a category 1 standard of care treatment for prostate cancer. However, the utilization of proton beam as the radiation modality for prostate cancer is an area of debate. Proton beam has unique properties compared to standard photon or x-ray beam in its ability to deposit radiation dose. Often, fewer proton beams can be utilized to achieve a dose distribution that is similar to standard photon beam. This potentially results in fewer areas of low scattered radiation dose when using proton beams. The question, however, is whether the use of proton beam will result in any significant improvement in clinical outcome. Proton therapy is currently utilized and strongly indicated in settings where severe toxicities would result if normal tissue constraints cannot be met by photon beam. However, in the setting of localized prostate cancer, there has not been a demonstrable clinically significant improvement in either quality of life or reduction of high grade toxicities. Studies have not demonstrated a significant difference in overall survival nor normal tissue toxicities over photon beam when treating prostate cancer. These findings question the utility of proton beam radiation for prostate cancer, particularly in localized disease. While there are ongoing prospective trials investigating the potential benefits in disease outcomes and toxicities in this setting, no definite benefit has yet been demonstrated with proton therapy. Proton therapy may be indicated in some cases of unusual anatomy or in cases of re-irradiation of adjacent tissues. However, this is not the case for this particular patient. Overall, given this patient’s medical history and nature of the patient’s prostate cancer diagnosis, while radiation therapy in general is indicated for adequate treatment, proton beam therapy is not indicated. All told, the requested proton beam radiation therapy is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested treatment is not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-46039

12. Upheld 2025 · Medical necessity · age 51–64 Proton beam therapy · Cancer The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement for proton beam radiation therapy. Proton therapy may be considered in select cases where conventional radiation techniques cannot adequately…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement for proton beam radiation therapy. Proton therapy may be considered in select cases where conventional radiation techniques cannot adequately meet normal tissue constraints or would result in clinically significant toxicity. Clinical guidelines support its use in situations where it offers a clear advantage over standard photon-based radiation therapy. In this case, the available documentation indicates that standard radiation therapy techniques are capable of achieving appropriate target coverage while maintaining acceptable dose to surrounding structures. There is no clear evidence that proton therapy would provide a clinically meaningful benefit over conventional treatment in this setting. Therefore, the requested proton beam radiation therapy is not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the services at issue were not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewer is board-certified in radiation oncology and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

    Case MN25-45806