Does anyone have any examples of letters of medical necessity to justify the use of Tarceva / Avastin as a first line NSCLC therapy? Or if anybody has some insurance experience with this combination therapy to share, that would be most appreciated.
My father is a 67 yo Asian male, never smoker with EGFR (exon 19 deletion)+ NSCLC with wide-spread mets. Excellent condition ECOG 0. Currently on day 5 of Tarceva as his first-line of treatment. Tarceva has been approved already by insurance.
After reading the literature, it seems that Tarceva/Avastin seems promising, and we would like to seek prior-authorization for the Avastin. We are located in Houston, Texas, with a Medicare HMO, Blue Cross/Blue Shield coverage.
It would be helpful if we could read some persuasive insurance letters (letters of medical necessity or appeal letters) that would help us put a packet together to obtain approval for Avastin. So far, we have the Dr. Kato study but no actual letters from Doctors proposing this.
Welcome to GRACE. I hope that someone will be able to chime in with an actual letter that they have used to seek coverage for this combination, but in the meantime you may be able to use some of Dr. West’s arguments in its favor found in this post of his.
You may also want to review this discussion of Tarceva paired with Avastin by Drs. Hanna, Johnson and West.
Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa
I am to begin the combo first line treatment of Tarceva and Avastin next week and BCBS has approved it. My doctor did the request so I don’t have a letter but he is at MUSC. I have the egfr, but also the PDL-! mutation and am wondering if anyone else has both mutations?