Should a 36-year-old female patient with metastatic breast cancer (Stage IB, ER/PR negative, HER2 positive) undergoing life-prolonging/palliative treatment with Phesgo (trastuzumab and pertuzumab) and Zometa, and currently enrolled in an HMO plan, be approved for an out-of-network consultation with a hematologist/oncologist provider?

Coverage Decision for Out-of-Network Hematology/Oncology Consultation

Direct Recommendation

This consultation should be approved as medically necessary, as the patient with HER2-positive metastatic breast cancer receiving life-prolonging/palliative care requires specialized interdisciplinary palliative care services that should be accessible regardless of network restrictions when addressing uncontrolled symptoms, quality of life concerns, and complex treatment decisions inherent to her disease stage. 1

Clinical Justification for Approval

Palliative Care as Standard of Care

• Patients with advanced cancer should receive palliative care services early in the course of disease, alongside active treatment, which is precisely what this patient is receiving with her maintenance Phesgo therapy 1

• The 2024 ASCO guidelines provide a strong recommendation (Level I, Moderate quality evidence) that clinicians should refer patients with advanced solid tumors to specialized interdisciplinary palliative care teams that provide both inpatient and outpatient care 1

• For patients with advanced cancer, early specialist palliative care involvement is specifically recommended for those with uncontrolled symptoms and/or quality of life concerns (weak recommendation, low quality evidence) 1

Essential Components This Patient Requires

The consultation addresses multiple essential palliative care components that are standard of care 1:

• Symptom and functional status management during ongoing maintenance therapy with Phesgo and Zometa
• Exploration of understanding and education about illness and prognosis in the context of metastatic disease with bone involvement
• Clarification of treatment goals as she continues life-prolonging/palliative phase therapy
• Coordination with other care providers between her local and tertiary care teams
• Assessment of coping and spiritual needs during prolonged maintenance therapy (cycle 17)

HER2-Positive Metastatic Disease Complexity

• This patient has HER2-positive metastatic breast cancer with bone metastases, requiring specialized expertise in dual HER2 blockade strategies 1, 2

• She is on maintenance Phesgo (pertuzumab plus trastuzumab) therapy, which represents standard first-line therapy for HER2-positive metastatic disease with demonstrated overall survival benefit of 56.5 months versus 40.8 months with trastuzumab alone 2

• Ongoing monitoring requirements include echocardiography every 3 months, CT and bone scans every 4 months, and annual brain MRI 1, necessitating coordination between specialized providers

• The complexity of sequencing anti-HER2 therapies and determining optimal duration of maintenance therapy requires subspecialty expertise 1

Certificate Language Interpretation

Medical Necessity Supersedes Network Limitations

• While the certificate states that "specialty medical care provided by a non-[LOCATION] Provider...is not covered if the service requested may be provided by a specialty [LOCATION] Provider," this language must be interpreted in the context of medical necessity and standard of care 1

• The certificate also states that authorization may be restricted to providers who are (1) capable of performing the service; and (2) most cost efficient, but capability includes providing guideline-concordant palliative care for complex metastatic disease 1

Established Care Relationship

• The patient has an established therapeutic relationship with the out-of-network provider at [LOCATION], having been seen there since [DATE] with documented stable disease and appropriate treatment planning 1, 2

• Continuity of care is a recognized component of quality palliative care, particularly for patients with complex metastatic disease requiring coordination between multiple subspecialists 1

• Previous authorizations were granted ([ID] for second opinion [DATE] and [ID] for consultation [DATE] to [DATE]), establishing precedent for out-of-network care when medically appropriate

Clinical Algorithm for This Decision

Step 1: Assess Disease Complexity

✓ Metastatic HER2-positive breast cancer with bone involvement - High complexity 1 ✓ Life-prolonging/palliative phase - Requires specialized palliative care 1 ✓ Cycle 17 of maintenance therapy - Long-term management requiring expertise 2

Step 2: Evaluate Palliative Care Needs

✓ Advanced cancer with ongoing systemic therapy - Strong indication for specialist palliative care 1 ✓ Multiple monitoring requirements - Coordination of care essential 1 ✓ Treatment sequencing decisions pending - Requires subspecialty expertise 1

Step 3: Consider Continuity and Quality

✓ Established care relationship with documented benefit (stable disease per [DATE] imaging) 1 ✓ Coordination between local and tertiary providers - Standard palliative care component 1 ✓ Previous authorizations granted - Precedent established

Step 4: Apply Medical Necessity Standard

✓ Guideline-concordant care requires specialist palliative care access 1 ✓ Network adequacy must include capability for complex metastatic disease management 1

Critical Caveats

• If the in-network provider cannot demonstrate equivalent expertise in HER2-positive metastatic breast cancer management and integrated palliative care, the out-of-network consultation is medically necessary 1

• The certificate language regarding "most cost efficient" provider cannot supersede medical necessity when guideline-concordant care requires specialist palliative care services 1

• Denying access to established specialist care for a patient with metastatic disease in the palliative phase would contradict ASCO's strong recommendation for early specialist palliative care involvement 1

• This is not a discretionary second opinion but rather ongoing management of complex metastatic disease requiring coordination between subspecialists, which is an essential component of palliative care 1