Unacceptable Denials

Health Net recently denied coverage for Lutathera (¹⁷⁷Lu-DOTATATE; Advanced Accelerator Applications) treatment of a patient with a neuroendocrine tumor. The denial letter stated: “According to the Medical Technology Directory, Health Net, Inc. considers Lutathera (lutetium ¹⁷⁷Lu dotatate) to be investigational (not proven). This is a drug for the treatment of neuroendocrine tumors (type of cancer). There is not sufficient information in the literature showing its safety and that it works. Your certificate of insurance does not cover investigational services. The request for Lutathera is denied.”

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Johannes Czernin

This denial echoes many others received by patients and their treating physicians (1,2). It shows ignorance about regulatory approvals and published data. It ignores the fact that the Food and Drug Administration approved this drug in January 2018. It also fails to acknowledge Centers for Medicare and Medicaid Services coverage of Lutathera. The denial letter indicates that Health Net simply ignores the extensive published body of evidence indicating the safety and efficacy of this treatment. Should they choose to do so, Health Net experts could Google “Strosberg J,” “NETTER trial,” “theranostics,” or any of dozens of other related terms directly associated with peer-reviewed literature on the extraordinary progress in treating neuroendocrine tumors dating back to the 1990s.

Patients and treating physicians deserve more careful, professional, and well-researched services from health insurance entities than they frequently receive. Hours are currently wasted on paralyzing phone trees and on so-called peer-to-peer discussions—time that could be spent improving patient care. Patients endure additional anxiety at an already difficult time. Lifelong learning should be mandatory not only for practicing physicians but also for those who make crucial decisions about coverage of life-saving treatments.

The reflex denial culture must end. This is a travesty.

• © 2020 by the Society of Nuclear Medicine and Molecular Imaging.