Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer 
Treatment: Diagnostic laparoscopy and cytoreductive (the use of extreme cold to destroy abnormal tissue) surgery with HIPEC (hyperthermic chemotherapy)
The insurer denied the Diagnostic laparoscopy and cytoreductive (the use of extreme cold to destroy abnormal tissue) surgery with HIPEC (hyperthermic chemotherapy).
The denial is upheld.

The health plan should not cover the proposed treatment.  
The patient in this case has metastatic adenocarcinoma of unknown primary. She was evaluated for a change in bowel habits and was found to have a transverse colon mass.  Colonoscopy was done and revealed a stricture at the splenic flexure.  Biopsy at that time was negative for malignancy. She underwent left hemicolectomy and pathology revealed metastatic adenocarcinoma.  Carcinoma was present at both bowel margins and an abdominal wall lesion was also positive for adenocarcinoma.  Site of origin was not determined.  She was treated with FOLFOX chemotherapy and completed 12 cycles.  
Computed tomography (CT) scan done was notable for a subtle hypo enhancing 27 millimeter (mm) mass in the tip of the tail of the pancreas with atrophy of the pancreatic tail at that level. This mass was noted to have been present previously and was possibly a little smaller and was felt to possibly be this patient's primary tumor.  Magnetic resonance image (MRI) was recommended for further evaluation.
Diagnostic laparoscopy revealed peritoneal metastatic lesions mostly involving the right hemidiaphragm but also present in other areas of the abdomen and pelvis. Biopsy of one lesion was negative for carcinoma.
On initial consultation, the AP recommended review of imaging and also recommended diagnostic laparoscopy to both try to determine the primary site of her cancer and also to determine whether she was a suitable candidate for cytoreductive surgery with heated intraperitoneal chemotherapy treatment.   He wanted to make sure that the patient did not have metastatic pancreatic cancer, as he would not recommend cytoreductive surgery in that case.
Positron emission tomography (PET)/CT was done and revealed progressive segmental atrophy of the pancreatic tail without increased FDG uptake.  This was felt to be due to an obstructing tumor at the body-tail junction. A previously noted left lower abdominal wall hyper metabolic mass had resolved.  There was some residual mild peritoneal thickening.
The pancreatic tail mass was biopsied but the results were non-diagnostic.
The requested service is not likely to be more beneficial than any standard treatment(s) for the insured's condition or disease.  
There is no evidence that this treatment can improve health outcomes over standard treatment options.
This patient has been diagnosed with metastatic unknown primary cancer.  While the most recent imaging suggests she has a tumor in her pancreatic tail (this is based on both the CT done and PET/CT done), it remains unclear whether that pancreatic mass is malignant, and if so whether it is a primary tumor or a metastatic lesion.  The biopsy done was non-diagnostic and does not rule out malignancy.  No other likely primary site has been determined or can be supported based on the provided medical records.  Therefore, it is most reasonable to conclude that this patient has either metastatic unknown primary adenocarcinoma or she has metastatic pancreatic cancer.  
Cytoreductive surgery with heated intraperitoneal chemotherapy has not been shown to improve health outcomes for either diagnosis.  No prospective clinical trial has shown that this treatment is effective for metastatic unknown primary adenocarcinoma or metastatic pancreatic cancer.  The National Comprehensive Cancer Network (NCCN) guidelines for both occult primary and for pancreatic adenocarcinoma do not mention cytoreductive surgery with heated intraperitoneal chemotherapy as a recommended treatment, or even as a treatment consideration, for any subset of patients.