Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Physician 1: The patient is a 61-year-old male with a Gleason score of 6/7 with adenocarcinoma of the prostate clinically localized. He wants to undergo robotic-assisted laparoscopic prostatectomy for cure. The Health Plan indicates there is insufficient evidence in the peer-reviewed literature showing robotic assistance results in superior outcomes.Robotic-assisted laparoscopic prostatectomy has been proven to be superior to conventional radical prostatectomy in many aspects. Oncologic results of laparoscopic prostatectomy are superior to conventional surgery. Laparoscopic prostatectomy can be performed without robotic assistance, but there are significant advantages to robotic assistance in terms of recovery and complications. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: This 61-year-old male patient has a Gleason score of 6/7 adenocarcinoma of the prostate with a PSA of 4.1 as of May 2005. Present treatments have been discussed inclusive of open surgery, radiation therapy, laparoscopic surgery with robotics and watchful waiting. The patient has opted for robotic-assisted laparoscopic prostatectomy. The Health Plan has denied authorization and coverage for the requested procedure indicating it is considered investigational.A review of the literature fails to supply a prospective and randomized comparison of open radical prostatectomy and robotic-assisted laparoscopic prostatectomy. With regard to robotic-assisted versus non-robotic assisted prostatectomy, it is generally believed robotic assistance provides little additional benefit. Though some in the urologic community believe the improved tissue handling and magnification of the robotic-assisted procedure improves the results of surgery, the medical literature does not yet support this contention. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 61-year-old male with prostate adenocarcinoma. As of January 2005 the patients total PSA was 3.94. In February 2005, one hard nodule on the right side of the prostate was noted on a rectal examination. In April 2005, an ultrasound guided transrectal prostate biopsy showed Gleason score of 3+4=7 adenocarcinoma in two of six cores on the right and Gleason score of 3+3=6 adenocarcinoma in four of seven cores on the right. Staging would be T2b. In May 2005, the patients PSA was 4.1. The patient has requested authorization and coverage for robotic-assisted laparoscopic radical retropubic prostatectomy to treat his cancer, which based on Partins Table, has a less than 50% chance of being organ confined. The Health Plan indicates it will authorize a laparoscopic radical retropubic prostatectomy without robotic assistance if requested.Robotic-assisted laparoscopic radical prostatectomy is a variation of the standard laparoscopic radical retropubic prostatectomy performed for potentially curable prostate adenocarcinoma. The procedure is performed with the aid of a surgical robot, usually the da Vinci system. This is a relatively new development in the treatment of prostate adenocarcinoma. To date, there is insufficient data demonstrating the robotic-assisted laparoscopic prostatectomy is superior to the non-robotic assisted surgery. As of this time, no long-term data is available to determine if robotic assistance will produce better results in terms of complications or survival. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.