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

Physician 1: The patient is a 14-year-old male who was diagnosed with stage IV alveolar rhabdomyosarcoma in March 2004. At that time he apparently had a large mass in his gluteal region, involvement of much of his spine, and involvement of his bone marrow. PET scan at that time showed multiple additional areas of cancer, multiple bones, bone marrow, and lymph nodes.The patient was treated with intensive chemotherapy. The current status of his disease is unknown. He has apparently recently undergone MRI of his entire spine, as well as essentially total body CT scanning. A PET scan has been requested, which has been denied by the Health Plan on the basis it is considered investigational.The usefulness of PET scanning in oncology is rapidly expanding as it has proven very beneficial in a wide variety of cancer types in terms of initial staging, evaluation of therapy, and re-staging. Though PET scanning has not been specifically included for use in sarcomas, it does appear to be quite useful in such cancers.However, PET scanning does not always add information that is of therapeutic use. In the case of this patient, it appears his disease has been adequately re-evaluated by extensive MRI and CT scanning. Furthermore, there is no supporting request or explanation for the possible need/usefulness of a PET scan by the patients treating physicians. For these reasons, I have determined that the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 14-year-old male who was diagnosed with rhabdomyosarcoma in March 2004. For purposes of staging and determining metabolic character of the tumor a PET was performed in March 2004 as complementary to other anatomic imaging. This scan showed extensive areas of increased tumor metabolism and established the presence of multiple metastases. It also established a metabolic profile, which would be used to determine response to therapy and for restaging.A second PET scan was performed in May 2004, which showed the supraclavicular and subphrenic disease activity was gone with diminished paravertebral and vertebral uptake. This was stated to be a dramatic response. There was still suggestion of persistent marrow metastases, originally seen on marrow biopsy of March 2004. No other PET reports are included in the submitted information. The patients mother has requested authorization and coverage for another PET scan. The Health Plan has denied the request on the basis the requested PET scan is considered investigational for evaluation of the patients condition.The use of PET scanning to stage, restage and determine response to chemotherapy for soft tissue tumors is accepted as the standard of practice in the medical, oncology, and nuclear medical community. It has established efficacy and is medically warranted for the ongoing care and management of patients such as this patient. As such, I have determined that the requested PET scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3: The patient is a 14-year-old male who was diagnosed with grade IV alveolar rhabdomyosarcoma in March 2004. There is metastatic disease as documented on multiple CT, MRI and PET scans. The patient is presently having severe pain. Authorization and coverage for a PET scan has been requested by the patients mother. The Health Plan has denied the request.PET and PET/CT scans have been proven very useful in planning treatment in several cancers including colorectal, non-small lung cancer, esophageal and lymphoma. The use of PET scans in other cancers, including soft tissue sarcomas, has not yet been proven to be efficacious. While there are anecdotal studies in the literature regarding the use of PET scans in rhabdomyosarcoma, these studies were part of clinical trials. The most recent article from the American Roentgen Ray Society concludes further prospective clinical trials are necessary to determine the role of PET and PET/CT in the management of pediatric sarcomas. In addition, PET scans are most useful when the findings with conventional imaging are equivocal. In this patient, both CT and MRI scans have been useful in the evaluation of this patients disease. Therefore, I have determined that the requested PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.