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

Physician 1: The patient is a 60-year-old female who was recently involved in a motor vehicle accident.  An emergency CT scan was performed to rule out fracture or intra-abdominal injury.  The chest CT revealed 3mm calcified nodule in the right mid lung. Enlarged lymph nodes were identified in the hilar and pre-carinal regions measuring up to 4.2cm in the left hilum. Right hilar and sub-carinal calcifications were also present. The abdominal and pelvic CTs were negative. The findings are consistent with previous granulomatous disease and bilateral hilar and mediastinal adenopathy of unknown etiology. The patient also has a history of recent weight loss and chronic GI symptoms. The patients clinician has requested authorization for a PET scan to further evaluate the adenopathy. The Health Plan has denied authorization for the PET scan citing the investigational nature of the procedure in this clinical context.The Centers for Medicare and Medicaid Services (CMS) do not approve PET scan for a diagnosis of adenopathy without a specific etiology.  PET scans may be positive in both malignancy and inflammation and may show variable activity in other conditions. For instance, the sensitivity for PET scan in carcinoid tissue is variable approximately 29% of the time. Therefore, neither a positive nor a negative PET scan would add to the evaluation of the patients adenopathy. If a specific diagnosis is needed, then biopsy should be considered with mediastinoscopy or bronchoscopy. Another option is to do a follow-up CT scan to show stability of the lesion. Comparison to a previous exam would also be helpful if available.Based upon the information set forth above, I have determined that the requested diagnostic procedure 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 60-year-old female who was involved in a motor vehicle accident (MVA) in February 2006. CTs of the chest, abdomen and pelvis were obtained due to trauma and complaints of sternal pain. The CT of the chest showed mediastinal and hilar adenopathy with no associated lung abnormalities. The patients medical history is negative for malignancy.  The patient has requested authorization for a PET scan to further evaluate her condition.  The Health Plan denied the request because they consider the use of PET scan experimental/investigational in this clinical setting.A PET scan is not medically appropriate or necessary for the evaluation of hilar and mediastinal adenopathy in the absence of a tissue diagnosis. A positive PET scan does not indicate a definitive diagnosis of malignancy. A positive PET scan in this situation might be secondary to an infectious or an inflammatory process. Furthermore, PET scans cannot differentiate the type of malignancy, i.e. lymphoma vs. metastatic disease. The gold standard for the diagnosis of this patients hilar and mediastinal adenopathy is tissue biopsy, either by broncoscopy or mediastinoscopy. Therefore, I have determined that the requested diagnostic procedure 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 3: The patient is a 60-year-old female who had a CT scan of the chest in February 2006 following a motor vehicle accident.  The scan revealed hilar and mediastinal adenopathy and a calcified 3mm nodule.  The patients provider has requested a PET scan for a more comprehensive assessment of the CT findings.  The Health Plan deemed the diagnostic procedure experimental/investigational for evaluation of the patients medical condition and denied the request.There are typically only two pulmonary indications for a PET scan. If there is a solitary pulmonary mass identified, a PET scan is utilized to make a determination regarding lung cancer.  Additionally, a PET scan is employed for restaging of a patient with known lung cancer following treatment. A PET scan would not be authorized for this patients diagnosis under the CMS guidelines.   A 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.