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

Physician 1This patient is a 53-year-old female who has breast cancer metastatic to her lungs. She is status post multiple chemotherapeutic regimens. She is currently stable. She has requested authorization for positron emission tomography (PET) scanning to monitor her clinical situation. The Health Plan has denied the patients request on the basis that PET scanning is considered investigational for this indication.The patient has metastatic breast cancer, status post resection and has undergone multiple courses of chemotherapy. She requires careful follow-up for evidence of recurrence. Multiple modalities exist including PET and CT scans. PET scanning has been approved by the Food and Drug Administration for use in cases of breast cancer. Given that the patient has been utilizing PET scanning to follow recurrence/response, she should remain with the current modality. Therefore, I have determined that the requested PET scanning 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 2The patient is a 53-year-old woman who was diagnosed with breast cancer of an unusual type (metaplastic carcinoma) in May 2001. At that time she underwent surgery, chemotherapy, and radiation therapy to the breast. In March 2003, she was found to have a large recurrent tumor in her right lung. She underwent further chemotherapy followed by resection of the residual lung mass in October 2003. The patient then received further chemotherapy and, as of June 2004, had no evidence of cancer.The patient has undergone past PET scans, which showed strong uptake in the area of the lung tumor. It has been requested that she be followed with routine PET scans every three months in an effort to detect further recurrent disease. It has been stated that following with CT scan is limited by the presence of scar tissue in the lung recurrent disease. The Health Plan has denied authorization for PET scanning on the basis that it is considered investigational.Review of the medical literature indicates PET scans have multiple uses in the evaluation of many types of cancers. In particular, pre-operative staging of lung and other cancers has been a major area of usefulness for PET scans. In addition, since PET scanning depends on metabolic uptake of glucose by tumor cells, it can sometimes distinguish between benign and malignant masses seen on other studies. However, PET scans can cause misleading results. For instance, it is well known that one can see abnormal PET isotope uptake for many months after surgery. Thus, there is a real possibility of being misled by a PET scan in this patient, especially in the area of the lung surgery. CT scans have the advantage of actually showing a mass and enabling one to get an accurate sense of possible size and involvement of other structures by a recurrent malignant mass. Overall, it appears this patient will be best followed with regular CT scans of the chest, abdomen, and pelvis. Based upon the information set forth above, I have determined that the requested PET scanning 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 3The patient is a 53-year-old female with a history of two breast cancers. The first ductal carcinoma in situ (DCIS) was of the right breast in approximately 1996. The patient underwent surgery and radiation, and apparently received chemotherapy. She subsequently developed a metaplastic carcinoma of the left breast in 2002. The cancer recurred in her right lung and she has undergone chemotherapy with several regimens, followed by resection of residual disease, and then additional chemotherapy. The patient is presently without evidence of disease but has residual radiographic abnormality in her right breast. Her cancer was intensely PET positive, i.e., FDG avid.The patients provider has recommended that the patient be followed with routine PET scans every three months. The Health Plan has denied authorization and coverage for the requested PET scanning on the basis that it is considered investigational.The patients cancer has already demonstrated intense PET positivity/avidity. PET scans can clearly differentiate between benign and malignant masses or abnormalities demonstrated by other imaging means, i.e., CT, MRI, and bone scans. PET scans can be sensitive to malignant tumor masses as small as 0.5-1.0cm, particularly if they are FDG avid. Furthermore, PET scans can detect tumor response earlier than other radiographic modalities like CT, MRI, and bone scans. PET scanning will clearly be useful in this patients follow-up and is medically reasonable. Therefore, I have determined that the requested PET scanning 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.