Appeal type: Medical Necessity
Decision: Insurer Denial Overturned

Summary Reviewer 

The patient is a 74-year-old female who has a long history of an aggressive left breast cancer. The malignancy was apparently first detected in 2014. At that time, she was treated with a left mastectomy.  The patient has requested reimbursement for PET scan with CT for attenuation performed on 3/02/20 and 9/01/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) has published guidelines. In their 2021 guideline, the recommended surveillance schedule is aHistory and physical exam 1-4 times per year as clinically appropriate for five years, then annually.a Further, the NCCN states, aIn the absence of clinical signs and symptoms suggestive of recurrent disease, there is no indication for laboratory or imaging studies for metastases screening.a The NCCN then also states, aFDG PET/CT is most helpful in situations where standard imaging studies are equivocal or suspicious. FDG PET/CT may also be helpful in identifying unsuspected regional nodal disease and/or distant metastases when used in addition to standard imaging studies.a Lam writes, aOther imaging modalities available for breast cancer screening include contrast enhanced spectral mammography, positron emission mammography, and gamma imaging, including molecular breast imaging or breast-specific gamma imaging. To our knowledge, no studies to date have evaluated these imaging modalities for post-treatment imaging surveillance of women with a personal history of breast cancer, and there is insufficient evidence to support their use. Guidelines for metastatic disease evaluation are consistent in their recommendations. In the United States, guidelines from the Choosing Wisely initiative of the American Board of Internal Medicine Foundation, American Cancer Society and American Society of Clinical Oncology, and National Comprehensive Cancer Network recommend against advanced imaging (e.g., PET, PET/CT, or radionuclide bone scan) or circulating biomarker testing to monitor for recurrence in patients without symptoms who have been treated for breast cancer with curative intent. Internationally, multiple organizations also recommend against additional imaging to evaluate for metastatic disease. These recommendations are based on randomized trials that showed no survival benefits in screening for metastasis in the population without symptoms.a In this particular patient, the PET/CT scan performed on 3/20/20 was medically necessary. The patient had a suspected metastatic skin lesion detected on physical examination, and it was appropriate to determine if there were other occult areas of metastatic disease that should have been addressed at that time. The PET scan was negative. The repeat PET/CT scan performed on 9/01/20, however, was not medically necessary, as there were no clinical signs or symptoms that were worrisome. All told, the PET scan with CT for attenuation performed on 3/02/20 was medically necessary for the evaluation of this patient. The medical necessity of the PET scan with CT for attenuation performed on 9/01/20 has not been demonstrated.