Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Estrogen Receptor Positive

Treatment: CPT (current procedural terminology) code 78815, PET (positron emission tomography) scan

The insurer denied coverage for CPT code 78815, PET scan

The denial is upheld

The patient has estrogen receptor positive (ER) positive, human epidermal growth factor receptor (Her) 2 negative breast cancer.  The treating provider has requested Positron Emission Tomography-Computed Tomography (PET/CT). The request was denied by the insurer.

American Society of Clinical Oncology (ASCO) notes, "Don't perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.

Imaging with PET, CT, or radionuclide bone scans can be useful in the staging of specific cancer types.  However, these tests are often used in the staging evaluation of low-risk cancers, despite a lack of evidence suggesting they improve detection of metastatic disease or survival.  In breast cancer, for example, there is a lack of evidence demonstrating a benefit for the use of PET, CT, or radionuclide bone scans in asymptomatic individuals with newly identified ductal carcinoma in situ (DCIS), or clinical stage I or II disease.

Unnecessary imaging can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis."

Brothers, J. M., et al. noted, "A total of 169 of 340 patients (49.7%) underwent staging evaluation for distant metastases (CT chest, abdomen, pelvis, bone scan, and/or PET-CT). Of these, 146 (86.4%) had at least one suspicious or indeterminate finding.  Follow-up studies were performed in 73 (43.2%) patients.  Nineteen patients were diagnosed with metastatic disease at diagnosis, 18 of whom had stage III disease. In patients without metastatic disease at diagnosis, 32 later developed recurrence.  Non-calcified pulmonary nodules were associated with shorter time to disease recurrence (hazard ratio 2.51, 95% CI 1.135.57, p=0.02).  Conclusions Imaging for distant metastases frequently reveals indeterminate findings, most of which are not associated with disease recurrence.  The association between pulmonary nodules and recurrence warrants validation in an independent cohort.  Overall, these findings support current guidelines recommending against routine extent of disease evaluation in patients with newly diagnosed stage II breast cancer."

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.      

There is no evidence to support the routine use of advanced imagining such as PET/CT or CT scans to evaluate for metastatic disease in newly diagnosed early stage breast cancer absent signs or symptoms of metastatic disease.  This is settled medicine with studies dating back to early 2000 showing that this is of no clinical value and of low yield.  This was identified as unnecessary care by the American Society of Clinical Oncology (ASCO) choosing wisely campaign.  In the event imaging is needed to evaluate for metastasis, CT imaging should be used.

The insurer's denial of coverage for the CPT code 78815, PET scan is upheld. Medical Necessity is not substantiated.