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

Physician 1The patient is a 48-year-old female with a history of ductal carcinoma in situ treated with lumpectomy and radiation therapy in 1996. She experienced a recurrence and underwent a mastectomy in January 2004. Pathology findings are not included in the information provided. A PET scan in March 2004 showed uptake in the left axilla consistent with tumor. Based upon the submitted documentation, it is not known if this was documented pathologically. Nor is it known if the patients tumor marker was elevated at that time. She has received dose-dense adjuvant chemotherapy followed by Taxol. It has been indicated the patients tumor marker is rising.PET scans have broad utility in the management of multiple cancers. PET scans are of recognized value in restaging of relapsed breast cancers. However, upon review of the submitted information it is not known if the patients breast cancer is FDG-18 avid. As such, 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 at this time. The Health Plans denial should be upheld at this time. However, if it is determined that the patient has been demonstrated to be PET avid, and if her cancer marker is clearly rising (at least three or more determinations) and is in the abnormal range, then repeat PET scanning is warranted and should be authorized.  Physician 2The patient is a 48-year-old female who was diagnosed with ductal carcinoma in situ in 1996. At that time she underwent lumpectomy and radiation therapy. A recurrence of disease has been found. The patient underwent a mastectomy in January 2004. A PET scan in March 2004 showed uptake in the left axilla consistent with tumor. The patient has received dose-dense adjuvant chemotherapy followed by Taxol. The patients tumor marker has begun to rise. A repeat PET scan has been recommended. The Health Plan has denied authorization and coverage for the requested PET scan on the basis it is considered investigational in this clinical setting.PET scanning has been approved by the Centers for Medicaid and Medicare Services for staging and restaging of breast cancer. The use of a PET scan for evaluation of patients such as this patient is within the current practice of oncology and nuclear medicine. A PET scan for this patient is medically appropriate and should be approved at this time. Therefore, 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 3The patient is a 48-year-old female who was diagnosed with ductal carcinoma in situ of the right breast in 1996 and underwent a lumpectomy and radiation. In January 2004, the patient was found to have recurrent disease in the right breast, infiltrating ductal carcinoma, and underwent a right mastectomy. The patients post-operative course was complicated by a wound infection. A PET scan performed in March 2004 showed activity in the right lateral left axilla. There has been a progressive rise in the patients CA 15-3 serum marker to 54.6 U/M.  The patients oncologist has recommended a PET scan for restaging. The Health Plan has denied coverage for a PET scan on the basis it is considered investigational for evaluation of patients such as this patient.Over the last decade, there have been many studies showing the efficacy of PET scan for staging breast cancer. In October 2002, the Centers for Medicare and Medicaid Services (CMS) approved PET scans for breast cancer staging/restaging of local/regional recurrence or distant metastases. PET scan has been shown to be more sensitive and specific than CT scans for detection of mediastinal and internal mammary lymph node metastases. In addition, the PET scan has been shown to be more sensitive, specific, and accurate and to have better positive and negative predictive values than conventional imaging for detecting local recurrence or distant metastases. Furthermore, the PET scan has been shown to have a significant impact on the management of breast cancer patients, influencing both clinical stage and management. It also has been shown that PET scan is more sensitive than serum marker CA 15-3 in detecting relapsed breast cancer.In addition, two recent articles continue to support the role of PET scan in evaluating patients with breast cancer. One study by Van der Hoeven and colleagues found the addition of FDG PET to the standard workup of patients with locally advanced breast cancer may lead to the detection of unexpected distant metastases. Another study by Eubank, et al., concluded the sensitivity and specificity of PET for recurrent/metastatic breast cancer are high, 94% and 91% with the results of the PET scan altering the therapeutic plan in 32% of patients.In the case of this patient she has had a prior PET scan, which can be used for comparison adding more value to the follow-up scan.Based upon the information set forth above, 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.