Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adenoma of the adrenal gland. 

Treatment: Computed tomography (CT) scan of the stomach without dye followed by a CT scan with dye.

The insurer denied coverage for a CT scan of the stomach without dye followed by a CT scan with dye.

The denial is upheld.

This is a female patient with a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, hypothyroidism, sciatica, adenoma of the adrenal gland, and sleep apnea. The patient had a follow-up visit for her type 2 diabetes mellitus. The attending physician found the patient to have bilateral adrenal masses. The patient has been diagnosed with diabetes for many years with complications of neuropathy. The patient is on metformin and tolerates it well. The patient had a computed tomography (CT) scan of the abdomen pelvis done in the past for a clinical history of adrenal lesion. The result was as follows: Right adrenal gland 2.3 centimeter (cm) low attenuation and 1.6 cm low attenuation lesion left adrenal gland both low attenuation prior to contrast. Left adrenal gland nonspecific per report. No significant change in bilateral adrenal lesions. The patient's right adrenal lesion was compatible with an adenoma. The left adrenal lesion was nonspecific, but likely to represent adenoma. Unless the patient has a known malignancy, a follow up study in 1 year would be recommended. The treating provider ordered a CT scan of the adrenal with or without contrast for the patient's adenoma of left adrenal gland and adenoma of right adrenal gland.
As per Wang et al. (2018), "With benign nature, adrenocortical adenomas are the most common adrenal tumors (17). In addition, most incidentally discovered adrenal lesions are also benign adrenal adenomas (18, 19).The incidence of adenomas is 3% at autopsy. It has been reported that the prevalence of adrenocortical adenomas is associated with age. The proportion of adenomas in men and women is about 1:2."

As per Duh (2016), "The new guidelines [from the European Society of Endocrinology in collaboration with the European Network for the Study of Adrenal Tumors] recommend that after the initial evaluation, no further follow-up, either hormonal evaluation or repeat scanning, is necessary for patients with homogeneous-appearing non-secreting incidentalomas <4 [centimeter (cm)] in diameter on non-contrast [computed tomography (CT)] <= 10 [Hounsfield unit (HU)]. This recommendation will have an enormous impact on clinical practice. Surgical indication for non-secreting adrenal incidentalomas has, therefore, changed from focusing on size (>4-6 cm in diameter) to appearance (>10 HU with indeterminate imaging features); for instance, a 3 cm non-secreting incidentaloma of 15 HU now has a stronger surgical indication then a 6 cm tumour of 5 HU. As non-secreting adenomas are the most common adrenal incidentalomas, a considerable amount of health-care resources will be saved if a confident, definitive diagnosis of adenoma can be made without additional work-up." (Duh 2016)

As per Garrett et al. (2016), "Despite clinical recommendations for prolonged imaging follow-up of adrenal nodules, few data support this practice for a benign nodule without hormonal activity." 

As per the National Comprehensive Cancer Network (NCCN), adrenal tumors <4cm and no change in size on repeat imaging in 6-12 months do not require further follow-up. Given the radiologist's opinion that the features of the tumor are consistent with benign nature, there is no indication for the requested CT scans. 

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the request for a CT scan of the stomach without dye followed by a CT scan with dye is not substantiated. The insurer's denial is upheld.