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

Physician 1: The patient is a 42-year-old male who was diagnosed with T2 N0 M0 seminoma of the testicle on August 2004. He was treated with surgery alone, followed by surveillance for recurrence. In October 2005 a CAT scan identified a new 1.4 cm lymph node in the retroperitoneum. A follow-up MRI in March 2006 showed a slight enlargement of the node to 1.6 cm and a new 1.8 cm lesion in the L2 vertebral body. Neither of the lesions is definitively representative of recurrent cancer. The patients provider requested authorization for a PET scan to further analyze the clinical situation. The Health Plan denied authorization citing the investigational nature of the procedure in this clinical context.PET scans are a very different kind of scan than MRI or CAT scan. PET actually looks at the metabolic actively of an area or lesion and can be quite useful in the detection and evaluation of cancer. There is general acceptance of its usefulness and with many types of cancer such as lung cancer, breast cancer, and lymphoma. Although there does not appear to be a great deal of published data on its utility in testicular seminoma, nuclear medicine experts support its application for this type of tumor. Because this technology has proven useful for other cancers and this patients clinical status clearly requires further definition, I have determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of his medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 42-year-old male with a history of seminoma treated with left orchiectomy in August 2004.  His follow-up scans were within normal limits until January 2006, when an abnormal lymph node in the area of the aortic bifurcation was found.  MR imaging of the abdomen identified an abnormal lymph node at the bifurcation and an additional lesion within the L2 vertebral body.   The patient requested authorization for a PET scan for further evaluation of the lesions.  The Health Plan denied authorization and coverage because they consider the diagnostic procedure investigational in this clinical setting.PET scan has not yet been proven to be efficacious for the staging of testicular cancer.  Presently, PET scans are utilized to stage lymphoma following a confirmed tissue diagnosis. The patients abnormal lymph node may be metastatic disease from the seminoma or it could represent the early changes of lymphoma.  To determine the etiology of the abnormal findings, a tissue diagnosis is necessary.  A positive PET scan cannot differentiate between seminoma and lymphoma. Therefore, I have determined that the requested diagnostic procedure 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 3: The patient is a 42-year-old male who underwent a left orchiectomy for seminoma in August 2004. A routine surveillance CT scan was performed in January 2006 and a new 1.4 cm retroperitoneal lymph node was identified when compared to a September 2005 study.  An MRI was performed in March 2006 and the retroperitoneal node was again present and had minimally increased to 1.6 cm.  An indeterminate lesion in the L2 vertebral body was also identified with the MRI. The patients urologist submitted a request for a PET scan to further study the lesions.  The Health Plan considers this an investigational procedure for evaluation of the testicular cancer and denied authorization.Previous Centers for Medicare and Medicaid Services (CMS) reimbursement standards did not include testicular cancers on its list of indications for PET scan.  However, the National Oncologic PET Registry (NOPR) was developed in response to the CMS proposal to expand coverage for PET scans and include cancers and indications not presently eligible for Medicaid reimbursement.  Through the registry, the diagnosis, staging, restaging and monitoring of testicular cancer is an eligible PET scan application.  The NOPR has been implemented for CMS and it is scheduled to open soon.  PET scan has been shown to be more sensitive and specific than CT for postchemotherapy seminoma and superior to conventional staging in non-seminomatous germ cell tumors.  Considering the high positive predictive value (PPV) and the high negative predictive value (NPV) for PET scan when applied to testicular tumors and the fact that the patients lymph node is a new finding, it is reasonable to complete a PET diagnostic examination before considering an invasive procedure.Based upon the information set forth above, I have determined that the requested diagnostic procedure 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.