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

Physician 1The patient is a 48-year-old man with a past history of colorectal cancer. In January 2002, his PSA was 6.8 with a negative digital rectal exam (DRE). In February 2003, a biopsy revealed Gleason 4+3 in both the right base and the right mid zones. The patient had a T2a lesion upon DRE. The patient consulted a medical oncologist who recommended prostatectomy. On 2/24/04, CT scan of the chest, abdomen and pelvis revealed a 2.2 x 1.8cm mass in the region of the right seminal vesicle and an 8mm lymph node in the mediastinum. On 2/27/04, the patient underwent a PET scan that was negative except for the questionable mediastinal activity. The patient has requested authorization for a PET scan for the purpose of staging his prostate cancer. The Health Plan has denied the patients request indicating that PET scanning for this indication is considered investigational.The Health Plans denial should be upheld. A PET scan is used only in investigational settings and should not be confused with clinical applications. PET has no practical or clinical value in prostate cancer as shown by the PET scan of this patient. The patients previous PET scan was negative in the area of the right seminal vesicle whereas a 2.2 x 1.8cm mass was noted by a CT scan performed three days earlier. This demonstrates the lack of value of PET for prostate cancer. Based upon the information set forth above, 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. The Health Plans denial should be upheld.Physician 2The patient is a 48-year-old male who was diagnosed with prostate cancer in February 2003. The patient underwent a prostatectomy and a follow-up CT scan was performed in February 2004. The CT scan showed a 2.2cm soft tissue density in the right pelvis of unknown etiology. An 8mm mediastinal lymph node was also identified. The patient underwent a positron emission tomography (PET) scan on 2/27/04, which showed a focus of increased activity in the mediastinum. The patients provider has recommended the patient undergo a PET scan for purposes of staging the patients prostate cancer. The Health Plan has denied authorization for the requested PET scan on the basis that it is considered investigational for staging of prostate cancer.According to the Centers for Medicare and Medicaid Services (CMS), prostate cancer is not an approved indication for PET scan. In addition, Kipper, et al (cited above) indicates that PET imaging is of limited use with prostate carcinoma due to the fact that most prostate carcinomas are slow growing, low metabolic rate tumors. There have been several studies over the last few years, which have shown mixed results for the role and efficacy of PET scan in prostate cancer. For instance, in a study of 22 patients (Salminen, et. al.) the accuracy of PET was 72%. This study concluded with the comment that a negative PET scan in prostate cancer should be interpreted with caution. Another study involving 12 patients (Jadvar, et. al.) concluded that PET is limited in the detection of osseous metastatic lesions, but may be useful in the detection of metastatic nodal and soft tissue disease. The role of PET scan in prostate cancer is still being studied with ongoing clinical trials. At this time, outside of clinical trials there is no role for PET scanning in patients with prostate cancer. Therefore, 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. The Health Plans denial should be upheld.Physician 3The patient is a 48-year-old man with an elevated PSA to 12.5. A positive prostate biopsy revealed Gleason 4+3 adenocarcinoma in the right prostate base and mid zone, with sonographic findings suspicious for a focus of extracapsular extension. The patient apparently underwent a radical prostatectomy last year. A CT scan performed on 2/24/04, showed a 2cm soft tissue mass in the right pelvis in the region of the prior seminal vesicle. A PET scan performed on 2/27/04 showed an 8mm hypermetabolic focus in the mediastinum. The submitted information notes that the patient has colorectal cancer. The patients provider has requested a positron emission tomography (PET) scan to restage the prostate cancer. The Health Plan has denied this request on the basis that there is not sufficient medical evidence to support its value in prostate cancer. Multiple studies have demonstrated that PET has not been found to be useful in staging prostate adenocarcinoma. Other studies, such as a PSA and other types of imaging studies (e.g., CT scan) are more useful in staging prostate adenocarcinoma. This is evidenced by the fact that the patients CT scan of 2/24/04, showed a pelvic mass 2cm in size, which was not found on the PET scan of 2/27/04. Therefore, 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. The Health Plans denial should be upheld.