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

Physician #1:  The patient is a 47-year-old female with a history of headaches, nausea, weight loss and a pineal cyst verified on MRI. Provider opinions differ, but the pineal cyst may be slightly larger on a follow-up scan. The patient has consulted with several specialists, and the general consensus is that the pineal cyst is a benign lesion. The consulting neurosurgeon recommends follow-up MRI and MRS to monitor the cystic lesion.  The Health Plan has denied the patients request for authorization of the MRS, citing the investigational nature of the diagnostic procedure in this clinical context.An MRS is not the standard test for on-going evaluation of a likely benign process such as a pineal cyst.  Serial MRIs as deemed necessary by the neurosurgeon are the most appropriate approach. The requested MRS is not likely to alter the care and management of this patients condition. 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 #2:  The patient is a 47-year-old female with significant headaches who has a cystic pineal region mass confirmed by MRI. The radiology reports from two different imaging centers show little change in the lesion. The patient has consulted with a neurosurgeon who thought the lesion might be slightly enlarged and recommended careful observation with MRI and MRS. The providers request for authorization of the MRS was denied by the Heath Plan based upon a determination that MRS is experimental/investigational for the evaluation of this type of lesion.An MRS in this instance is an investigational approach.  The results of the MRS are not likely to change the clinical management of the patient. An appropriate clinical course would include consistent follow-up and a repeat MRI and possibly a needle biopsy.  Consequently, 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 47-year-old female who presented for a head CT in November 2001 because of headaches. Her exam showed a cystic lesion in the pineal gland. Subsequent MRIs of the head with and without contrast confirmed a 1.8cm x 1.8cm x 1.0cm predominantly cystic pineal mass. A follow-up MRI of the head with and without contrast in November 2005 showed a 1.7cm pineal mass with the possibility of a tiny enhancement. An MRI of the brain done in February 2006 demonstrated the stable appearance of the 1.7cm pineal cyst. Recent consultation with her neurosurgeon raised the possibility that this pineal lesion has slightly increased in size. Clinically the patient continues to have headaches in addition to nausea, vomiting and weight loss.  The patient has requested authorization for an MRS. The Health Plan denied her request on the basis that the procedure has not been shown to have greater diagnostic value than standard imaging techniques.Management of a questionably enlarging pineal mass would involve a short term follow-up MRI of the head with and without contrast to determine if this mass is indeed becoming larger.  If the size of the lesion were to become significant, then surgery may be indicated.  My review of the literature could find no evidence to support the use of MRS in the patient.  MRS in general is a newer technique that has been used to help distinguish post-radiation changes from residual tumor and other such applications.  The use of MRS in this patient at this time is not supported by the peer-reviewed literature.Based upon the information set forth above, 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.