Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Esophageal cancer.

Treatment: Positron Emission Tomography and Computed Tomography (PET CT) Scan, Current Procedure Terminology (CPT) code 78815.

The insurer denied coverage for Positron Emission Tomography and Computed Tomography (PET CT) Scan, Current Procedure Terminology (CPT) code 78815.

The denial is overturned. 

This male patient has a diagnosis of esophageal cancer. He underwent upper endoscopy with findings of partially obstructing malignant esophageal tumor and malignant gastric tumor. Biopsies were positive for adenocarcinoma poorly differentiated gastric type. Distal esophagus biopsy showed squamous and gastric cardia epithelium. Computed tomography (CT) scan was obtained and showed significant adenopathy in the upper retroperitoneum /gastrohepatic ligament. The provider noted that if this is felt to be esophageal and/or gastroesophageal junction treatment is usually chemotherapy and radiation. If this is felt to be purely gastric cancer, then the treatment would probably start with chemotherapy followed by re-evaluation for surgery. The adenopathy is significant for more extensive disease. The provider recommended a positron emission tomography (PET) CT scan to complete the staging. 

The PET CT scan will give the provider the answer the physician requires in order to take care of his patient and the PET CT is appropriate based upon MCG Tumor Imaging Positron Emission Tomography (PET) and PET-CT Ambulatory Care: MCG 24th edition ACG: A-0098 (AC).  As noted by MCG Positron emission tomography (PET), with or without simultaneous computed tomography (PET-CT), for tumor imaging may be indicated for 1 or more of the following: Cancer or neoplasm, initial evaluation or staging needed (from diagnosis through initial staging), as indicated by ALL of the following: Additional imaging information required to assess 1 or more of the following: Anatomic extent of tumor, if results will assist with selection of optimal antitumor treatment or Appropriateness of patient for invasive diagnostic or therapeutic procedure or Optimal anatomic location for invasive procedure; PET or PET-CT not yet performed (prior to initiation of treatment); Solid tumor malignancy, biopsy-proven or strongly suspected; Treatment not yet initiated; and Type of tumor is   esophageal, or stomach as well as others.  Furthermore cancer or neoplasm, subsequent evaluation or staging needed (after completion of initial treatment through monitoring for recurrence), as indicated by ALL of the following: Additional imaging required to assess 1 or more of the following: Residual disease, suspected, after completion of initial treatment (restaging); Recurrent disease, suspected, well after completion of treatment (monitoring), as indicated by 1 or more of the following: Abnormal findings on physical examination, or Abnormal laboratory tests or other imaging studies; New symptoms; or Type of tumor is esophageal or stomach. 

MCG notes that for initial evaluation or staging of esophageal or gastroesophageal junction cancer, evidence demonstrates at least moderate certainty of at least moderate net benefit. PET-CT is preferred over PET alone for staging. National Comprehensive Cancer Network (NCCN) guidelines version 5.2020 notes that staging of distant metastatic disease is best assessed with PET CT scan.

PET CT has a significantly increased accuracy rate (68%) for preoperative staging as compared with PET scan (47%) or CT scan (53%) alone.  This was confirmed in NCCN guidelines version 4.2020 for gastric cancer notes.

The PET CT scan is medically necessary to adequately stage and plan for treatment for this patient.  

The insurer did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the Positron Emission Tomography and Computed Tomography (PET CT) Scan, Current Procedure Terminology (CPT) code 78815 is overturned.  The medical necessity is substantiated.