Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine cancer	

Treatment: Computed tomography (CT) thorax (code 71250) and CT abdomen/pelvis (code 74176)

The insurer denied coverage for computed tomography (CT) thorax (code 71250) and CT abdomen/pelvis (code 74176)

The denial is upheld 

The patient had computed tomography (CT) thorax (code 71250) and CT abdomen/pelvis (code 74176) performed to assess for endometrial cancer. 

The insurer has denied coverage for computed tomography (CT) thorax (code 71250) and CT abdomen/pelvis (code 74176) as not medically necessary. In a Final Adverse Determination letter, they stated that imaging may be supported if the tumor has spread to more than 50% of the womb muscles or lymphatic system. The patient did not meet criteria for approval. The requested service is denied based on eviCore Imaging Guidelines Section(s): Uterine Cancer - Initial Work-up/Staging (ONC 22.2). 

The patient's oncologist is appealing. In an appeal letter, the patient's oncologist stated that a CT of the chest, abdomen, and pelvis was done for concern for recurrent endometrial cancer.  

This is a patient with uterine cancer. The magnetic resonance imaging (MRI) of the pelvis showed a lesion confined to the uterus. The patient underwent computed tomography (CT) thorax (code 71250) and CT abdomen/pelvis (code 74176) performed on 11/28/2022. 

The patient has uterine cancer. The MRI of the pelvis showed a lesion confined to the uterus. There is no rationale to perform computed tomography (CT) thorax (code 71250) and CT abdomen/pelvis (code 74176) on an individual who had disease limited to the uterus by MRI that was done. There is no reason to repeat abdominal imagining or perform a CT of the chest in this setting.

Given the above, the computed tomography (CT) thorax (code 71250) and CT abdomen/pelvis (code 74176) performed was not medically necessary.

"Adenocarcinoma of the endometrium (also known as endometrial cancer, or more broadly as uterine cancer or carcinoma of the uterine corpus) is the most common malignancy of the female genital tract in the United States. It is estimated that 65,950 new uterine cancer cases will have occurred in 2022, with 12,550 deaths resulting from the disease. Endometrial carcinoma includes pure endometrioid cancer and carcinomas with high-risk endometrial histology (including uterine serous carcinoma, clear cell carcinoma, carcinosarcoma [also known as malignant mixed Mullerian tumor], and undifferentiated/dedifferentiated carcinoma). Stromal or mesenchymal sarcomas are uncommon subtypes accounting for approximately 3% of all uterine cancers" (1).

"Endometrial adenocarcinoma or endometrioid carcinoma is the most common subtype of endometrial cancer. Endometrial adenocarcinoma develops as a result of unopposed estrogen exposure. Estrogen has a proliferative effect on the endometrium, which leads to endometrial hyperplasia. Unmonitored proliferation leads to dysplasia and later carcinoma. Adipose tissue in the body converts androgens into estrogen and hence conditions like obesity, metabolic syndrome, and diabetes mellitus type II that lead to increased estrogen levels and can increase the risk of endometrial carcinoma. More than 50% of endometrial cancers are attributable to obesity alone" (2).                                                         

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for computed tomography (CT) thorax (code 71250) and CT abdomen/pelvis (code 74176) is not substantiated.