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

Physician 1: The patient is a 58-year-old female who had surgical treatment of her cervical cancer in August 2003 and has been followed by her gyn-oncologist who noted that follow-up exams have shown a firm area at the vaginal apex. On 12/13/04, the area was noted to be more nodular though still small. The patients provider is concerned that this change represents recurrent tumor. Therefore, the patients provider has recommended a FDG-PET scan to characterize its metabolic activity. If it is cold (low), tumor is most unlikely. If it is hot (high), this is quite specific for tumor in this setting. The Health Plan has denied coverage for a PET scan on the basis it is considered investigational in this setting. The use of PET scanning in this clinical setting is within the standard of current practice of oncology, gynecology, and nuclear medicine. Furthermore, in the case of this particular patient, her physician has specific and well-considered reasons for requesting a PET scan. A PET scan is likely to be useful in the ongoing care and management of this patient. As such, I have determined that the requested PET scan 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. Physician 2: The patient is a 58-year-old woman diagnosed with squamous cell carcinoma of the cervix in August 2003. At that time she underwent radical hysterectomy and bilateral salpingo-oophorectomy. She then developed a small bowel obstruction and underwent a laparotomy in October 2003. In December 2004, physical exam noted a hard area, about 1cm in size at the apex of the vagina. The patients provider believes that MRI or CT scans would not be able to resolve the issue as to whether this represents scarring or recurrence of cancer. Therefore, the patient s provider has proposed that the patient undergo a PET scan to determine if this is an area that can be observed or whether more prompt action must be taken. The Health Plan has denied authorization and coverage for the requested PET scan. PET scanning is rapidly becoming a very accepted and quite efficacious technique for the evaluation of a wide variety of cancer types. It has been proven to be efficacious in evaluating many cancers, and the list is expanding rapidly. The submitted articles referenced above support the usefulness of PET scanning in cervical cancer. A PET scan in this situation will be of real clinical meaning and usefulness and is likely to be of greater benefit than other standard diagnostics. Based upon the information set forth above, I have determined that the requested PET scan is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Physician 3: The patient is a 58-year-old female with cervical cancer who had a complicated postoperative course and has increased risk for recurrence of cervical cancer. An examination in December 2004 revealed physical findings of concern. There is still curative potential therapy, but due to the risk involved it is essential to be sure the patient requires such therapy. PET scans can be sensitive to malignant tumor masses as small as 0.5-1.0cm, particularly if they are FDG avid. PET scanning will clearly be useful in this patients follow-up and is medically appropriate. Conventional diagnostic modalities are not likely to be as useful as PET scanning. Therefore, I have determined that the requested PET scan 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.