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

Physician 1The patient is a 64-year-old woman with locally advanced breast cancer. The patient detected a mass approximately five years ago and at that time decided to pursue alternative therapies. The patient is now being considered for mastectomy with either curative intent or for local-regional control. The patients surgeon wishes to use PET scanning as an adjunct to clinical decision-making. The Health Plan has denied authorization for the requested PET scan on the basis that it is considered investigational.The Health Plans denial should be upheld. The treating surgeons do not provide a specific need for the PET derived information that could not be met by standard imaging techniques. Furthermore, it is likely that any unexpected PET findings would lead to a need for traditional imaging studies for corroboration since PET alone cannot be used for surgical planning. The use of PET scanning in medical planning should be confined to a specific indication, preferably one in which a benefit in some clinical outcome (survival, improved symptoms or reduced toxicity of therapy) has been shown.  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 2The patient is a 64-year-old woman who was first seen by her current provider in April 2003. At that time she reported a history of a breast mass for approximately four years. She had been pursuing alternative therapies for this apparent cancer. The patient then underwent hormonal biopsy, confirming the diagnosis of invasive ductal carcinoma, and accepted hormonal therapy with oral letrozole. There was good response, with diminution of her breast mass, but she was unable to symptomatically tolerate the letrozole and therefore, it was discontinued.The patients breast mass began to grow again and in June 2004 the patient indicated she was willing to consider surgical treatment of the cancer. A PET scan was recommended in an attempt to stage her disease, not only in the breast and adjacent nodal areas, but in the rest of her body as well. The Health Plan has denied authorization and coverage for a PET scan on the basis that it is considered investigational.Though there is a great deal of literature speaking to the uses of PET scans, particularly as compared to other available modalities, it is not entirely clear which imaging modality is best for the evaluation of the axilla and internal mammary nodal areas, or even the whole body, in women with breast cancer. However, PET scanning is now commonly used by clinicians in the initial evaluation of breast cancer because it often indicates findings that change the therapeutic approach. Furthermore, in the case of this particular patient, her physicians have specific and well-considered reasons for requesting a PET scan. 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.Physician 3The patient is a 64-year-old female with right breast cancer diagnosed in April 2004. Prior to her breast biopsy, the patient was aware of a right breast mass for approximately four years. She was treated with letrozole to decrease the tumor size. The tumor did decrease in size; however, letrozole was discontinued due to side effects. The patient is now being considered for surgery and her clinician has ordered a PET scan for preoperative staging. The Health Plan has denied authorization for the requested PET scan on the basis that it is considered investigational.The Centers for Medicare and Medicaid Services (CMS) has approved PET scans for breast cancer staging/restaging of local/regional recurrence or distant metastases. Review of the medical literature indicates that when comparing PET scanning to conventional imaging, PET scanning significantly altered the treatment plan and clinical management in approximately one-third of patients involved in the studies. The sensitivity, specificity, and accuracy of PET scan in breast cancer are high, greater than 90%. Furthermore, the patients physician has clearly stated the reason for ordering the exam and how the results will be used. As such, the use of PET scan is medically appropriate and should be authorized.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. The Health Plans denial should be overturned.