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

Physician 1:  The patient is a 42-year-old male who had a right orchiectomy in August 2004 for seminoma. A 1.4cm retroperitoneal lymph node was identified on a follow-up CT scan. MRI of the abdomen in March 2006 showed increased activity in the retroperitoneal lymph node and in the right axilla. The patient received radiation therapy to his periaortic and pelvic lymph nodes. No abnormality was identified in the right axilla on the CT scan. A follow-up PET scan has been ordered to assess the activity in the axilla. The Health Plan has denied coverage for the requested PET scan.Prior Centers for Medicare and Medicaid Services (CMS) reimbursement standards did not include testicular cancer as an indication for PET scan. However, the National Oncologic PET Registry (NOPR) was developed in response to the CMS proposal to expand coverage for PET scans to include cancers and indications not previously eligible for Medicare reimbursement. NOPR lists testicular cancer as an indication for PET scan for the purposes of diagnosis, staging, restaging, and monitoring. PET scanning has been shown to be more sensitive and specific than CT for postchemotherapy seminoma, and superior to conventional staging in non-seminomatous germ cell tumors. PET scanning is highly specific for active tumor in both seminoma and non-seminomatous germ tumor after salvage chemotherapy. In addition, in the case of this patient, there is a prior PET scan for comparison, which adds to the value of this follow-up exam.For the reasons 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.Physician 2:  The patient is a 42-year-old man who had stage I testicular seminoma and a left orchiectomy as of August 2004. A surveillance CT performed in January 2006 noted a retroperitoneal node. There was a slight increase in size on an MRI performed in March 2006. A PET scan performed in April 2006 showed intense uptake with standard uptake value (SUV) of 8.7. Also noted were two right axillary presumed nodes with SUV of 5.8, very suspicious for metastases. Apparently, a biopsy was not performed on the axilla. No axillary nodes were palpable.The patient completed a course of external beam radiation therapy to the nodes during May and June 2006. In July 2006 his provider indicated that a repeat PET scan was needed in three months to check the current status/metabolic state of the irradiated nodes and to follow-up on the right axillary abnormality suspicious for metastases. The Health Plan has denied coverage for the PET scan on the basis that it is considered investigational for evaluation of the patients condition.It is well known that the specificity and positive predictive value of PET is much higher than CT in detection and recognition of seminoma and its metastases. In this case, the use of PET to re-examine the right axillary tissue and to assess the current status of metastases in the nodes is consistent with the current practices of Radiation Oncology and Nuclear Medicine. As such, the proposed PET scan is clinically appropriate and indicated and should be authorized. Accordingly, 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 3:  The patient is a 42-year-old male who has a history of seminoma treated with orchiectomy in August 2004. The patient was diagnosed with recurrent disease in March 2006 involving a lymph node at the level of the aortic bifurcation. He underwent radiation therapy for the recurrent retroperitoneal disease. Prior to radiation therapy a PET scan was performed that showed abnormal uptake within the right axilla. Biopsy of this area was attempted, though at the time of the biopsy no abnormalities were found within the right axilla. Another PET scan has been requested to evaluate the right axilla. The Health Plan has denied authorization for the requested PET scan citing a lack of proven value in this clinical setting.According to the submitted records, no abnormalities were found within the right axilla during the attempted biopsy. Additionally, the PET scan report of April 2006 indicates there was concern of mis-registration artifact in the region of the right axilla (potentially, affecting the accuracy of the PET scan in this region).The appropriate follow-up imaging study in this case is a CT scan of the chest with attention to the right axilla. If there is an abnormality within the right axilla, it could then be biopsied. A positive repeat PET scan (showing uptake within the right axilla) could indicate an infectious or inflammatory process or could indicate malignant disease. As such, the proposed PET scan is not likely to be superior to standard diagnostic techniques in this case.Based upon the information set forth above, 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.