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

Physician 1The patient is a 53-year-old female with the diagnosis of two primary cancers, lung and ovarian. On 1/9/04, the patient had a percutaneous biopsy of a left supraclavicular mass, which showed a poorly differentiated squamous cell carcinoma, probably lung in origin. On 2/1/04, the patient underwent a total abdominal hysterectomy and a bilateral salpingo-oophorectomy (TAH-BSO), which revealed a serous cystadenocarcinoma, grade III. A positron emission tomography (PET) scan was performed on 2/24/04, which showed widespread metastatic disease involving left supraclavicular area, mediastinum, right lung, retroperitoneum, and pelvis. A CT scan was performed on 5/3/04 and was compared to the prior exam of 1/14/04. There had been the interval TAH-BSO and marked improvement in the pulmonary nodules and mediastinal and retroperitoneal adenopathy. A 4cm post-operative hematoma was noted in the pelvis. The patient is currently being treated with chemotherapy and her oncologist has requested a follow-up PET scan to reassess the extent of disease.  The Health Plan has denied authorization and coverage for the requested PET scan on the basis that it is considered investigational.The patient has two primary cancers, lung and ovarian. The Centers for Medicare and Medicaid Services (CMS) has approved PET scans for the diagnosis, staging, and restaging of non-small cell lung cancer. The role of PET scanning in the staging of ovarian cancer is less clear. Sensitivity ranges from 83-100% and specificity from 67-100% for the identification of macroscopic disease. The literature indicates that the role of PET appears to be for problem solving and as a complementary test in the patient with suspected recurrence. Thus far, clinical evidence of PET efficacy for the evaluation of ovarian masses, preoperative staging or monitoring response to therapy is preliminary. However, the value of the PET scan for lung cancer is well documented and it is now considered part of standard medical practice. Since this patient has lung cancer and underwent a prior PET scan, which can be used for comparison, the results can be used to help determine future therapy. As such, the requested PET scan is medically reasonable and 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.Physician 2The patient is a 53-year-old woman who underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy in early February 2004. The patient subsequently underwent a PET scan on 2/24/04. The scan revealed extensive disease in the left supra clavicular region, mediastinum, right lung, retroperitoneum, post pelvis centrally, and paravertebral region near L-5. The patient was subsequently treated with chemotherapy for three months and reassessed on 5/3/04, with CT scans of chest, abdomen and pelvis. These scans showed significant regression of the tumor and very good response to chemotherapy. The patients provider has requested a PET scan to compare the results to those of the previous PET scan of 2/24/04 in order to determine the patients response to chemotherapy.The PET scan on 2/24/04 was effective in detecting the extent of spread of the ovarian tumor. On 5/3/04, the CT scans showed favorable response of the tumor to chemotherapy. The patients previous PET scan was positive for tumor detection and therefore, was effective. The patients tumor response to chemotherapy has already been evaluated by CT scans. Therefore, the requested PET scan is redundant and is not likely to be beneficial or alter the patients ongoing treatment. 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.Physician 3The patient is a 53-year-old female with ovarian cancer and apparent lung cancer. The stage of the lung cancer is unclear. On 2/24/04, the patient underwent a PET scan, which showed extensive metastatic disease. The patient has had a partial response to carboplatin/Taxol chemotherapy, but with associated myelosuppression. The patients provider has recommended a repeat PET scan to monitor the patients response to chemotherapy. The Health Plan has denied authorization and coverage for the requested PET scan on the basis that it is experimental.PET scanning is useful in initial staging and restaging of non-small cell and small cell lung cancers. While there is less data with regard to PET scanning in ovarian cancer, it clearly is a sensitive technique in detecting ovarian cancer at any stage and also post- treatment. Furthermore, post-treatment CT scans are not as sensitive to residual cancer activity in residual tumor masses. PET scanning in this patient is likely to be useful in monitoring residual abdominal pelvic ovarian cancer, particularly if the cancer does not have a CA-125 serum marker. Moreover, PET scanning is likely to be useful in monitoring discordant responses of the ovarian and lung cancers. 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.