Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Metastatic breast cancer.
Treatment:  Positron Emission Tomography (PET) scan (procedure code 78815).

The insurer denied coverage for PET scan (procedure code 78815).  The denial is upheld.

This is a woman with a left breast mass. A PET scan of the skull base to mid-thigh revealed left breast cancer with 2 hypermetabolic left axillary nodes, four hypermetabolic hepatic lesions, and a subtle 6 millimeter (mm) lucent lesion suspicious for metastatic disease. The patient's liver biopsy confirmed the metastatic disease and continued follow-up, and a repeat PET scan was referred. In an appeal letter, the patient writes that her provider requested pre-service approval for a PET scan based on liver lesions that were not well characterized and required further evaluation in computed tomography (CT) of the abdomen/pelvis, and new lung lesion in a CT of the chest with attention on follow-up scan recommendation. The patient decided to pay for her PET scan and the results showed a new 6 mm left lower lobe nodule, an interval increase in the number of numerous scattered liver lesions, and the right femur with a standardized uptake value (SUV) of 4.5.

The patient had a PET scan and again 3 months later, with a CT of the abdomen for acute abdominal pain/fever. The first PET scan was for initial treatment planning for breast cancer and was compared to prior CT of the chest, abdomen, and pelvis. The subsequent PET scan was compared to the CT of the chest, abdomen, and pelvis done early this year, PET-CT and bone scan report done late last year. Further, a liver biopsy was done last year and confirmed the metastatic disease. Per the visit note early this year, the provider noted, the plan is for the patient to follow up in 2-3 weeks with a PET prior. As the patient had CT scans performed, PET was not necessary.      

There was no need for another PET scan, particularly as a CT was done at the beginning of this year.  PET is an alternative to CT but is not supported in addition to CT.  The patient has had multiple CT scans, in combination with a bone scan and PET scans; the patient has had scanning performed every month since November.

"Once a breast cancer patient has been diagnosed with metastases, accurate assessment of treatment response is of the uppermost importance. Currently follow-up assessment is based on anatomic imaging (CT or magnetic resonance imaging [MRI]). Treatment response, particularly in clinical trials, is evaluated by the RECIST (Response Evaluation Criteria in Solid Tumors) 1.1 criteria. A change in the size of a given metastasis during treatment is a measure of response. In soft tissue metastases (e.g., liver, lung, and brain), this approach is currently acceptable." (Bick et al., 2019)

"For example, imaging guidelines from the United States National Comprehensive Cancer Network (NCCN) Imaging Appropriate User Criteria (AUCTM)1 do not provide suggestions for some gastrointestinal malignancies. For metastatic breast cancer, they recommend scans every 26 months for treatment with endocrine therapy and every 24 cycles for treatment with cytotoxic therapy, with the stipulation that optimal frequency is uncertain. They recommend scans every 24 cycles or every 612 weeks (with actual scan frequency within these guidelines being a "clinical decision") for nonsmall cell lung cancer, every 23 cycles during treatment and at "every subsequent follow up visit" for small cell lung cancer, and every 616 weeks (based on "physician discretion and patient clinical status") for kidney cancer." (Stewart et al., 2019)                                                   

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Positron Emission Tomography (PET) scan (procedure code 78815) is upheld. Medical Necessity is not substantiated.