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

Physician 1The patient is a 59-year-old male who received brachytherapy for prostate adenocarcinoma in October 1998. PSA levels have fluctuated from 1.0 in December 1999 to 5.0 in July 2004. The patient has recently been experiencing poor bladder emptying. A CT scan of the abdomen and pelvis performed in August 2004 revealed small prostate with seed implants, no enlarged lymph nodes, fatty liver, small right renal cyst, small right renal stone, and mild left pelviectasis vs. small parapelvic cysts. A bone scan revealed no evidence of metastatic disease. The patient wishes to undergo cryosurgery. The Health Plan has denied authorization and coverage for cryosurgery on the basis it is considered investigational. The patient is a 59-year-old man with biochemical failure indicated by rising PSA following brachytherapy for prostate adenocarcinoma in October 1998 As of July 2004, the patients PSA had risen to 5.0, with no evidence of metastatic disease on CT and bone scans in August 2004. However, the patient does have poor bladder emptying and possible left hydronephrosis, which is at least suspicious for recurrent disease at the bladder neck with left ureterovesical obstruction. An alternative explanation may be benign disease based on bladder neck contracture and left peripelvic cysts. If the patient does have recurrent disease only within the prostate itself, there is potential for curative treatment with cryosurgery.Further diagnostic testing is needed before it can be determined that cryosurgery is indicated. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy at this time. The Health Plans denial should be upheld at this time. The patient should undergo a Prostascint scan to assess biochemical failure after radical prostatectomy or radiation therapy. If the Prostascint scan shows recurrent carcinoma only within the prostate and no evidence of uptake outside that area, then cryosurgery should be authorized. However, if the Prostascint scan shows recurrent prostate adenocarcinoma outside of the prostate, cryosurgery would not be indicated and should not be authorized. Androgenic hormonal deprivation therapy would be the most appropriate treatment is this scenario.Physician 2This patient is a 59-year-old man who was treated with I-125 brachytherapy in October 1998. The patients PSA leveled off at 1.0 between December 1999 and February 2000.  It has since increased to 5.0 as of July 2004. At this point, the patient may pursue either palliative therapy or curative therapy. Palliative treatment options consist of: hormonal therapy, orchiectomy, and watchful waiting. Curative treatment options consist of: cryotherapy, interstitial hyperthermia, brachytherapy, and prostatectomy. The patient has requested authorization and coverage for cryosurgery. The Health Plan has denied the patients request on the basis that cryosurgery is considered investigational for treatment of prostate adenocarcinoma.Review of the scientific literature reveals cryosurgery of prostate adenocarcinoma is a viable treatment option in cases of recurrent localized disease. The five-year survival ranges are from 30% to 76%. Interstitial hyperthermia and brachytherapy are accomplished in either low dose rate or high dose rate with equal efficacy. For local recurrence of prostate cancer, the local control rate is over 65% at five years. However, rectal necrosis occurs in 20% of cases. The complications associated with cryosurgery are less severe. In order to determine if the patient is an appropriate candidate for cryosurgery, further workup is required to determine if the recurrence is confined to the prostate.Based upon the information set forth above, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy at this time. The Health Plans denial should be upheld at this time. However, a biopsy of the prostate should be performed. If the biopsy results reveal evidence of local recurrence, cryosurgery should be authorized.  If the biopsy results do not reveal evidence of local recurrence, cryosurgery should not be authorized.Physician 3The patient is a 59-year-old male who underwent brachytherapy for treatment of prostate cancer in 1998. He has experienced progressive elevation of his PSA to 5.0. Metabolic workup including bone scan and CT scan were unremarkable. The patient has requested authorization and coverage for cryosurgery. The Health Plan has denied the patients request on the basis that cryosurgery is considered investigational.Upon review of the submitted medical records it appears further workup of this patient is required. A biopsy of the prostate is needed to confirm local recurrence. If this is in fact a local recurrence, treatment options include hormonal therapy, surgery or cryosurgery. Hormonal treatment does not provide a long-term cure. Furthermore, although surgery carries the possibility of long-term cure, it is associated with significant morbidity. Cryosurgery remains an effective option for this patient and is not likely to result in significant morbidity. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy at this time. The Health Plans denial should be upheld at this time. However, a biopsy of the prostate should be performed. If the biopsy results reveal evidence of local recurrence, cryosurgery should be authorized.  If the biopsy results do not reveal evidence of local recurrence, cryosurgery should not be authorized.