Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient is a 55-year-old woman who was found to have a mediastinal mass on a routine chest x-ray in 1997. She underwent a CT scan, which revealed a 3.7cm anterior mediastinal mass. She was informed of this finding and opted for follow-up. A repeat CT scan was performed in 1999 that revealed the mass was enlarged to approximately 6cm in size. She was evaluated by two thoracic surgeons, both of whom recommended surgery for the possibility of a malignant neoplasm of the anterior mediastinum. She refused surgery and chose conservative evaluation with repeat radiologic imaging. In August 2003, a repeat CT scan revealed the mediastinal mass to be essentially unchanged in size, though three new liver lesions were found. Ultimately, two of these lesions were confirmed to be hemangiomas, but the third raised concerns for metastatic disease. The patient underwent CT-guided biopsy of both the mediastinal and liver mass. The results of the pathology when both lesions were reviewed together was a poorly differentiated non-small cell carcinoma with neuroendocrine features, of either thymic or lung primary. A PET scan confirmed these two lesions as the only site of disease.The patient was discussed at a thoracic Tumor Board and chemotherapy was recommended. She underwent five cycles of VP-16/cisplatin, which she tolerated poorly. After two cycles, a repeat CT scan showed some response; however, a CT scan after the fifth cycle showed essentially stable disease (compared to the pre-treatment CT scan). The patient underwent repeat PET scan, CT scan, and MRA, which revealed the development of a second liver metastasis and a mediastinal tumor abutting several central vascular structures. In August 2004, the patient underwent urgent hepatic resection. She has now requested authorization and coverage for a thoracic resection. The Health Plan has denied coverage for the hepatic and thoracic resections on the basis that these procedures are not medically necessary for treatment of the patients medical condition.  The patient is a 55-year-old woman who appears to have a metastatic thymic carcinoma that has failed to respond to VP-16/cisplatin. The tumor histologically would fit into the high grade/high risk group. She initially had an abnormality noted in 1997, but declined further evaluation. In 1999, she was recommended to undergo surgery by two thoracic surgeons, but refused. In 2003, she was found to have metastatic disease confirmed on biopsy, at which point surgical resection of the primary or metastatic tumor was not felt to be beneficial.Given the results of the patients biopsy, the location of the tumor, and the absence of any lung primary seen over the last seven years, it appears the patient has a thymic carcinoma. Thymic carcinomas are exceedingly rare, and little is known of the role of the resection of metastatic disease to the liver. However, given the development of a second lesion in a short period of time, and the lack of response to chemotherapy, it is unlikely that the hepatic resection performed in August 2004 provided the patient with any meaningful chance of life prolongation. Systemic chemotherapy remains the primary modality of therapy, though disease control is uncommon and survival is usually short in the presence of metastatic disease. For these reasons, thoracic surgery to resect the primary mediastinal disease is unlikely to have any beneficial impact and therefore, is not medically necessary, especially since the surgery will be difficult given the results of the CT and MRA. Surgical resection of the disease has not been shown to have a significant role in metastatic disease. Based upon the information set forth above, I have determined that the services at issue are not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.