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

Physician 1:The patient is a 59-year-old man who has PSA levels under 5.0. He had a prostate biopsy in February or March 2005, which revealed well-differentiated adenocarcinoma with a Gleason score of 6 (3+3). The patient wishes to have treatment with brachytherapy. The radiation therapist is requesting a Prostascint scan with MRI pelvic fusion imaging study to evaluate the seminal vesicles prior to seed placement. The Health Plan has denied authorization and coverage for the requested Prostascint scan on the basis it is considered investigational.The submitted evidence provides no information to indicate a specific risk of seminal vesicle involvement by the prostate cancer. The usefulness of the Prostascint study alone is limited by the high incidence of false-negative and false-positive findings. Fusion studies are relatively new and their long-term reliability and accuracy is not yet known. Review of the Partin Table indicates a 0% to 1% chance of seminal vesicle involvement in this situation. The requested Prostascint scan is extremely unlikely to produce any information that would impact any therapeutic decision to be made in this case.Based upon the information set forth above, I have determined that the requested Prostascint 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 2: The patient is a 59-year-old male who has been diagnosed with prostate cancer. His Gleason grade is 6 and his prostate specific antigen blood test (PSA) was 4.1. A Prostascint scan was requested for the purpose of ruling out metastatic disease before proceeding with definitive therapy. In this case, the patient has chosen radiation in the form of brachytherapy as his therapy of choice. The Health Plan has denied authorization for the Prostascint scan indicating it is considered investigational and experimental for evaluating the patient's condition and is not likely to benefit his care.Prostascint scans are used to identify metastatic prostate cancer as part of preoperative or preradiation staging in those patients where there is thought to be `a moderate to high probability of occult extraprostatic metastasis,` or in patients who have a rising PSA probability where standard scanning (CT and bone scan) fail to identify the site of recurrence and local adjuvant therapy is being considered. Such is not the case here. The patient has an early clinical prostate cancer with a moderate Gleason score and low PSA. The possibility that he has occult metastasis is extremely low, less than 1 or 2%, based on Partin Table criteria. If surgery were performed, lymph node sampling would not even be required. The test has such a low probability of being positive that it is not indicated. Furthermore, there are issues involved with Prostascint in terms of specificity, sensitivity, and false positives.The Health Plan's assertion that a Prostascint scan has no clinical value in the evaluation and treatment of this patient is correct. Based upon the information set forth above, I have determined that the requested Prostascint 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 3: The patient is a 59-year-old male with prostate cancer. He has a Gleason Score of 6 and a PSA of 4.1. He is requesting a Prostascint scan for evaluation to determine if any metastatic disease exists. The Health Plan has denied the patients request.Based on the information provided and a review of the relevant literature, there are no reports, which show an unequivocal advantage of pre-treatment Prostascint scanning over conventional bone and pelvic scans. It is highly unlikely that this patient has metastatic disease due to the relatively low volume and low PSA. Prostascint scanning may be helpful post-treatment, but is rarely indicated pre-treatment. Therefore, I have determined that the requested Prostascint 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.