Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Memory Loss.
Treatment: PET scan.
The insurer denied a PET scan.
The determination is upheld.

The patient has a PET scan requested for evaluation of  dementia. The PET scan is under review. At issue is whether the proposed health service or treatment radiology services- brain imaging, positron emission tomography services (PET scan) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No, the proposed health service or treatment radiology services- brain imaging, positron emission tomography services (PET scan) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Per Nestor et al (2018): "Although there is an overall lack of evidence on which to base strong recommendations, it was generally concluded that fluorodeoxyglucose (FDG)-PET has a diagnostic role in all scenarios. Prospective studies targeting diagnostically uncertain patients for assessing the added value of FDG-PET would be highly desirable."
Per Smailagic et al (2018): "Systematic and comprehensive assessment of studies of 18FDG-PET for prediction of conversion from mild cognitive impairment (MCI) to Alzheimer's Disease (AD) dementia reveals many studies have methodological limitations according to Cochrane diagnostic test accuracy gold standards, and shows accuracy remains highly variable, including in the most recent studies. There is some evidence, however, of higher and more consistent accuracy in studies using computer aided metrics, such as single case statistical parametric mapping (sc-SPM), in specialized clinical settings. Robust, methodologically sound prospective longitudinal cohort studies with long (greater than or equal to (>=) 5 years) follow-up, larger consecutive samples, and defined baseline threshold(s) are needed to test these promising results. Further evidence of the clinical validity and utility of 18F-FDG PET in people with MCI is needed."
Per Martinez et al (2017): "Although sensitivity was good in one included study, considering the poor specificity and the limited data available in the literature, we cannot recommend routine use of 18F-florbetapir PET in clinical practice to predict the progression from MCI to Alzheimer's disease dementia (ADD). Because of the poor sensitivity and specificity, limited number of included participants, and the limited data available in the literature, we cannot recommend its routine use in clinical practice to predict the progression from MCI to any form of dementia. Because of the high financial costs of 18F-florbetapir, clearly demonstrating the diagnostic test accuracy (DTA) and standardizing the process of this modality are important prior to its wider use."
There is a lack of studies that specifically look at the incremental benefit of PET over standard clinical evaluation alone, which is accurate in up to 90% (percent) of cases. Finally, there is no evidence in the peer reviewed literature to indicate that the use of PET scans contributes to improved outcomes in any group with dementia. The use of PET imaging in the evaluation of AD and other dementias needs further study to further define its role in the management of these conditions.
There is insufficient evidence to conclude that positron emission tomography services (PET scan) are likely to be more beneficial than any standard treatment or treatments for the insured's condition.