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

Physician 1: The patient is a 40-year-old male with a history of prostate cancer diagnosed in 2004. The patient is HIV positive. He wishes to undergo treatment with robotic-assisted laparoscopic prostatectomy. Other treatment options include open surgical prostatectomy, seed implantation, hormonal manipulation or close observation. The Health Plan has denied authorization for robotic-assisted laparoscopic prostatectomy based on a lack of documented efficacy.Based upon a review of the relevant medical literature including the submitted bibliography, the best treatment option for this patient is robotic-assisted laparoscopic prostatectomy. Robotic-assisted laparoscopic prostatectomy is clearly being recognized as a superior approach to open surgical prostatectomy with better cure rates, less morbidity (i.e., blood loss, pain control) and earlier return to normal activities. The robotic-assisted procedure offers a better chance for cure for this young patient and less morbidity. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 40-year-old male with localized prostate cancer. Past medical history is significant for positive HIV. The patient wishes to undergo robotic-assisted laparoscopic prostatectomy for treatment of his prostate cancer. The Health Plan has denied the request on the basis the requested procedure is considered investigational. Oncologic results of laparoscopic prostatectomy are superior to conventional surgery. However, to date, there is insufficient data demonstrating robotic-assisted laparoscopic prostatectomy is superior to non-robotic-assisted laparoscopic prostatectomy. As of this time, no long-term data is available to determine if robotic assistance will produce better results in terms of complications or survival. 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. The Health Plans denial should be upheld.Physician 3: The patient is a 40-year-old male with recently diagnosed cancer of the prostate. It is local disease and his physicians believe it is amenable to surgical removal via robotic-assisted laparoscopic prostatectomy. The grade and state of the disease is such that the procedure is likely to be curative. The patient is HIV positive, but otherwise in good general health. The Health Plan has denied coverage for the proposed procedure indicating it is considered investigational.Radical prostatectomy is an appropriate treatment for early localized prostate cancer. It is likely to be curative. The patients request is for a robotic-assisted laparoscopic radical prostatectomy. The Health Plan indicates it will authorize non-robotic-assisted laparoscopic radical prostatectomy.The requested procedure involves the use of the da Vinci robot. It does not alter how the surgery is performed and does not provide improved outcomes. Outcomes are dependent on the skill and experience of the surgeon and not the use of this particular tool. There is no evidence the use of robotics provides superior results. The services proposed by the Health Plan are medically reasonable and appropriate. Therefore, I have determined that the requested robotic-assisted laparoscopic prostatectomy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.