Appeal type: Medical Necessity
Decision: Overturned

Physician 1: This case involves a 35-year-old male with a high-grade glioma status post two surgeries, chemotherapy, and radiation. The patient is currently stable, but carries a very guarded prognosis. His neurosurgeon and neuro-oncologist believe a magnetic resonance spectroscopy (MRS) is needed to assist in planning further treatment. The Health Plan has denied coverage for an MRS indicating there is insufficient peer-reviewed evidence demonstrating the accuracy of MRS is superior to alternative diagnostic modalities.MRS is now widely used for the treatment planning of gliomas. There is copious recent literature supporting its use in this clinical setting. This patient has a high-grade glioma; MRI alone is likely to be equivocal. Therefore, an MRS is medically appropriate and within the standard of care. Accordingly, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.Physician 2: This patient is a 35-year-old male with an anaplastic Grade III astrocytoma. He is status post chemotherapy, radiation and two craniotomies. He is requesting authorization and coverage for a magnetic resonance spectroscopy (MRS) to help plan his future treatment. The Health Plan has denied this request indicating the requested MRS is not medically necessary.Current conventional MRI studies demonstrate findings consistent with either residual/recurrent tumor, scarring or radiation necrosis. Standard MRI scanning is unable to differentiate these issues. PET scanning is one method available for this differentiation, but proton MRS is available for histologic grading of astrocytomas. There is ample literature including a number of small clinical trials and peer-reviewed reports to suggest an MRS would be useful and appropriate in this case. Furthermore, the use of MRS in this clinical setting is supported by radiology society guidelines.Based upon the information set forth above, I have determined the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.Physician 3: The patient is a 35-year-old male who had had two surgical resections for a grade III anaplastic astrocytoma in addition to radiation therapy and ongoing chemotherapy. MRIs have shown residual tumor following the two surgical resections. A recent MRI performed in July 2005 continued to show an area of abnormal signal and peripheral enhancement. It is uncertain if these MR abnormalities are secondary to recurrent tumor or if these changes represent post-radiation necrosis. The patients medical therapy will depend on knowing what the findings on MRI correlate with. The patients provider has recommended the patient receive a magnetic resonance spectroscopy (MRS). At issue is whether MRS is medically necessary for evaluation of the enrollees medical condition.Review of the scientific literature regarding MRS continues to show its usefulness in the treatment planning of patients with aggressive brain tumors. While it is true that the published studies have involved small study groups, the studies reviewed all had similar outcomes. In this patient, standard MR imaging is not able to answer the question of recurrent tumor versus radiation necrosis. MRS can provide an answer to this question and is readily available with minimal or no risk to the patient. Therefore, MRS is more clinically appropriate than MRI for the diagnosis and treatment of this patients medical condition.As set forth above, I have determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.