Appeal type: Medical Necessity
Decision: Upheld

The patient is a 57-year-old male diagnosed with prostate cancer. He had medical problems including diabetes mellitus, hypertension, and hypercholesterolemia, and was not experiencing erections or engaging in sexual activity.PSA was elevated at 13.7 in February 2006, and unilateral prostate induration was palpable on digital rectal examination. Ultrasound-guided prostate biopsy performed in April 2006 revealed a Gleason grade of 4+3 adenocarcinoma of the prostate involving 30% of the biopsy specimen from the left side and 5% of the biopsy specimen from the right. Prior to treatment the patient was diagnosed with a Gleason grade total 7, clinical stage T2c adenocarcinoma of the prostate.In April 2006 alternatives for treatment were discussed with the patient including radical surgery, external radiation, and brachytherapy, and a bone scan was ordered. The bone scan was negative for metastatic disease. In May 2006 alternatives for treatment were again discussed including open surgery, laparoscopic surgery, laparoscopic robotic assisted surgery (a non-Plan procedure), external radiation and brachytherapy.In May 2006 there was a consultation with another urologist regarding laparoscopic radical prostatectomy. If the patient chose to undergo this procedure with this surgeon (without robotic assistance) it was likely he would have to wait until September 2006 for the surgery unless there were surgical cancellations that could make an earlier time slot available. The urologist indicated that if the patient chose this option, hormonal ablation therapy would be given to keep the tumor from growing and spreading during the waiting period.The patient decided to pursue surgical treatment outside the Health Plan, and in June 2006 underwent a robotic assisted laparoscopic radical retropubic prostatectomy, with left pelvic lymphadenectomy.The final pathology report revealed a Gleason grade of 4+4 (total 8) prostate adenocarcinoma involving both sides of the prostate, 25% of the gland overall, extending to the margins of the specimen in multiple areas, with perineural space involvement and extraprostatic extension including spread to the seminal vesicles (pathological stage T3c). The left pelvic lymph nodes were negative for metastasis.The patient has requested reimbursement for the robotic assisted laparoscopic prostatectomy. The Health Plan has denied this request on the basis that the procedure was not medically necessary.This 57-year-old patient with significant medical problems was diagnosed with prostate adenocarcinoma, Gleason grade 4+3, clinical stage T2c. Alternative treatments were discussed including external radiation, brachytherapy (radiation with seed implant), open radical retropubic prostatectomy, laparoscopic radical retropubic prostatectomy, and robotic assisted laparoscopic radical retropubic prostatectomy. The patient wanted to have surgery, specifically laparoscopic surgery, and eventually chose robotic assisted laparoscopic surgery.The patient was offered laparoscopic surgery, without robotic assistance, within the Health Plan, but with up to a four-month delay in scheduling. During this period the patient would have been treated with hormonal ablation therapy to keep the tumor from growing and spreading during that time. The use of hormonal ablation therapy is not unusual in treating prostate carcinoma and is used to treat metastatic disease, to shrink the tumor prior to treating with radiation therapy, and to control the tumor while awaiting a final decision by the patient regarding surgery or other attempts at curative treatment. Its main side effect in the short term would be erectile dysfunction, which this patient was already experiencing.The patient chose to go outside of the Plan, having the surgery performed laparoscopically with robotic assistance. Unfortunately, even though he proceeded with the surgery without delay, the cancer was aggressive and had already spread outside the confines of the prostate gland. Acceptable treatment for the patients prostate cancer was made available to the patient in a reasonable time frame once the diagnosis had been made. Reasonable treatment options, including laparoscopic prostatectomy without robotic assistance, were discussed with the patient by the Health Plan. Although there was a waiting period for the surgery, hormonal therapy would have been an appropriate response to the surgical delay.Furthermore, there is no evidence that robotic assisted laparoscopic radical retropubic prostatectomy has been proven to be superior to the other treatment offered, including laparoscopic radical retropubic prostatectomy and open radical retropubic prostatectomy in terms of long-term survival from prostate adenocarcinoma. Though short-term survival and complication rates appear to be comparable, long-term data on the procedures efficacy are not yet available. Based upon the information set forth above, I have determined that the procedure at issue was not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.