Appeal type: Experimental/Investigational
Decision: Upheld

Physician #1:  The patient is a 47-year-old male recently diagnosed with stomach carcinoma involving the greater curvature. CT scan in January 2006 also showed adenopathy within the surrounding mesentery adjacent to the stomach. A PET scan was performed prior to surgery. The Health Plan has denied coverage for the PET scan on the basis that its use in this setting is considered investigational.A review of the peer-reviewed literature showed no substantial medical evidence to support the use of PET scans in the staging of gastric cancer. A few small studies have found anecdotal evidence of positive efficacy of PET scans in gastric cancer. However, the use of PET in these cases has been no more accurate than conventional imaging (i.e., CT scans). In conclusion, there is not sufficient medical evidence to support the use of PET scans for staging of gastric carcinoma. Therefore, I have determined that the PET scan at issue was 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 47-year-old previously healthy male who in December of 2005 was placed on penicillin, and later switched to clindamycin for a dental infection. Thereafter, he developed gastric upset and distress, which lead to an upper GI radiographic study. This radiographic investigation showed a gastric ulcer. On endoscopy there was a giant ulcer in the body of the stomach with heaped up edges, which was biopsied and determined to be poorly differentiated adenocarcinoma of the stomach. A CT scan was performed and it showed a sizeable mass in the upper body of the stomach with no evidence of adenopathy or liver metastases. The patient consulted a surgeon who recommended surgery but wanted to obtain a PET scan prior to surgery to rule out any distant metastatic disease. According to the Health Plan, the results of the PET scan were not likely to improve diagnostic decision-making with regard to treatment. An extensive literature review reveals that there is no documentation in the peer-reviewed literature to support the contention that PET scanning is superior to standard imaging techniques (primarily CT scanning) for the detection of lymphadenopathy or distant metastases in gastric cancer. Although this is a rapidly changing field, based upon the scientific studies performed to date there is no evidence that PET scanning would be superior to standard imaging technique for specifically gastric cancer. Based upon the information set forth above, I have determined that the PET scan at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician #3:  This case involves a 47-year-old male with EDG/biopsy proven adenocarcinoma of the stomach. There are no clinical signs of metastatic disease, and a staging CT scan demonstrated the mass and some adjacent, enlarged lymph nodes as well as some nodes in the mesenteric fat inferior to the stomach. The patients provider recommended the patient undergo a PET scan prior to surgical resection. The Health Plan has denied reimbursement for the PET scan on the basis it is experimental/investigational in nature.Review of the current literature demonstrates that the efficacy of PET scanning in this clinical setting remains unproven. Although some studies suggest PET scanning may be beneficial in detecting nodal disease with gastric cancer, this has not been shown to be a necessary factor in making any clinical decisions. Although there is increasing support for the use of PET in various clinical settings, it has not yet been established that PET scanning is efficacious for identifying gastric malignancies. Accordingly, I have determined that the PET scan at issue was 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.