Adenocarcinoma Of The Prostate denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) attenuation. The records document that this patient presents with a history of elevated prostate specific antigen and adenocarcinoma of the prostate with perineural invasion. The patient’s pathology report noted Gleason score of 4+3=7. After consultation with his providers, the treatment plan included radical prostatectomy with PET/CT scan for evaluation prior to surgery. Prostate specific membrane antigen (PSMA) PET/CT has been demonstrated to be superior in detecting micro-metastatic disease preoperatively than other conventional imaging. The National Comprehensive Cancer Network (NCCN) agrees with the preoperative use of PET/CT as in this patient’s clinical setting.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for SpaceOAR System (CPT 55874). This patient has a history of stage T1 Gleason score 4+4=8 adenocarcinoma of the prostate. The patient underwent treatment with Lupron as well as prostate seed implantation along with external beam radiation therapy with placement of SpaceOAR perirectal spacers. One important consideration during prostate radiation is rectal toxicity due to exposure of the adjacent rectum to radiation. A mechanism of dealing with this issue is to create a space between the prostate and rectum, so that the rectum is out of the radiation treatment field and receives less radiation. Karsh and colleagues reported on a phase 3 study evaluating the safety and effectiveness of the SpaceOAR perirectal spacer in the treatment of prostate cancer.

Where the denial was upheld

Physician 1: The patient is a 52-year-old male diagnosed with adenocarcinoma of the prostate, Gleason grade 3+3=6/10, PSA 16.8, and clinical stage T1c, based on the August 2006 consultation. Two of four cores from the right side of the prostate were positive involving 10% to 12% of the biopsy specimen. The pathology report did not indicate any other conditions such as benign prostatic hypertrophy (BPH) or chronic prostatitis. The metastatic workup included an MRI scan, bone scan, and CT scan of the pelvis with contrast. All were negative for evidence of metastatic disease. The consulting radiation oncologist recommended the combined treatment of photon and proton radiation.

Physician 1: The patient is a 61-year-old male with a Gleason score of 6/7 with adenocarcinoma of the prostate clinically localized. He wants to undergo robotic-assisted laparoscopic prostatectomy for cure. The Health Plan indicates there is insufficient evidence in the peer-reviewed literature showing robotic assistance results in superior outcomes.Robotic-assisted laparoscopic prostatectomy has been proven to be superior to conventional radical prostatectomy in many aspects. Oncologic results of laparoscopic prostatectomy are superior to conventional surgery. Laparoscopic prostatectomy can be performed without robotic assistance, but there are significant advantages to robotic assistance in terms of recovery and complications.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving adenocarcinoma of the prostate, then check the rights and deadlines that apply to your plan.