PET CT Scan denials in California external review
In the California DMHC record, independent physician reviewers decided 59 published external-review cases involving PET CT Scanand overturned the plan’s denial in 71.2%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind PET CT Scan denials
| Category | Decisions | Overturned |
|---|---|---|
| Breast Cancer | 4 | 50% |
| Pancreatic Cancer | 3 | 66.7% |
| Multiple Myeloma | 3 | 66.7% |
| Endometrial Cancer | 3 | 66.7% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 35 | 71.4% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 24 | 70.8% |
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/computed tomography (PET/CT) scan for evaluation of the enrollee’s pelvic tumor. Findings: 2/3 of the physician reviewers found that this is a complex medical case involving a solitary fibrous tumor, which is an exceedingly rare tumor. Considering the rarity of her diagnosis, there is little literature regarding the best means to perform follow-up imaging. However, PET/CT has several benefits over other standard modalities for the evaluation of patient’s tumor. One advantage to PET/CT is that, not only are masses demonstrated, but there is information garnered by the fludeoxyglucose PET/CT avidity in those masses. As has been shown in patients with Hodgkin’s disease, on occasion, one will see a residual mass that is no longer FDG avid.
Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) for attenuation, skull base to mid-thigh, and/or PET with CT for attenuation, skull base to mid-thigh. According to the American College of Radiology (ACR) criteria for monitoring response to neoadjuvant systemic therapy for breast cancer in a patient with known breast cancer and clinical suspicion for metastatic disease, PET/CT scan is considered usually appropriate. As noted by the ACR, for the purposes of staging and monitoring treatment response, PET/CT detects 50-100% of distant metastasis, with a specificity of 50-97%. In addition, multiple studies have demonstrated that PET/CT is particularly useful in the ongoing assessment of patients with triple negative breast cancer.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography scan with concurrently acquired computed tomography for attenuation (PET/CT) from skull base to midthigh (CPT 78815). Findings: The physician reviewer found that PET/CT is a nuclear medicine study that has been demonstrated to be effective in the accurate staging of patients with certain malignancies. However, there is a paucity of data demonstrating the efficacy of PET/CT in the evaluation of this patient’s pancreatic cancer. As noted by the American College of Radiology (ACR), CT is considered “usually appropriate” for assessing primary pancreatic malignancy and metastatic disease, while PET/CT “may be appropriate” to serve as a supplemental imaging modality.
A 53-year-old female enrollee has requested a positron emission tomography/computed tomography (PET/CT) scan for evaluation of her medical condition. Findings: The physician reviewer found that it is well established in the peer-reviewed literature that CA-125 testing is not effective as a screening test for ovarian cancer. WebMD states that, “The CA-125 test is not recommended as a screening test for ovarian cancer at this time because it often has false-positive results”. Further, researchers for UpToDate report that, “Ovarian cancer cannot be diagnosed based upon the results of a CA-125 test. Many women with early ovarian cancer will have a normal CA-125 level”. For this reason, the authors concluded that, “CA-125 is not recommended as a standalone screening test for ovarian cancer”. It has also been shown that elevated CA-125 can be secondary to non-malignant conditions.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 PET CT Scan, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY