PET Scan denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1The patient is a 55-year-old woman diagnosed with stage IIB (T2N1) breast cancer in June 2002. She was ultimately treated with a modified radical mastectomy and immediate reconstruction using a TRAM flap. Final pathology documented a 3cm (T2) grade III tumor with angiolymphatic invasion with 2/10 modes positive. The tumor was ER (+) PR (-) HER2/neu (-). The patient received six cycles of TAC adjuvant chemotherapy and hormonal therapy of letrozole. She also received Zometa as part of a clinical trial.In May 2004, the patient was found to have locoregional recurrence involving the supraclavicular nodal basin as well as a large chest wall recurrence with direct rib invasion. She was started on Xeloda therapy following staging studies of a CT chest and PET scan. On examination, the mass in the upper chest was noted to decrease in size and become softer.

Physician 1The patient is a 53-year-old female with the diagnosis of two primary cancers, lung and ovarian. On 1/9/04, the patient had a percutaneous biopsy of a left supraclavicular mass, which showed a poorly differentiated squamous cell carcinoma, probably lung in origin. On 2/1/04, the patient underwent a total abdominal hysterectomy and a bilateral salpingo-oophorectomy (TAH-BSO), which revealed a serous cystadenocarcinoma, grade III. A positron emission tomography (PET) scan was performed on 2/24/04, which showed widespread metastatic disease involving left supraclavicular area, mediastinum, right lung, retroperitoneum, and pelvis. A CT scan was performed on 5/3/04 and was compared to the prior exam of 1/14/04. There had been the interval TAH-BSO and marked improvement in the pulmonary nodules and mediastinal and retroperitoneal adenopathy.

Where the denial was upheld

Physician 1: The patient is a young woman with breast cancer with a very high risk of relapse based on persistently positive lymph nodes after induction chemotherapy. She has had PET imaging as follow-up in 2002 and 2003. The patient wishes to undergo further PET imaging. She has no localizing symptoms or findings. Based upon the records provided, other imaging has not been performed recently. The Health Plan has denied coverage for the requested PET scan on the basis it is considered investigational in this clinical setting. PET scanning is not indicated as a screen for recurrent cancer in this setting. It is only questionably more sensitive and specific than other modalities. In addition, treatment would not be based on a PET scan alone (other imaging and biopsies would be needed).

Physician 1The patient is a 48-year-old man with a past history of colorectal cancer. In January 2002, his PSA was 6.8 with a negative digital rectal exam (DRE). In February 2003, a biopsy revealed Gleason 4+3 in both the right base and the right mid zones. The patient had a T2a lesion upon DRE. The patient consulted a medical oncologist who recommended prostatectomy. On 2/24/04, CT scan of the chest, abdomen and pelvis revealed a 2.2 x 1.8cm mass in the region of the right seminal vesicle and an 8mm lymph node in the mediastinum. On 2/27/04, the patient underwent a PET scan that was negative except for the questionable mediastinal activity. The patient has requested authorization for a PET scan for the purpose of staging his prostate cancer.

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 Scan, then check the rights and deadlines that apply to your plan.