Positron Emission Tomography denials in California external review

What the reviewers wrote

Where the denial was overturned

Physician 1This patient is a 53-year-old female who has breast cancer metastatic to her lungs. She is status post multiple chemotherapeutic regimens. She is currently stable. She has requested authorization for positron emission tomography (PET) scanning to monitor her clinical situation. The Health Plan has denied the patient’s request on the basis that PET scanning is considered investigational for this indication.The patient has metastatic breast cancer, status post resection and has undergone multiple courses of chemotherapy. She requires careful follow-up for evidence of recurrence. Multiple modalities exist including PET and CT scans. PET scanning has been approved by the Food and Drug Administration for use in cases of breast cancer. Given that the patient has been utilizing PET scanning to follow recurrence/response, she should remain with the current modality.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography for evaluation of the enrollee who has a history of breast cancer and neurocognitive disorder. Findings: The physician reviewer found that Mild cognitive impairment (MCI) is a clinical presentation that is in the transitional stage between normal aging and frank dementia. When memory loss is the predominant symptom, it is referred to as MCI amnestic type. One distinguishing factor from Alzheimer’s disease is that patients with MCI with generally have preservation of general cognitive and functional abilities. Neuroimaging has helped to narrow the differential diagnosis. Most patients will initially have either a computed tomography scan (CT) or magnetic resonance imaging (MRI) study of the brain.

Where the denial was upheld

A 56-year-old female enrollee requested authorization and coverage for a magnetic resonance imaging (MRI) scan of the chest/breasts and a positron emission tomography (PET) scan. Findings: Two physician reviewers found that the patient had a positive biopsy for ductal carcinoma in situ (DCIS) and underwent an MRI of the breasts. In the right breast, the patient was noted to be status post lumpectomy and radiation changes with a new stereotactic staple within the 3:00 position. For this new area, an excisional biopsy was recommended and performed and the specimen was consistent with high grade DCIS. In addition, a PET scan was negative, with no noted pathologic hypermetabolic activity. A summary of the lumpectomy report states the size of lesion was 1.5 cm and high grade DCIS was identified, solid and cribiform type. No lymph nodes were noted to be present.

A 47-year-old female enrollee has requested authorization and coverage for positron emission tomography (PET) scans every nine weeks. The Health Plan has denied this request indicating that the requested diagnostic imaging is considered investigational for evaluation of the enrollee’s stage IV lung cancer. Findings: Two physician reviewers found that the patient was diagnosed with stage IV non-small cell lung cancer (NSCLC) 5 years ago. There was tissue confirmation, and the patient had brain metastases. She has been treated with chemotherapy, and is currently on a regimen of pemetrexed administered every three weeks. According to the patient’s physician, the patient is in complete remission, with no evidence of recurrent disease. Multiple recent PET scans have been reported as not showing evidence of tumor.

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 Positron Emission Tomography, then check the rights and deadlines that apply to your plan.