Positron Emission Tomography-computed Tomography denials in California external review
In the California DMHC record, independent physician reviewers decided 13 published external-review cases involving Positron Emission Tomography-computed Tomographyand overturned the plan’s denial in 84.6%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
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. | 10 | 90% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 3 | 66.7% |
What the reviewers wrote
Where the denial was overturned
A 69-year-old male has requested coverage for a positron emission tomography (PET) scan for evaluation of his renal cancer. Findings: Three physician reviewers found that the patient has undergone right nephrectomy for renal cell cancer. Prior magnetic resonance imaging (MRI) and computed tomography (CT) scans showed liver metastases which have shrunken over time with treatment. The patient has a solitary kidney with impaired function. Laboratory testing reveals that his serum creatinine level is 1.6 and glomerular filtration rate (GFR) is 43. Previous imaging with positron emission tomography/computed tomography (PET/CT) demonstrated that the liver lesions are PET avid, thus his provider has recommended repeat PET/CT to evaluate the remaining liver lesions as well as other sites for potential treatment with radiofrequency ablation (RFA).
Nature of Statutory Criteria/Case Summary: An enrollee has requested a positron emission tomography/computed tomography (PET/CT) for evaluation of his medical condition. Findings: Two physician reviewers found that in terms of follow-up for this patient, the provider suggested two possibilities that might explain the lesion, and the conclusion was that the lesion had overall benign features. Both lymphangiomas and duplication cysts are relatively rare lesions. In the lesser sac, one is more likely to find a pancreatic pseudocyst or a gastrointestinal stromal tumor (GIST). Significant pancreatic lesions can also be cystic. GIST tumors are the most frequent mesenchymal malignancy of the gastrointestinal tract, and on occasion, may also have cystic or otherwise benign features.
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for whole-body positron emission tomography/computed tomography (PET/CT). The patient has a history of monoclonal gammopathy of uncertain significance. Monoclonal gammopathy of renal significance is diagnosed by renal biopsy. PET/CT or whole-body low-dose CT is recommended for initial evaluation of suspected multiple myeloma or solitary plasmacytoma. Solitary plasmacytoma is a localized clonal plasma cell tumor without systemic features of multiple myeloma. The patient has not undergone bone marrow biopsy, and multiple myeloma or plasmacytoma has not been established. Therefore, PET/CT is not indicated and is not medically necessary for this patient.
Nature of Statutory Criteria/Case Summary: An enrollee has requested a positron emission tomography/computed tomography (PET/CT) diagnostic screening for colon cancer. Findings: Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting. The patient had no clinical signs of tumor recurrence and the previous PET/CT was negative with absence of any clinical or a biochemical finding to indicate possible tumor recurrence. The PET/CT scan at issue was not likely to have been of benefit. The National Comprehensive Cancer Network guidelines do not recommend PET/CT as routine surveillance if there is no clinical sign of tumor recurrence/metastasis.
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 Positron Emission Tomography-computed Tomography, 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