Positron Emission Tomography-computed Tomography Scan denials: what the review data shows
Independent reviewers have decided 13 published cases where an insurer denied Positron Emission Tomography-computed Tomography Scan — and they overturned the insurer 69.2% of the time. A denial for Positron Emission Tomography-computed Tomography Scan is a starting position, not a final answer.
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. | 7 | 57.1% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 6 | 83.3% |
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for positron emission tomography/computed tomography (PET/CT) scan performed. Findings: The physician reviewer found that the follicular variant of papillary thyroid cancer (FV-PTC) is the most common subtype of papillary thyroid cancer. The medical evidence indicates that FV-PTC patients have a better survival rate than follicular thyroid cancer patients and fewer instances of lymph node and soft tissue invasion than patients with classical papillary thyroid cancer. Despite the high incidence in survival rates, the clinical behavior and outcomes of FV-PTC remain undecided, making it a challenge to establish a standard treatment protocol.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for a positron emission tomography-computed tomography (PET-CT) scan. Molecular imaging using PET scans are a powerful and well-established tool in breast cancer management. PET scans are commonly used in cancer management, especially for staging purposes. These scans can provide quantitative pictures of biological processes even at a low radiative dose. Moreover, PET scans are able to provide better spatial resolution, high sensitivity, and regional tracer uptake quantification compared to other molecular imaging techniques. PET scans have traditionally been performed in conjunction with CT scans in cancer imaging.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the positron emission tomography/computed tomography (PET/CT) scan. Findings: Three physician reviewers found that in this patient’s case, the guidelines do not support the efficacy of the PET/CT scan at issue. This patient presented with an incidental finding of a 4 mm pulmonary nodule, noted on a CT scan. The Society of Thoracic Imaging and Diagnosis, otherwise known as the Fleischner Society, is a well-known organization that has established guidelines for the evaluation of incidentally detected pulmonary nodules. These evidence based guidelines were revised in 2017 and are widely used throughout radiology. For incidentally detected nodules that are greater than 8 mm, the Fleischner Society guidelines call for either a follow up CT scan in three months, and/or a PET/CT, and/or a biopsy.
Findings: The physician reviewer found that The patient has requested authorization and coverage for positron emission tomography/computed tomography (PET/CT) scan. The records provided for review document that this patient has a history of bilateral breast cancer status post bilateral mastectomy. The patient’s provider has recommended evaluation with PET/CT for staging purposes. However, there is a lack of support for PET/CT for assessment of this patient based on the available documentation. The National Comprehensive Cancer Network (NCCN) guidelines do not recommend PET/CT scan as an initial staging diagnostic tool for the evaluation of patients with non-metastatic breast cancer work-up.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Positron Emission Tomography-computed Tomography Scanwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY