Positron Emission Tomography Scan denials in California external review
In the California DMHC record, independent physician reviewers decided 83 published external-review cases involving Positron Emission Tomography Scanand overturned the plan’s denial in 47%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Conditions behind Positron Emission Tomography Scan denials
| Category | Decisions | Overturned |
|---|---|---|
| Breast Cancer | 5 | 60% |
| Prostate Cancer | 4 | 50% |
| Melanoma | 3 | 66.7% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 42 | 42.9% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 41 | 51.2% |
What the reviewers wrote
Where the denial was overturned
Physician 1The patient is a 60-year-old female who was diagnosed with stage IV ovarian cancer in October 2003. The patient presented with a malignant pleural effusion and subsequently at laparotomy was found to have carcinomatosis. The patient completed six cycles of chemotherapy and has been followed with CA-125, CT scans, and PET scans.As of 10/14/04, the patient’s CA-125 increased to 47.6, which is elevated. A CT scan performed on 9/9/04 showed increased right hydronephrosis and a borderline enlarged left axillary lymph node. A PET scan in June 2004 showed right hydronephrosis with no other abnormal areas of increased activity.
Nature of Statutory Criteria/Case Summary: The patient is a 59-year-old female with a history of hyperlipidemia, anxiety, and hypothyroidism who presented with a chronic cough for four months. Findings: The physician reviewer found that A chest x-ray demonstrated bilateral large perihilar masses. A computed tomography (CT) scan of the patient’s chest/abdomen/pelvis was subsequently obtained on 9/9/20, which demonstrated a large heterogeneously enhancing anterior mediastinal mass, mediastinal and right internal thoracic chain adenopathy, interlobular septal thickening in the anterior portions of both upper lobes concerning for lymphangitic spread of tumor, and a large heterogeneously enhancing pelvic mass. The patient was referred to an oncologist given the high suspicion for cancer who subsequently ordered a biopsy as well as a PET scan for further work up.
Where the denial was upheld
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan. Researchers define traumatic brain injury (TBI) as an alteration in brain function, or other evidence of brain pathology, caused by an external force. TBI encompasses a broad range of pathologic injuries to the brain, of varying clinical severity, that result from head trauma. Researchers note that in patients with mild TBI, head computed tomography (CT) without contrast is the most appropriate examination choice. Head magnetic resonance imaging (MRI) without contrast may be sensitive in detecting intracranial injury that is occult on CT, such as subtle blood products or secondary signs of injury like edema.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a positron emission tomography (PET) scan and/or whole-body scan (WBS) with radioiodine (RAI). Thyroid cancer is the most common endocrine cancer each year in the United States with rising incidence. Conventional imaging methods used in the workup of thyroid cancer include ultrasound, computed tomography (CT) scan, and magnetic resonance imaging (MRI) scans which can provide important anatomic information about the thyroid and surrounding structures. CT and MRI are useful in the workup for locally advanced thyroid cancers to assess tumor extension into surrounding structures and cervical lymph node metastases.
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 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