Positron Emission Tomography With Computed Tomography denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for positron emission tomography (PET) scan with computerized tomography (CT) for attenuation. Findings: As noted by one study, membranous nephropathy is the most common cause of idiopathic nephrotic syndrome in adults. The authors commented further that, “NELL1-associated membranous nephropathy has a unique histopathology characterized by incomplete capillary loop staining, IgG1-predominance, and is more often associated with malignancy than other known types of membranous nephropathy.” Thus, the primary reason to evaluate patients with membranous nephropathy for malignancy is to avoid primary treatment that may worsen the patient’s prognosis.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh. Although PET/CT is not considered part of the standard workup of sarcoidosis, there is increased evidence showing that it is a valuable tool in the diagnosis and management of sarcoidosis, as well as the detection of additional inflammatory processes. PET/CT is sensitive for the detection of inflammatory activity in any organ in the body and is especially useful in complex medical cases. PET/CT can detect the presence of reversible granuloma, treatment response, extent of disease, and organ involvement. Additionally, it can help determine the site of diagnostic biopsy.

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) with concurrently acquired computed tomography (CT) scan. The National Comprehensive Cancer Network (NCCN) has established criteria for the detection of pancreatic carcinoma. Per the NCCN guidelines, “PET/CT scan may be considered after formal pancreatic CT protocol in patients with high risk to detect extra-pancreatic metastases.” The NCCN specifically noted that “it is recognized that patients can demonstrate progressive disease clinically without objective radiologic evidence of disease progression.” In this patient’s case, she has not undergone evaluation with a dedicated three-phase pancreatic CT scan, which would be beneficial.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT), skull to thigh for evaluation of the enrollee, who has a history of fatigue, palpitations, chest pain, shortness of breath and intermittent pain in the right shin and upper thighs. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the requested services. In this patient’s case, the guidelines do not support the efficacy of the PET/CT. In recent years, PET/CT scanning has become increasingly common, primarily as a tool to evaluate the presence or extent of malignancy. There are non-oncologic indications, such as evaluating fevers of unknown origins and dementias, but these are far less common.

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 With Computed Tomographywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.