Diagnosis: Adenocarcinoma of the esophagus.
Treatment: PET/CT scan.

The insurer denied the PET/CT scan.
The health plan's determination is overturned.

This is a female with moderately differentiated adenocarcinoma of the esophagus. A positron emission tomography (PET)/computed tomography (CT) has been ordered for staging; this is under review.

The Positron Emission Tomography and Computed Tomography (PET CT) is medically necessary for this patient.

This patient has at least T1 adenocarcinoma of the esophagus. In this setting, consideration is given for treatment with curative intent when possible. A PET/CT is recommended for patient without evidence of M1 disease by the National Comprehensive Cancer Network (NCCN) Guidelines.

The authors of UpToDate state "...FDG (fluorodeoxyglucose)-PET is more sensitive than contrast-enhanced CT or endoscopic ultrasound (EUS) for the detection of distant metastases...The addition of PET to the preoperative assessment alters management in 5 to 20 percent of cases, mainly by detecting occult metastases (i.e., upstaging) that reduces the number of patients who undergo needless surgery... The improved sensitivity of PET for the detection of metastatic disease makes it potentially the most effective method of identifying patients with occult metastases for whom curative therapy should not be pursued...".

A major drawback of PET for the evaluation of the primary site and nodal metastases is its poor spatial resolution that makes it difficult to localize the anatomic location of the FDG (fluorodeoxyglucose) uptake. This limitation is significantly reduced by the use of integrated PET/CT imaging, which is the service under review and recommended by the NCCN. This approach is recommended by the authors of Up-to-date and in the peer-reviewed literature. The use of PET/CT for initial staging of patients with potentially resectable disease is not the subject of ongoing investigation. For these reasons, medical necessity has been established for this service.