Diagnosis: Germ cell tumor
Treatment: Magnetic resonance image (MRI) scan (abdomen and pelvis)
The insurer denied the Magnetic resonance image (MRI) scan (abdomen and pelvis)
The denial is overturned.

The patient is a male with germ cell tumor. The attending physician (AP) has performed magnetic resonance image (MRI) for surveillance every six months. The patient recurred and underwent retroperitoneal lymph node dissection (RPLND). The attending physician (AP) has requested magnetic resonance image (MRI) scans.

The health plan denied the proposed magnetic resonance image stating that "Per health plan policy guidelines, and per national cancer guidelines (NCCN), CT (computed tomography) scans, not MRI scans, are medically necessary to follow-up testicular cancer. Follow-up scans three months after surgery, six months after surgery, and 12 months after surgery are approved by the health plan. Then every six months for two more years. Then, annually through year five. The timing of your exam, was nine months after surgery. This does not follow the recommended intervals according to the health plan or the national cancer guidelines."

Yes, the proposed magnetic resonance image (MRI) is medically necessary.
The National Comprehensive Cancer Network (NCCN) does state that magnetic resonance image (MRI) can replace computed tomography (CT) scans for surveillance of germ cell tumor. The National Comprehensive Cancer Network (NCCN) does not list what circumstances would justify this approach. However, as this is in line with the National Comprehensive Cancer Network (NCCN) it would be considered appropriate. In addition, the National Comprehensive Cancer Network (NCCN) does state that the same imaging needs to be used throughout the surveillance protocol.

Following surgery, for stage I seminoma without chemotherapy, the National Comprehensive Cancer Network (NCCN) supports surveillance every six months for the first two years.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.