202210-154763
2022
Excellus
PPO
Cancer
Advanced Imaging Services (Including PET/ MRI/ CT)
Medical necessity
Overturned
Case Summary
Diagnosis: Prostate Cancer.
Treatment: Positron Emission Tomography and Computed Tomography (PET CT).
The insurer denied Positron Emission Tomography and Computed Tomography (PET CT).
The health plan's determination is overturned.
The patient is a male with metastatic prostate cancer. He has received androgen deprivation therapy as well as chemotherapy. Recent imaging has noted resolution of many bony metastatic sites; however, the recent results of standard imaging are ambiguous and require additional testing to assess the treatment response. This information would be used to guide further therapy.
The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.
The requested health service and treatment of Positron Emission Tomography and Computed Tomography (PET CT) is medically necessary for this patient. The patient has several areas identified on conventional imaging which require further clarification. The National Comprehensive Cancer Network (NCCN) guidelines endorse the use of this radiologic testing in this clinical situation. Literature notes, "Background PET CT imaging with the radiopharmaceutical molecular imaging and contrast agent [11C]-Choline has become a useful tool in the detection of prostate cancer, mainly used in the assessment of treated patients presenting rising prostate-specific antigen (PSA) and negative response after conventional imaging procedures."