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202304-161907

2023

CIGNA Healthcare of NY

PPO

Cancer

Advanced Imaging Services (Including PET/ MRI/ CT)

Medical necessity

Overturned

Case Summary

Diagnosis: Breast Cancer
Treatment: positron emission tomography (PET) / computed tomography (CT)
The insurer denied positron emission tomography (PET) / computed tomography (CT).
The determination is overturned.
This is a female patient with metastatic estrogen receptor (ER) positive (+)/ progesterone receptor (PR) +/ human epidermal growth factor receptor 2 (HER2) negative (-) breast cancer. The patient is currently on palbociclib and letrozole. The patient had a magnetic resonance imaging (MRI) scan of the liver with findings concerning for progression - a 5.2 centimeter (cm) lesion in the right hepatic dome. A positron emission tomography (PET) / computed tomography (CT) was obtained to confirm this and is under review for medical necessity.
The patient's magnetic resonance imaging (MRI) demonstrated a suspicious area in the liver. Imaging was otherwise unremarkable for progressive disease. The PET/CT was obtained to assist in determining the status of disease (i.e. progression) given that there was no other clinical or radiographic evidence of progressive disease in this patient. The National Comprehensive Cancer Network (NCCN) Guidelines state "...fludeoxyglucose (FDG) PET/ CT is most helpful in situations where standard staging studies are equivocal or suspicious...." This approach is similarly echoed in the peer-reviewed literature and by the authors of UpToDate.The authors of UpToDate state PET/CT is preferred"...as it has demonstrated high sensitivity and specificity in detecting metastatic disease and can reliably assess response to therapy.." This study was not obtained for convenience nor in the context of a clinical trial. For these reasons, criteria for medical necessity have been satisfied.

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