Physician 1st Quarter 2016 Radiology IRR Case Study #1 - Oncology
54yoF CIGNA SI-PPO/OAP
Provider Specialty: Oncology
Request Initiated: 01/21/2016
CPT: 78815 - PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh
ICD10: C50.112 - Malignant neoplasm of central portion of left female breast
Nurse Reviewer Note:
Per ACDS Notes/Fax Notes/ Onc req PET CT 78815 for 54yoF.
LOV: 01/19/16
Reason: Restaging Metastatic Breast CA; follow-up per review.
ONC Member hx: Updated.
Date of Diagnosis: 11/17/14
Cell Type and Location: Grade 3 IDC, L Breast poorly differentiated
Stage at Diagnosis: Stage IV (T2 N1 M1)
Current Stage: NA
Type of Treatment: Palliative chemo; Arimidex; Herceptin/Perjeta
Treatment Dates: 3/26/15; 6/17/15 - on holiday
Recurrence or Metastasis Date of Diagnosis: NA
Recurrence or Metastasis Site: Brain, bone, liver, R adrenal gland, L axillary nodes, hilar/mediastinal nodal mets.
Prior Imaging: (9/1/15) PET Scan: There is no scintigraphic evidence of malignancy. Abnormal activity within right hilar lymph nodes has completely resolved.
PE: No abnormal findings.
Sx: Fatigue, arthralgias
Labs/ Tumor Markers: (12/2/15) CEA 1.5; CA 27-29 was 10. Alk Phos 62; AST 13; ALT 8
ACDS Notes and Fax Notes reviewed.
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