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Small cell lung cancer and treatments

Patient: Her CT scan shows a pleural base mass in the left apex appears to have some growth along the medial margin comparing with PET/CT assessment 07/08/10. While this extends to the pleural surface it does not clearly invade directly into the chest wall or the adjacent posterior lateral left third rib. Left suprahilar and mediastinal adenopathy appears to be essentially stable since 07/08/10. Multilevel thoracic bony metastatic disease is present. Hypodense liver metastasis appears slightly improved comparing with July, more substantially improved comparing with chest CT of 04/21/10.


Treatment: This is a very pleasant female 67-year-old female with extensive stage small cell lung cancer. She had one treatment postponed due to counts. She had low blood counts this week requiring platelet transfusion, so we are going to dose reduce for six treatments by 10%. As far as the back pain, she clearly has evidence of progressive bone metastasis in T3, T11, T12, and T1 and questions about the soft tissue mass pleural base mass in the lateral left apex. I am going to refer back to Dr. X to see if there might be some palliative radiation to deal with the left back and scapular region.


Is Preauth Required? The prior authorization justification for the treatment for the patient would be that the patient has evidence of progressive bone metastasis in the thoracic spine, and the soft tissue mass in the pleural base requires further evaluation by a specialist. The prior authorization justification for the condition would be that the CT scan shows a pleural base mass in the left apex, multilevel thoracic bony metastatic disease, and hypodense liver metastasis.

Will the claim be denied? Based on the information provided, it is likely that the claim for the treatment and condition described will be approved. The CT scan shows that the pleural base mass does not appear to be invading the chest wall or the adjacent rib, which indicates that it is not an aggressive form of cancer. Additionally, the PET/CT assessment shows that the left suprahilar and mediastinal adenopathy appears to be stable and that the liver metastasis has improved since July, suggesting that the treatment is having a positive effect.

When is the following treatment medically necessary for the condition specified? Treatment is medically necessary for this condition as she has evidence of progressive bone metastasis in the spine and questions about the soft tissue mass pleural base mass in the left apex. Radiation therapy may be used to relieve the pain and other symptoms caused by the bone metastases, such as pathologic fracture and nerve or spinal cord compression. In addition, radiation therapy may be used to shrink the pleural base mass in the left apex, if it is determined to be a malignancy.

What are the relevant codes for the treatment? I'm not sure about the specific HCPCS and CPT codes for this case, but based on the information provided the ICD 10 CM codes that support medical necessity would likely be C41.2 (Malignant neoplasm of bones of skull and face), C41.3 (Malignant neoplasm of ribs, sternum and clavicle), C41.4 (Malignant neoplasm of pelvic bones, sacrum and coccyx), C45.1 (Mesothelioma of peritoneum), C45.7 (Mesothelioma of other sites), C47.0 (Malignant neoplasm of peripheral nerves of head, face and neck), C48.0 (Malignant neoplasm of retroperitoneum), C48.8 (Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum), and C49.0 (Malignant neoplasm of connective and soft tissue of head, face and neck).

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