Program Operations Manual System (POMS)
TN 1 (10-08)
DI 23022.260 Ovarian Cancer
COMPASSIONATE ALLOWANCE INFORMATION
Ovarian Cancer forms in tissues of the ovary. Most ovarian cancers are either ovarian epithelial carcinomas or malignant germ cell tumors. Ovarian Epithelial Cancer is a disease in which malignant cells form in the tissue covering the ovary.
Those with a family history of ovarian cancer are at an increased risk of developing ovarian cancer. Some ovarian cancers are caused by inherited gene mutation. Hereditary ovarian cancers make up approximately 5% to 10% of all cases of ovarian cancer. Tests that can detect mutated genes are sometimes performed for members of families with a high risk of cancer.
Ovarian Epithelial Carcinoma, Ovarian Epithelial Cancer, Ovarian Carcinoma
DIAGNOSTIC TESTING AND CODING
The following may be used to diagnose the disease: blood tests, urinalysis, GI series, exploratory laparoscopy, ultrasound, abdominal CT scan, and/or MRI of the abdomen.
Treatment may include surgery, radiation, and/or chemotherapy.
If the cancer is inoperable or unresectable, treatment with radiation and/or chemotherapy can be utilized for palliation, but the prognosis is poor.
The prognosis for individuals with ovarian cancer is often poor. About 76% with ovarian cancer survive 1 year after diagnosis and about 45% live longer than 5 years after diagnosis.
SUGGESTED PROGRAMMATIC ASSESSMENT*
Suggested MER for Evaluation: A pathology report and an operative report are the preferred methods for documentation.
In the absence of these reports, the adjudicator may use a physician's opinion that indicates the cancer is inoperable or unresectable based on described objective findings.
“Inoperable” refers to a physician's opinion that surgery would not be beneficial based on a review of imaging studies, laboratory results, and physical examination findings. Unresectable cancer is established when the operative report indicates that the cancer is not completely removed or the pathology report notes that the surgical specimen has positive margins.
Suggested Listings for Evaluation:
Ovarian Cancer that is inoperable, unresectable, or with distant metastases has a poor prognosis, but is currently not specifically listed under Listing 13.23 E.
13.23 E 1 a
Ovarian Cancer that is inoperable, unresectable, or with distant metastases equals Listing 13.23 E 1 a, as it has a similar prognosis to this listing.
* Adjudicators may, at their discretion, use the Medical Evidence of Record or Listings suggested to evaluate the claim. However, the decision to allow or deny the claim rests with the adjudicator.
Last Updated: 9/30/08
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