Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer
Treatment: Intensity modulated radiation therapy (IMRT), APBI (accelerated partial breast irradiation)
The insurer denied coverage for intensity modulated radiation therapy (IMRT), APBI (accelerated partial breast irradiation).
The denial is overturned.
 
The patient is diagnosed with high grade ductal carcinoma in situ (DCIS). She is status post (s/p) lumpectomy to negative margins. She has been recommended to proceed with accelerated partial breast irradiation (APBI). The request for intensity modulated radiation therapy (IMRT), accelerated partial breast irradiation (APBI) is under review.

Intensity modulated radiation therapy (IMRT), accelerated partial breast irradiation (APBI) is considered medically necessary for this patient. APBI (accelerated partial breast irradiation) is widely utilized and supported by the National Comprehensive Cancer Network (NCCN) guideline in this patient's situation. It is proven to minimize the risk for tumor recurrence and high grade morbidity. IMRT (Intensity modulated radiation therapy) is required for delivery of APBI (accelerated partial breast irradiation) and is supported by the American Society for Therapeutic Radiation Oncology (ASTRO) Model Policy and Florence IMRT (Intensity modulated radiation therapy) trial, as it allows for optimal target coverage while minimizing exposure to the patient's surrounding normal tissues.

"The utilization of APBI (accelerated partial breast irradiation) has increased in the past decade because of the shorter treatment schedule and a growing body of outcome data showing positive cosmetic outcomes and high local control rates in selected patients undergoing breast conserving therapy. Technological advances in various APBI (accelerated partial breast irradiation) modalities, including intracavitary and interstitial brachytherapy, intraoperative radiation therapy, and external beam radiation therapy, have made APBI (accelerated partial breast irradiation) more accessible in the community" (Tann, A. W., et al.). 

"Accelerated partial breast irradiation (APBI) is an alternative approach to breast conserving therapy (BCT) where radiation (RT) is delivered over a shorter period of time compared with whole breast irradiation (WBI), resulting in improved patient convenience and cost savings" (Goldberg, M., & Whelan, T. J.).

"Acute and late treatment-related toxicity and cosmesis outcomes were significantly in favor of APBI (Accelerated partial breast irradiation)" (Meattini I, et al.).

"APBI (Accelerated partial breast irradiation) is progressively being used to treat early-stage breast cancer as an alternative to WBI (whole breast irradiation), as it offers much lower normal tissue doses. Long-term outcomes show consistent and low ipsilateral breast tumor recurrence rates for APBI" (Frederick, A., et al.). 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for intensity modulated radiation therapy (IMRT), accelerated partial breast irradiation (APBI) services is substantiated.