Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Brain Metastases.
Treatment: 5 Treatment sessions of Multi-Fraction Cranial Stereotactic Radiosurgery (SRS) (Using Photons).
The insurer denied: 5 Treatment sessions of Multi-Fraction Cranial Stereotactic Radiosurgery (SRS) (Using Photons).
The denial is overturned.

The patient is an adult male with a history of limited stage small cell lung cancer status post definitive lung radiation to 66 Gy (Gray) two years ago. The patient subsequently presented with brain metastasis status post two courses of stereotactic radiosurgery (SRS)/fractionated stereotactic radiotherapy (fSRT). He recently presented with three progressive brain lesions and a few stable and regressing brain lesions. Another course of brain radiation was recommended, and SRS (stereotactic radiosurgery) was requested. 

The health plan should cover the requested Stereotactic Radiosurgery. 

Stereotactic radiosurgery or fractionated stereotactic radiotherapy has been shown to be safe and effective for the treatment of brain metastases. It can provide similar or better local control compared to surgical resection and/or whole brain radiation. SRS/fSRT (stereotactic radiosurgery/fractionated stereotactic radiotherapy) can also reduce the risk of neurocognitive toxicity compared to whole brain radiation. 

The standard of care for solitary and oligo-metastasis to the brain has been surgical resection followed by whole brain radiation therapy. More recently, however, radiosurgery has been used instead of surgery for patients with brain lesions. There is clinical data showing that stereotactic radiosurgery is as effective and perhaps safer compared to surgical resection. 

A Mayo clinic study published in 2003 compared patients with solitary brain metastasis treated with neurosurgery versus SRS (stereotactic radiosurgery). A total of 97 patients were evaluated. The authors concluded that "There was no significant difference in patient survival (p = 0.15); the one year survival rate was 56 percent for the SRS (stereotactic radiosurgery) patients and 62 percent for the neurosurgery patients," and that, "There was a significant (p = 0.020) difference in local tumor control between neurosurgery and radiosurgery for solitary brain metastasis; none of the SRS (stereotactic radiosurgery) group had local recurrence compared to 19 (58 percent) of the neurosurgery group." 

A recent 2017 study evaluated 294 patients that underwent SRS (stereotactic radiosurgery) to 697 lesions, of which 65 patients had controlled systemic disease (CSD). Overall survival at 1 and 5 years for CSD (controlled systemic disease) were 65% and 13% with USD (uncontrolled systemic disease) yielding 41% and 7%, respectively. The authors concluded that patients with brain metastases after 1 year or longer of primary and systemic disease control represent a particularly favorable cohort, with lower regional CNS (central nervous system) failure and prolonged survival, for an approach of SRS (stereotactic radiosurgery) alone. 

The American Society for Therapeutic Radiology and Oncology (ASTRO) also performed an evidence-based review of the role of radiosurgery for brain metastasis and concluded that, "Based on Level I-III evidence, for selected patients with small (up to four centimeters) brain metastases, the addition of radiosurgery boost to whole brain radiotherapy improves brain control as compared with whole brain radiotherapy alone. In patients with a single brain metastasis, radiosurgery boost with whole brain radiotherapy improves survival." 

The patient is very functional and has stable disease extracranially. Surgical resection or whole brain radiation may cause significant brain toxicity. If left alone, the brain lesion will continue to progress and would eventually cause severe symptoms. Stereotactic radiosurgery is a safe and effective way to improve local control and relieve symptoms. Stereotactic radiosurgery is medically appropriate and should be covered by the health plan.