Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2:

Diagnosis: Tonsil cancer

Treatment: Proton Beam Radiation Therapy (PBT)

The insurer denied coverage for Proton Beam Radiation Therapy (PBT)

The denial is overturned

The patient is an adult seeking coverage for proton beam radiation therapy (PBT) (77520, 77523, and 77525).  The patient had cT3-4N1 (stage III-IVA, 7th edition) left palatine tonsil squamous cell carcinoma status post biopsy.  The patient presented for second opinion on definitive chemoradiation.  At a multidisciplinary tumor board it was felt that the patient was not a good surgical candidate, and standard of care chemoradiation was recommended.  The patient reported persistent sore throat and otalgia.  There was mild dysphagia but no odynophagia.  There was some limitation in left tongue movement.  The patient was a candidate for chemotherapy followed by chemoradiation with 30 gray (Gy) pending results of restaging imaging and scans.  If at that point, the patient was not a candidate for de-escalation, they would recommend standard of care chemoradiation to 70 Gy.  They reviewed proton therapy versus photon therapy.  Proton therapy enabled sparing of normal organs/tissues at the skull base which would reduce possible side effects.  It was felt that the patient is a good candidate for proton therapy.  The patient elected to proceed with treatment at Memorial Sloan Kettering (MSK) with protons if approved.  The patient would receive 70 Gy of proton beam radiation therapy to control cancer.  Multiple normal tissues and organs at risk were of concern.  Proton beam therapy was supported in instances where sparing the surrounding normal tissue could not be adequately achieved with photon-based radiotherapy.  The treatment areas extended into the base of the skull directly impacting the brainstem, spinal cord, and normal brain.  A decrease in the amount of dose inhomogeneity and large treatment volume was required to avoid an excessive dose hotspot within the treated volume to lessen the risk of excessive early or late normal tissue toxicity.  A photon-based technique would increase the probability of clinically meaningful normal tissue toxicity by exceeding an interval dose based metric associated toxicity.  Intensity modulated radiation therapy would deliver needless radiation to nontarget tissue which would increase the patient's risk of feeding tube dependence by 2-fold and increase the probability of incurring a secondary malignancy.

Proton beam radiation therapy (PBT); codes 77520, 77523 and 77525 have final approval from the appropriate regulatory bodies for this diagnosis. PBT is Food and Drug Administration (FDA) approved.

This patient is a good candidate for proton beam radiation therapy (PBT); codes 77520, 77523 and 77525.

The adverse risks are not  increased over standard treatment/services.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of proton beam radiation therapy (PBT); codes 77520, 77523 and 77525 and coverage for the requested treatment should be reversed. 

This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.