Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ovarian cancer.

Treatment: Stereotactic body radiation therapy (SBRT).

The insurer denied coverage for Stereotactic body radiation therapy (SBRT).

The denial is overturned.

 
This case involves an adult seeking authorization for stereotactic body radiation therapy (SBRT) treatment. The patient presented for an evaluation related to metastatic serous ovarian cancer to the bone. The patient underwent total abdominal hysterectomy/bilateral salpingo oophorectomy including omentectomy, liver mobilization, right diaphragm stripping, right pelvic lymph node dissection, appendectomy, partial hepatectomy, cholecystectomy, and complete gross resection. The patient was subsequently started on carboplatin and paclitaxel. The patient completed 6 cycles of treatment with disease recurrence. This was followed by weekly Taxol with addition of Bevacizumab. The patient presented to participate in discussion regarding the role of palliative radiation therapy in the management of her disease. The patient described pain in the left hip just above the left buttock that radiated down the buttocks. The patient's symptoms are worsened at night and when sleeping. Imaging indicated that the source of pain was likely the lesions at the left sacroiliac joint and left ischium. These were outside of prior radiation therapy fields and would be amenable to palliative radiation therapy.

The treating provider requested reconsideration for stereotactic body radiation therapy treatment. The patient had stage IV (4) high-grade serous ovarian cancer. The patient had undergone total abdominal hysterectomy and bilateral salpingo oophorectomy with extension resection resulting in complete gross resection. Final pathology showed an 18.5 centimeters (cm) serous adenocarcinoma originating in the right ovary but involving bilateral ovaries and fallopian tubes. The patient was now status post multiple lines of systemic therapy with continued progression of disease. The patient received palliative stereotactic body radiation therapy to the sacrum with complete resolution of pain as well as palliative radiation therapy to the right hip again with resolution of pain. The patient had presented with pain in the left hip that started about the left buttocks and radiated down to below the buttocks. On extensive review of imaging, the source of the pain in the left hip was likely caused by lesions at the left sacroiliac joint and left ischium. The areas were outside of radiation therapy field. Thus, they would be amenable to palliative radiotherapy. Given the relatively radioresistant histology, close proximity to prior radiation fields, and excellent clinical response to prior course of stereotactic body radiation therapy, a course of stereotactic body radiation therapy to the new areas of bone metastasis was recommended.

Additionally, the provided plan comparison noted that tumor coverage and uniformity of dose within the tumor were improved with intensity modulated radiation therapy. The dose to normal tissue 1 and dose to normal tissue 2 were lower with intensity modulated radiation therapy. This supports that the requested stereotactic body radiation therapy is more appropriate than the 3D (three-dimensional) conformal given a more favorable safety profile. Additionally, it should not be ignored that the patient had a favorable response to the same treatment in the past without evidence of adverse effect. Therefore, the safest, most reasonable, and medically necessary treatment for the patient is the requested stereotactic body radiation therapy (SBRT) treatment.

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 stereotactic body radiation therapy (SBRT) treatment is substantiated.