Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Angiosarcoma
Treatment: Photon based radiation therapy service codes 77523 x 8 and its associated radiation codes 77290, 77295, 77300 x10, G6002 x 8, 77427 x2, 77334 x11 and 77336 x2
The insurer denied the coverage for service codes 77523 x 8 and its associated radiation codes 77290, 77295, 77300 x10, G6002 x 8, 77427 x2, 77334 x11 and 77336 x2.
The denial was upheld.   

This male patient has a history of recurrent angiosarcoma of the left upper back, is immunosuppressed, and has Klippel-Trenaunay syndrome. He initially underwent resections. 

The patient received systemic therapy with Doxil and later with gemcitabine and docetaxel as well as some targeted therapy. Due to progression on multiple systemic therapies, the patient requires radiation therapy for control of this area. Due to the location of the Angiosarcoma (in the chest wall in the left scapular region, this is very close to the heart, lung), proton therapy is required to optimally protect the lung and heart in this patient who requires high doses of radiation and has had multiple prior therapies that can compromise his overall heart and lung. The patient was treated with proton beam therapy. 

This is a rare case of angiosarcoma. The patient was treated with surgery, chemotherapy and immunotherapy. He was treated with palliative radiation with short course of radiotherapy (RT). Proton beam radiotherapy is FDA approved.  However, there is no published data to support Proton beam for palliation for angiosarcoma. A search using Pubmed with terms angiosarcoma and proton revealed a general lack of data limited to small series or case reports. 

Based on review of the peer reviewed medical literature, the evidence is insufficient for any definitive conclusions about the safety and efficacy of proton beam radiotherapy (PBRT) for the treatment of soft tissue sarcomas. Some of the studies regarding PBRT primarily focus on treatment planning and dosimetric data. There are no data supporting improvement of health outcome.      

This patient was treated with palliative radiation. This can be done with intensity-modulated radiation therapy (IMRT). DVH comparison of Proton and photon was provided. The patient could have been treated with photon based IMRT.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

National Comprehensive Cancer Network (NCCN) Guidelines do not recommend PBRT for palliative radiation of angiosarcoma. "Angiosarcoma is a highly malignant endothelial tumor, with high rates of local and distant recurrence. Due to its pathological diversity, histological examination is the only reliable method for definite diagnosis of angiosarcomas. The majority of developing angiosarcoma cases have no clear etiology. Current treatments of angiosarcomas have their limitation. However, surgical resection with adjuvant radiotherapy remains the cornerstone of treatment for patients with localized angiosarcomas. It is challenging to avoid recurrent metastasis after treatment. Chemotherapy is the main treatment option for metastatic angiosarcoma despite it being hampered by the toxicities of frequently-used agents which are recommended in treatment. With the developing understanding of disease biology, biological therapies have the most potential to find optimal treatment strategy for this rare disease. It is hoped that targeted medicine will improve progression-free survival and OS and even achieve a complete cure of angiosarcoma. Overall further prospective studies are needed for better prevention, early diagnosis, and effective therapy." (Cao, J., et al. 2019).

The requested treatment was not the best available treatment for this patient at this time.     Thus, the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.
                                                 
The carrier's denial of service codes 77523 x 8 and its associated radiation codes 77290, 77295, 77300 x10, G6002 x 8, 77427 x2, 77334 x11 and 77336 should be upheld.