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 overturned.   

This male patient has a history of recurrent angiosarcoma of the left upper back.  The documentation indicated that the patient initially underwent resections. The patient has been receiving systemic therapy as well as some targeted therapy.  Due to disease progression on multiple systemic therapies, it was recommended the patient undergo radiation therapy.  The documentation indicated that the patient initially presented with a lesion in the left scapula with a punch biopsy showing angiosarcoma.  Initially, the patient also had a 5 mm lung nodule which had essentially been stable.  The patient's condition had involvement of the left axillary lymph node with no overall metastatic disease.  The documentation indicated that radiation therapy with photon treatment would significantly increase the dose that goes to the underlying lung whereas proton therapy with a sharp Bragg peak and follow-up would appropriately treat the lesion with minimal risk of toxicity to neighboring organs.

Based on the review of the medical record, this patient's condition would most likely require more chemotherapy after the current course of radiation, and would also likely need additional courses of radiation. The patient is to be considered for radiation treatment, including proton beam radiation therapy (PBRT). The patient's physician is considering delivery a significant radiation dose to the tumor, which is in the back/chest area near the esophagus, lung, heart, and other critical structures. As per literature review, proton radiation is generally accepted as medically necessary for the following conditions: 1) intracranial arteriovenous malformations (AVMs); 2) Ocular tumors, including intraocular/uveal melanoma (includes the iris, ciliary body and choroid); or 3) Skull-based tumors (e.g., chordomas or chondrosarcomas). 

The National Comprehensive Cancer Network (NCCN) Guidelines version 2.2020 for Soft Tissue Sarcomas describes appropriate postoperative radiation as IMRT(intensity-modulated radiation therapy) photons or other conformal techniques, including proton therapy to improve the therapeutic effect. This update indicates that for proton beam therapy achieving highly conformal dose distributions is especially important for patients whose primary tumors are aggressive as they will require higher overall doses of radiation to achieve a beneficial effect; and who are being treated with curative intent and or will have long life expectancies following treatment. Proton beam therapy is also to be used to treat patients with the most challenging disease, for which other radiation therapy (RT) options are not felt to be safe or of any benefit. The guidelines further indicate that there are a few randomized and single institution reports and systemic comparisons demonstrating safety and efficacy of proton beam therapy in the above-mentioned specific clinical scenarios. In this case, this patient's condition falls into the category described above. The patient has disease, located in a specific anatomical area, near the spinal cord, near previously treated regions that requires extremely specific and conformal dosing. 

The American Society for Radiation Oncology (ASTRO) Report on Emerging Technologies indicates that the proton beam therapy for sarcomas, while not necessarily a standard of care currently, may be considered in appropriate situations. The records do indicate an improvement of proton therapy over photon therapy. Regarding medical necessity, while proton therapy may not be the only standard of medical practice, it may be safe and effective and may be considered more effective than standard photon therapy for this patient's condition. The proton plan could also lower the dose to the surrounding abdominal, thoracic, and interior mediastinal structures also keeping them within reasonable limits for tolerance. It is possible that protons will reduce short term toxicity and reduce significant long-term side effects. The potential for pneumonitis, carditis, mucositis, nausea and esophagitis are significantly reduced for the proton plan. This will result in less long-term issues and side effects. It will allow for better tolerance of additional chemotherapy, allowing for more treatment options. As this patient may have a significant five-year survival, this will be important. 

Thus, the requested service is 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 x2 should be overturned.