Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy (including CPT code 77525 x 35 proton beam radiation therapy; CPT G6002 x 35 Dailey stereoscopic; CPT 77301 x 1 IMRT plan; CPT 77300 x 10 MU calculations; CPT 77336 x 7 complex treatment device; CPT 77427 x 7 physician treatment management; CPT 31575 x 1 laryngoscopy; CPT 77263 x 1 physician clinical planner; CPT 77470 x 1 special treatment procedure; CPT 77334 x 2 custom immobilization; CPT 77370 x 1 physics consult; and CPT 70553 x 1 magnetic resonance imaging (MRI) brain with and without contrast).Findings:  The physician reviewer found that meningiomas, standard treatment options are surgery, conventionally fractionated radiation or stereotactic radiosurgery. Deliver of conventionally fractionated radiation or radiosurgery is with proton or photon radiation therapy. Tumors abutting or close to the orbit and optic apparatus are not amenable to radiosurgery. This patients provider recommended fractionated proton radiotherapy. Other forms of radiation include intensity modulated radiation therapy (IMRT) and conventional three-dimensional (3D) conformal radiation with photon therapy. Certain conditions such as base of skull chordomas and chondrosarcomas are responsive to treatment with proton therapy, due to the sharp dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue. Whether proton therapy affords any benefit over photon-based radiation therapy remains unknown. Arvold and colleagues reported on a dosimetric study of 10 patients with meningiomas comparing IMRT versus proton therapy. The authors concluded that doses received by neurocognitive, visual, and auditory organs were significantly lower among proton plans, yet there was no significant difference in anticipated late toxicities using normal tissue complication probability models. Any potential benefit with respect to neurocognitive function has been poorly characterized (Gondi et al). Given these findings, the proton beam radiation therapy (including CPT code 77525 x 35 proton beam radiation therapy; CPT G6002 x 35 Dailey stereoscopic; CPT 77301 x 1 IMRT plan; CPT 77300 x 10 MU calculations; CPT 77336 x 7 complex treatment device; CPT 77427 x 7 physician treatment management; CPT 31575 x 1 laryngoscopy; CPT 77263 x 1 physician clinical planner; CPT 77470 x 1 special treatment procedure; CPT 77334 x 2 custom immobilization; CPT 77370 x 1 physics consult; and CPT 70553 x 1 magnetic resonance imaging (MRI) brain with and without contrast) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the proton beam radiation therapy (including CPT code 77525 x 35 proton beam radiation therapy; CPT G6002 x 35 Dailey stereoscopic; CPT 77301 x 1 IMRT plan; CPT 77300 x 10 MU calculations; CPT 77336 x 7 complex treatment device; CPT 77427 x 7 physician treatment management; CPT 31575 x 1 laryngoscopy; CPT 77263 x 1 physician clinical planner; CPT 77470 x 1 special treatment procedure; CPT 77334 x 2 custom immobilization; CPT 77370 x 1 physics consult; and CPT 70553 x 1 magnetic resonance imaging (MRI) brain with and without contrast) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the proton beam radiation therapy (including CPT code 77525 x 35 proton beam radiation therapy; CPT G6002 x 35 Dailey stereoscopic; CPT 77301 x 1 IMRT plan; CPT 77300 x 10 MU calculations; CPT 77336 x 7 complex treatment device; CPT 77427 x 7 physician treatment management; CPT 31575 x 1 laryngoscopy; CPT 77263 x 1 physician clinical planner; CPT 77470 x 1 special treatment procedure; CPT 77334 x 2 custom immobilization; CPT 77370 x 1 physics consult; and CPT 70553 x 1 magnetic resonance imaging (MRI) brain with and without contrast) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.