Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer of base of tongue. 
Treatment: Proton beam therapy and associated treatment support codes. 

The insurer denied coverage for proton beam therapy and associated treatment support codes. 

The denial is overturned. 

This is a male who has been diagnosed with invasive basal cell carcinoma of the right base of tongue. The request is for approval of proton beam radiation therapy (PBT) and associated treatment support codes. 

The treating provider has supplied a proton/photon plan comparison, which revealed that the photon-based Intensity-Modulated Radiation Therapy (IMRT) plan is unable to spare the patient's salivary tissue, which would lead to an unacceptable and unnecessary risk for xerostomia and long-term swallowing dysfunction (including risk for aspiration). The PBT plan was able to significantly reduce the salivary exposure to within known safe tolerance limits, thereby minimizing the patient's risk for high grade late toxicity. 

In 2014, the American Society of Radiation Oncology (ASTRO) categorized PBT clinical indications into group 1, for which health insurance coverage is recommended, and group 2, for which coverage is recommended only if additional clinical requirements are met.15 The ASTRO considers use of PBT reasonable in instances in which sparing the surrounding healthy tissue cannot be adequately achieved with photon-based radiotherapy and PBT use is of added clinical benefit to the patient. The guidelines were updated in 2017." 

The patient is a good candidate for the requested procedures, the procedures are the best available treatment for the patient at this time and 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. 

The carrier's denial of procedure codes 77263, therapeutic radiology treatment planning; complex; 77301, intensity modulated radiotherapy plan, including dose volume histograms for target and critical structure partial tolerance specifications; 77293, respiratory motion stimulation; 77336 (x7), continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy, 77300 (x10); basic radiation dosimetry calculation, central axis depth dose calculation TDF (Time Dose Fractionation Factor), NSD (Nominal Standard Dose), gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician; 77427 (x7), radiation treatment management, 5 treatments; 77332 (x10), treatment devices, design and construction; simple (simple block); 77333 (x10), treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus); 77334 (x10), treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds, or casts); 77370, special medical radiation physics consultation; 77470, special treatment procedure; 77331, special dosimetry only when prescribed by the treating physician, 77520 (x35) Proton treatment delivery; simple, without compensation, 77523 (x35) proton treatment delivery; intermediate, 77525 (x35) proton treatment delivery, complex; 77014 (x35) computed tomography guidance for placement of radiation therapy fields, G6002 (x35) stereoscopic x-ray guidance for localization of target volume for delivery of radiation therapy and 77387 (x35) guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed should be overturned.