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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for proton beam therapy for treatment of the enrollees high grade intrinsic brainstem glioma. Findings: Two of the three physician reviewers found that the patient has a radiographically diagnosed high grade diffuse intrinsic brainstem glioma. The patient also has a history of a small bowel carcinoid tumor, which was partially resected. He presented with a metallic taste in his mouth, asymmetric gait and numbness in his right face and mouth. A magnetic resonance imaging revealed a right pontine mass with a necrotic core and surrounding infiltrative component. A computed tomography of the chest, abdomen and pelvis was unremarkable other than revealing a thyroid mass, which was biopsied and proved to be nonmalignant. An octreotide scan did not show uptake of this brainstem lesion. Therefore, it was not assessed to be a metastatic site. He was referred for consideration of radiation and chemotherapy. A treatment planning note says that proton therapy will provide a homogeneous target volume coverage and reduction in normal tissue dose by minimizing dose to dose sensitive structures. The patient has requested reimbursement and prospective coverage for proton beam therapy. The Health Plan denied reimbursement and coverage for the services at issue as investigational for treatment of this patients medical condition. There is a lack of support in the medical literature showing that proton therapy will have a quantifiable and clinically meaningful benefit to this patient who is diagnosed with high grade brainstem glioma. Overall, the published data used to support proton therapy for gliomas is scant and represents small studies, dosimetric comparisons and/or studies which include various tumor types. There are some small studies that suggest there may be a dosimetric advantage to proton beam therapy in select patients with low grade glioma. However, this data is very limited data. From the American Society for Radiation Oncology, emerging technology committee report, they reported that, Overall, more clinical data (published clinical trials) are needed to fully establish the role of proton beam therapy (PBT) in central nervous system (CNS) tumors. The current National Comprehensive Cancer Network (NCCN) guidelines for CNS tumors do not address proton therapy for gliomas. Moreover, the recently released ASTRO model policy for proton therapy does not explicitly address proton therapy for brain cancer, although it cites several articles on proton therapy. While proton therapy may have a role in the treatment of some cancer patients, the clinical data as to its superior efficacy for treatment of this patient is lacking.  Further, the submitted documentation does not sufficiently provide the rationale for the need of proton beam therapy over intensity-modulated radiation therapy in this specific patient. Final Result: The reviewers determined that the services at issue were not and are 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: 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.