Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer
Treatment: Stereotactic Radiosurgery (SRS)
The insurer denied: Stereotactic Radiosurgery (SRS)
The denial is overturned

The patient is an adult female with a diagnosis of extensive stage small cell lung cancer status post chemotherapy and radiation therapy to the lung completed 1+ year prior presentation. The patient developed brain metastases status post stereotactic radiosurgery (SRS) with four brain lesions. She recently presented with a new metastatic brain lesion. Additional radiation therapy was recommended, and stereotactic radiosurgery (SRS) was requested.

The proposed treatment is medically necessary.

In this case, the patient is an adult female with a diagnosis of extensive stage small cell lung cancer status post systemic therapy and radiation therapy. The patient subsequently developed oligometastatic brain lesions status post stereotactic radio surgery (SRS). She presented with another progressive metastatic brain lesion. Palliative therapy to the brain lesion was recommended and stereotactic radiosurgery (SRS) was requested.

The standard of care for solitary and oligo-metastasis to the brain has been surgical resection followed by whole brain radiation therapy. More recently, however, radiosurgery has been used instead of surgery for patients with brain lesions. There is data showing that stereotactic radiosurgery is as effective and may be safer compared to surgical resection. A Mayo clinic study published in 2003 compared patients with solitary brain metastasis treated with neurosurgery versus stereotactic radiosurgery (SRS). A total of 97 patients were evaluated. The authors concluded that "There was no significant difference in patient survival (p = 0.15); the one-year survival rate was 56 percent for the SRS patients and 62 percent for the neurosurgery patients", and that "There was a significant (p = 0.020) difference in local tumor control between neurosurgery and radiosurgery for solitary brain metastasis; none of the SRS group had local recurrence compared to 19 (58 percent) of the neurosurgery group". 
A recent 2017 study evaluated 294 patients that underwent stereotactic radiosurgery (SRS) to 697 lesions, of which 65 patients had controlled systemic disease (CSD). Overall survival at one and five years for controlled systemic disease were 65% (percent)and 13% with uncontrolled systemic disease (USD) yielding 41% and seven percent, respectively. The authors concluded that patients with brain metastases after one year or longer of primary and systemic disease control represent a particularly favorable cohort, with lower regional central nervous system (CNS) failure and prolonged survival, for an approach of stereotactic radiosurgery (SRS) alone. 
The American Society for Therapeutic Radiology and Oncology (ASTRO) also performed an evidence-based review of the role of radiosurgery for brain metastasis and concluded that "Based on Level I-III evidence, for selected patients with small (up to four centimeters) brain metastases (up to three in number and four in one randomized trial), the addition of radiosurgery boost to whole brain radiotherapy improves brain control as compared with whole brain radiotherapy alone. In patients with a single brain metastasis, radiosurgery boost with whole brain radiotherapy improves survival". 
In this case, surgical resection or whole brain radiation may cause significant brain toxicity. If left alone, the brain lesion will continue to progress and would eventually cause severe symptoms. Complex isodose three-dimensional (3D) treatment is also suboptimal, as it is not as conformal and may result in excessive toxicity compared to stereotactic radiosurgery (SRS). 

Stereotactic radiosurgery (SRS) is a safe and effective way to improve local control and relieve symptoms. Stereotactic radiosurgery, therefore, is medically appropriate for this patient.