Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Brain Metastases.
Treatment: 5 Treatment sessions of Multi-Fraction Cranial Stereotactic Radiosurgery (SRS) (Using Photons).
The insurer denied: 5 Treatment sessions of Multi-Fraction Cranial Stereotactic Radiosurgery (SRS) (Using Photons).
The denial is upheld.

The patient is an adult male with stage II small cell cancer of lung, status post chemoradiation treatment. The patient then developed a 1.2 cm (centimeter) metastatic lesion in the left frontal lobe and was treated with SRS (stereotactic radiosurgery). Three months later, the patient developed three metastatic lesions in the brain and was treated with SRS (stereotactic radiosurgery). MRI (magnetic resonance imaging) of the patient's brain two months post stereotactic radiosurgery showed three new metastatic lesions, and SRS (stereotactic radiosurgery) is being requested to treat three new metastatic lesions from small cell lung cancer. This member has no evidence of disease progression or metastasis outside of brain and has performance status of KPS 90. 

The health plan should not cover the Stereotactic Radiosurgery. 

This patient has Karnofsky performance status of 90 with systemic disease is under control. He has life expectancy of greater than six months. All three new lesions on the most recent MRI (magnetic resonance imaging) of the brain are less than 5 cm (centimeters), and this patient has been treated with two episodes of radiosurgery in the past nine months. However, the patient's primary histology includes small cell for initial treatment of brain metastasis. Therefore, given the above, the requested SRS (stereotactic radiosurgery) does not meet requirements for SRS (stereotactic radiosurgery) of brain metastasis for previous treatment with SRS (stereotactic radiosurgery), and it should not be covered by the health plan. 

Clinical outcome evidence on the safety and efficacy of stereotactic radiosurgery (SRS) for solitary/oligo metastasis have been published in evidence based, peer-reviewed journals and textbooks. SRS (stereotactic radiosurgery) has become a standard of care in the treatment of solitary/oligo metastasis to the brain. Also, the aggressive management to prevent another recurrence of brain metastasis (including stereotactic radiosurgery) for patients with good performance status and no systemic disease is consistent with NCCN (National Comprehensive Cancer Network) practice guidelines. However, small cell cancer of lung has high propensity for metastasis throughout whole brain and to leptomeningeal metastasis. 

Current published clinical outcome evidence of SRS (stereotactic radiosurgery) in patients with small cell lung cancer is insufficient to consider as the standard of care. NCCN (National Comprehensive Cancer Network) guideline on small cell lung cancer v2022 notes that brain metastasis should be treated with whole brain RT (radiotherapy), rather than SRS (stereotactic radiosurgery) alone because these patients tend to develop multiple CNS (central nervous system) metastases. SRS (stereotactic radiosurgery) for brain metastasis from small cell lung cancer is not consistent with NCCN (National Comprehensive Cancer Network) guideline. 

The requested SRS (stereotactic radiosurgery) for recurrent metastatic small cell lung cancer in the brain has not been proven more beneficial than any standard treatment as SRS (stereotactic radiosurgery) for brain metastasis from small cell lung cancer is currently being investigated in clinical trials (ClinicalTrials.gov Identifier: NCT04516070, NCT03391362 and NCT03297788).