Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Adenocarcinoma of the superior segment of the left lower lobe of the lung.
Treatment: Radiation therapy for small cell lung cancer. 

The insurer denied coverage for radiation therapy for small cell lung cancer. 

The denial is overturned. 

This is a male patient with a diagnosis of adenocarcinoma of the superior segment of the left lower lobe of the lung.  This patient has had prior treatment with stereotactic body radiotherapy.  The patient was then treated with maintenance immunotherapy. Since then, there has been recurrence in the left hilum which was biopsy-confirmed. The physician indicated that the volume is small and likely nontoxic in the acute setting; however, hyperfractionation was required for infield re-irradiation.  The physician indicated that the patient lives over an hour away and they wanted to help with travel and offer 1.5 gray units (Gy) twice a day which should reduce late toxicity risk and improve convenience for the patient. 

The plan is to treat this patient's lung carcinoma with photon radiation, with delivery of 6000 Gy twice a day in 1.5 Gy fractions. The treatment plan is to deliver a course of radiation in conjunction with combination chemotherapy to the tumor to obtain local control, potentially impacting upon overall survival. Lung cancer, small cell or non-small cell can be treated with radiation, either alone or combined with chemotherapy.  In general, when radiation is used, the planning technique should be three-dimensional (3-D). As per the National Comprehensive Cancer Network (NCCN) Guidelines for Small Cell Lung Cancer, the goals of modern radiation therapy are to maximize tumor control and minimize treatment toxicity. This is accomplished through dose and treatment delivery. More advanced technologies than 3-D are appropriate when needed to deliver curative radiation therapy (RT) safely. Nonrandomized comparisons of using advanced technologies versus older techniques have demonstrated reduced toxicity and improved survival. It is expected that a comparison of 3-D and intensity modulated radiotherapy (IMRT) will show that 3-D cannot protect normal tissue and deliver sufficient dose to the tumor. 

The treating physician intends to deliver a definitive dose to a reasonable volume of uninvolved normal lung as the entire tumor volume can be encompassed in a single field. However, the target volume will also include the mediastinal structures and as such, dosing the target will also dose normal organs including the heart, spinal cord, aorta, trachea, and esophagus as well as the normal lung. There will be the potential to exceed tolerances here that could result in significant normal tissue complications. The treating physician will need to treat as little normal remaining lung as possible to allow for acceptable lung function after treatment in addition to minimizing dose to the other surrounding critical normal structures noted above. Given the constraints, 3-D planning cannot adequately cover the target volume and maintain normal tissue tolerances. To achieve the total dose required to control the tumor, an IMRT plan will be needed.  The patient has a good performance status prior to treatment. IMRT can provide a better plan than 3-D, given the information provided as to target and normal tissue dosing. The IMRT plan can be allowed in this patient's clinical situation. 

Given the patient's clinical situation and the treating physician's treatment intent, the treatment plan of using IMRT to deliver 60Gy at 1.5 Gy twice a day (BID) is appropriate and is considered medically necessary for this patient. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The insurer's Partial denial of coverage for radiation therapy for small cell lung cancer should be overturned.