Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatic Cancer. 
Treatment: 33 Fractions IMRT (intensity-modulated radiation therapy). 

The insurer denied the 3 Fractions IMRT (intensity-modulated radiation therapy). 
The denial is overturned. 

The patient is a female with a diagnosis of unresectable, stage T2N1 (The tumor is in the pancreas only, and it is larger than 2 centimeters but not larger than 4 centimeters, Cancer has spread to 1 to 3 regional lymph nodes) pancreatic cancer status post neoadjuvant chemotherapy and exploratory laparotomy.  Concurrent chemotherapy and radiation therapy was recommended, and IMRT (intensity-modulated radiation therapy) was requested. 

The request for IMRT (intensity-modulated radiation therapy) was initially denied by the health plan, because it was not deem medically necessary per health plan guidelines. 

Yes, the requested health service is medically necessary. 

There are several studies showing that IMRT (intensity-modulated radiation therapy) is a safe and effective treatment for pancreatic carcinoma. 

A University of Chicago study investigated 24 patients with pancreatic or bile duct cancers treated with IMRT (intensity-modulated radiation therapy). The authors concluded that "Compared with conventional RT [radiation therapy], IMRT [intensity-modulated radiation therapy] reduced the mean dose to the liver, kidneys, stomach, and small bowel. IMRT [intensity-modulated radiation therapy] was well tolerated, with 80% experiencing Grade 2 or less acute upper GI [gastrointestinal] toxicity." 

Another study from the Netherlands compared conformal radiotherapy with IMRT (intensity-modulated radiation therapy) for the treatment of pancreatic cancer. The authors concluded that "Compared with the CRT [conformal radiotherapy] plans, IMRT (intensity-modulated radiation therapy) significantly reduced the mean volume of right kidney exposed to 20 Gy [Gray] from 27.7% +/- (plus/minus) 17.7% to 16.0% +/- (plus/minus) 18.2% (standard deviation)," and that "The IMRT [intensity-modulated radiation therapy] plans also reduced the mean gastric, hepatic, and small bowel doses." 

Another study from Stanford University evaluated 47 patients with pancreatic cancer treated with IMRT [intensity-modulated radiation therapy]. The authors concluded that "IMRT [intensity-modulated radiation therapy] is well tolerated. Compared with those who received three-dimensional conformal radiotherapy in previously reported prospective clinical trials, patients with pancreatic adenocarcinoma treated with IMRT [intensity-modulated radiation therapy] in our series had improved acute toxicity." 

A more recent study from multiple institutions compared IMRT (intensity-modulated radiation therapy) vs. 3D (three dimensional) for the treatment of pancreatic cancer. The authors concluded that "significant improvements in 3D [three dimensional] plan performance with complex planning over the more frequently compared 3- or 4-field simple 3D [three dimensional] planning techniques. VMAT (volume modulated arc therapy) (IMRT [intensity-modulated radiation therapy]) plans continue to demonstrate potential for the most organ sparing." 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 
In this patient's case, the radiation target is extensive, and there are several surrounding critical organs at risk for high dose radiation therapy. The surrounding organs at risk include stomach, kidneys, liver, spinal cord, spleen and small bowel where most of the organs' tolerance doses are at or below the required dose of at least 50 Gy (gray). The tolerance dose of kidney is only about 18 Gy (gray), and the small bowel about 45-50 Gy (gray). In addition, the patient also had abdominal surgery, and care must be taken to minimize radiation exposure to the small bowel and liver. IMRT (intensity-modulated radiation therapy) is the best available option that would provide safe and effective treatments for this patient. It is, therefore, not considered unproven and is an appropriate treatment.