Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer

Treatment is outpatient radiation therapy for breast cancer initial phase: 9 fractions (treatment sessions) of 3D conformal and boost phase: 3 fractions (treatment sessions) of photons services

The insurer denied coverage for outpatient radiation therapy for breast cancer initial phase: 9 fractions (treatment sessions) of 3D conformal and boost phase: 3 fractions (treatment sessions) of photons services
 
The denial is upheld

This case involves an adult female with a history of breast cancer who was denied coverage for outpatient radiation therapy initial phase consisting of 9 fractions (treatment sessions) a 3D (dimensional) conformal and boost phase consisting of 3 fractions (treatment sessions) of photons with reports that this was not medically necessary. The request had exceeded limitations. The patient's oncologist was appealing the determination stating that the requested 25 fractions with 3D conformal with an 8-fractions boost to treat breast cancer would be beneficial in treating the patient's condition. She previously underwent a SAVI scout guided left breast lumpectomy, sentinel lymph node biopsy, reverse axillary mapping, left oncoplastic reconstruction, and a right breast reduction. The patient was authorized for an initial phase: 16 fractions (treatment sessions) of 3D conformal, Boost Phase: 5 fractions (treatment sessions) of Photons and Image Guided Radiation Therapy (IGRT) for the boost phase. This review pertains to the adjuvant radiation therapy with initial phase: 9 fractions (treatment sessions) of 3D conformal and boost phase: 3 fractions (treatment sessions) of photons. 

Medical literature states that for early-stage breast cancer, partial breast irradiation (PBI) allows for reduction in the irradiated volume of normal tissues by confining the radiation target to the area surrounding the lumpectomy cavity after breast-conserving surgery. Radiation therapy (RT) is an essential component in the management of breast cancer. Following breast-conserving surgery (BCS), adjuvant RT is the standard of care for most patients. The information noted the patient was status post left breast lumpectomy, sentinel lymph node biopsy, reverse axillary mapping, left oncoplastic reconstruction, and right breast reduction. She was approved for an initial phase: 16 fractions (treatment sessions) of 3D conformal, Boost Phase: 5 fractions (treatment sessions) of Photons and Image Guided Radiation Therapy (IGRT) for the boost phase. It was determined that the denial for coverage of outpatient radiation therapy for breast cancer initial phase: 9 fractions (treatment sessions) of 3D conformal and boost phase: 3 fractions (treatment sessions) of photons was appropriate as the approved treatment should adequately address the patient's condition. As such, the prior determination is upheld.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for outpatient radiation therapy for breast cancer initial phase: 9 fractions (treatment sessions) of 3D conformal and boost phase: 3 fractions (treatment sessions) of photons services is not substantiated.