Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Small cell lung cancer. 
Treatment: Proton treatment delivery (procedure codes 77522, 77523, 77525). 
The insurer denied coverage for the proton treatment delivery (procedure codes 77522, 77523, 77525). 
The denial is overturned. 

The patient is a male with a diagnosis of extensive stage small cell lung cancer. 

The medical records indicate the patient initially presented with a new cough during which a computerized tomography (CT) scan of the thorax revealed a right lower lobe (RLL) nodule. A follow up scan, six (6) months later, showed multiple nodules; the largest measuring 2.1 centimeters (cm). A positron emission tomography (PET) scan/CT scan confirmed multiple enlarging, increasingly avid right upper lobe (RUL) and right middle lobe (RML) pulmonary nodules, enlarging, increasingly avid right hilar node. 

The patient underwent a right upper lobe (RUL) CT guided biopsy, which confirmed high grade neuroendocrine carcinoma, with features of small cell lung carcinoma. 

Per small-cell lung cancer (SCLC) protocol, he was started on chemotherapy with Carboplatin-Etoposide, completing three (3) total cycles.

He was due for consolidative radiation therapy (XRT), but due to his history of pulmonary fibrosis, it was shown that conventional XRT could not be effectively and safely used on this specific patient; therefore, he was sent for proton radiation therapy, during which time plans were compared between protons versus (vs) Intensity-modulated radiation therapy (IMRT), clearly showing proton therapy is superior in this treatment plan, and is the safest option.

All available medical documentation was reviewed.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes.

The risk of complications could far exceed the actual radiation therapy treatment for this patient with protons, which have proven to allow for greater control of radiation dose and location of dose falloff, along with decreased lung doses and toxicity. As such, it would be wise to make any attempt to decrease normal tissue doses as much as possible, and proton therapy in this setting would be the best to achieve such a feat while still achieving the main goal of delivering a curative dose to the patient's cancer.     

The patient is a good candidate for 77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex.     

77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex is the best available treatment for this patient at this time.     

The adverse risks are not increased over standard treatment/services.

The risks are decreased with this radiation modality, and although Protons are mostly reserved for pediatric malignancies and/or central nervous system (CNS) tumors, it does become very valuable in such settings as in this patient, where the surrounding normal tissue is already sacrificed and will need to meet lower dose tolerances for best post-treatment  results and survivorship.     

Proton therapy is more likely to be more beneficial than other radiation therapy modality. This patient requires radiation for this cancer, as it is sensitive to radiation and proves to give better results than not receiving consolidate radiation therapy. To effectively deliver the radiation dose while minimizing surrounding normal tissue damage, I agree proton therapy would be the preferred modality here.

In summary, the denial of 77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.