Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastrointestinal Stromal Tumor (GIST)

Treatment: Stereotactic body radiotherapy (SBRT)

The insurer denied coverage for stereotactic body radiotherapy (SBRT).

The denial is overturned.

This patient has the medical diagnosis of gastrointestinal stromal tumor (GIST). The treating provider is requesting plan approval for treatment with coverage for stereotactic body radiotherapy (SBRT).

According to the clinical documentation provided for review, the treating provider is requesting plan approval for treatment with coverage for SBRT. The patient has a medical diagnosis of GIST. The patient has been seen and treated for a history of GIST. The patient is status post (s/p) multiple surgeries including liver resection and multiple systemic therapies. 

"Stereotactic body radiotherapy (SBRT) is a focused tumour treatment that produces high local control rates with low toxicity. Its use in metastatic cancer is evolving rapidly, with purported benefits in the oligometastatic setting and for better palliation of symptomatic disease. Another potential indication for SBRT is in the setting of oligoprogression, where there is progression of a solitary or a few tumours while all other tumours are responding or stable on a systemic therapy strategy. SBRT to the progressing 'rogue' tumours may delay the need to start or change systemic therapy. This may have clinical benefits including improved progression- free/overall survival and quality of life for patients. This review will summarize the limited published data. More prospective clinical trials are urgently needed to better identify and quantify the potential clinical benefits." (Cheung, 2016).

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

SBRT is a technique of delivering highly conformal radiation treatment to the target with sparing of adjacent normal tissues. It enables delivery of high dose RT (radiation therapy) in a few fractions. Published evidence has demonstrated its efficacy and safety for treatment of solitary/oligometastatic lesions in extra-cranial sites, such as in the liver and lung. Multiple peer-reviewed publications including ones from prospective trials have reported on high response rates of hepatic metastasis after SBRT with acceptable toxicities in selected patients with limited metastatic disease in the liver.

SBRT does not need final approval from the appropriate regulatory bodies for this diagnosis. It is not a subject of FDA (Food and Drug Administration) approval.

This patient is a good candidate for stereotactic body radiotherapy (SBRT).

There is no other radiation therapy technique that can delivery highly conformal radiation dose to tumor with sparing of normal tissues, as SBRT can achieve.

The adverse risks are not increased over standard treatment and/or service; the requested treatment is safer.

Standard treatment for this patient's condition will deliver higher dose to small bowel and kidney such that the risk of radiation complication to theses organs would be substantially higher than SBRT.

The requested service is likely to be more beneficial than any of the standard treatments and/or procedures for this patient.

The carrier's denial of stereotactic body radiotherapy (SBRT) is overturned.