Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Head and neck cancer

Treatment: Radiation Therapy (RT) for Head/Neck Cancer

The insurer denied coverage for Radiation Therapy (RT) for Head/Neck Cancer. The denial is reversed. 

This patient is a male with head and neck cancer who has been recommended to receive proton radiotherapy treatment.  The patient's cancer was characterized as T1N2BM0 L BOT SCC p16+, and the patient was status post carboplatin/5-fluorouracil treatment with concurrent radiotherapy with biopsy-proven recurrence of left neck. The patient received left neck dissection for this recurrence, and during this procedure, the patient was found to have 3/34 involved nodes. For this, the patient was recommended to undergo chemoradiation with proton therapy in the reirradiation setting.  As per progress note, the patient was seen and was recovering from treatments.  The patient indicated at this visit that he was doing well and denied pain.  It was recommended at this visit that the patient sign a consent form for radiation therapy.  The outcome was discussed with the patient.

Based on the review of the medical record, the patient has recurrent squamous cell carcinoma of the head and neck region, and he was considered for additional radiation treatment, including Proton Beam Radiotherapy (PBRT).  Proton beam therapy is also to be used to treat patients with the most challenging disease, for which other RT options are not felt to be safe or of any benefit. The guidelines further indicate that there are a few randomized and single institution reports and systemic comparisons demonstrating safety and efficacy of proton beam therapy in the above-mentioned specific clinical scenarios.

In this case, the patient falls into the category described above. The patient had recurrent disease, had been previously treated and had specific anatomical areas such as the base of the skull, spinal cord previously treated regions that required very specific in conformal dosing. The records also reflected a comparison of photons versus protons planning where proton planning can meet the constraints appropriately whereas the photon therapy will essentially fail to meet these constraints.

The ASTRO Report on Emerging Technologies indicates that the proton beam therapy for head and neck tumors while not necessarily a standard of care currently may be considered in certain situations. Regarding medical necessity, while proton therapy may not be a standard of medical practice it may be safe and effective and may be considered more effective than standard photon therapy for this patient's condition. Proton therapy can avoid dose to normal tissue while delivering adequate dose to disease safely. Thus, the proton plan is considered the appropriate level of service that could be safely provided to this patient.  For these reasons, included from the clinical information provided, the NCCN and ASTRO guidelines, proton beam therapy is considered medically necessary for this patient for treatment of his recurrent tumor in the head and neck region.  

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

The carrier's denial of coverage for Radiation Therapy (RT) for Head/Neck Cancer is reversed. The medical necessity is substantiated.