Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Breast cancer.

Treatment: 77523 x 28, proton treatment delivery; intermediate, 77520 x 28, proton treatment delivery; simple without compensation, 77525 x 28, proton treatment delivery; complex.

The insurer denied 77523 x 28, proton treatment delivery; intermediate, 77520 x 28, proton treatment delivery; simple without compensation, 77525 x 28, proton treatment delivery; complex.

The denial is overturned.

This case involves a female diagnosed with Estrogen Receptor/ Progesterone Receptor/ Human Epidermal Growth Factor Receptor 2 (ER/PR/HER2+) invasive carcinoma of the right breast. She was status post double mastectomy with tissue expander (TE) placement and right Sentinel lymph node biopsy (SLNB). The pathology report noted invasive micropapillary carcinoma, moderately differentiated, and 3 foci. Lymphovascular invasion (LVI) was also noted with invasive carcinoma noted to be less than or equal to 1 millimeter (mm) from anterior margin. At least 1 of 8 lymph nodes were noted to have invasive carcinoma spanning 9 mm with less than 2 mm extracapsular extension (ECE). The patient's Oncotype was 24 and adjuvant endocrine therapy was recommended. The physician noted the patient would require a right comprehensive regional nodal irradiation to the chest wall and lymph nodes including the internal mammary chain. 

The National Comprehensive Cancer Network (NCCN) guidelines state that radiation therapy (RT) uses high-energy radiation from x-rays, photons, protons, electrons, and other sources to kill cancer cells and shrink tumors. It is given over a certain period of time. Radiation therapy can be given alone or before/after surgery to treat or slow the growth of cancer. Sometimes, radiation is given with certain systemic therapies. It may be used supportive care to help ease pain or discomfort caused by cancer. The guidelines note that radiation therapy is not the main treatment for metastatic disease. 

Current medical literature has noted that adjuvant radiotherapy for breast cancer has been associated with an increased risk of ischemic heart disease with this treatment increasing the risk of coronary artery disease. Proton therapy reduces the dose to nontarget structures while optimizing target coverage. 

The treating physician stated that the patient's breast cancer is listed by the American Society for Radiation Oncology (ASTRO) as a category 2 indication for proton beam therapy treatment and is, therefore, suitable for coverage. The physician went on to state that there is long-term clinical data using proton-based treatments published from respected institutions demonstrating excellent cosmesis and local control. Because the patient's disease is along the chest wall and conventional radiation therapy is indicative of grade 3 and 4 toxicities to the heart and lungs, proton beam therapy would be more appropriate. Furthermore, proton beam therapy (PBT) has been shown to have a lower side effect profile. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. The requested proton treatment delivery, codes 77523 x 28, 77520 x 28, 77525 x 28 do have final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for the requested proton treatment delivery codes. The treatment is the best available treatment for this patient at this time. The adverse risks are not increased over standard treatment/service.

In summary, the denial of 77523 x 28, proton treatment delivery; intermediate, 77520 x 28, proton treatment delivery; simple without compensation, 77525 x 28, proton treatment delivery; complex and coverage for this 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.