Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: Proton Radiation Therapy. 

The insurer denied the Proton Radiation Therapy. 
The denial is upheld. 

The patient is a male with a diagnosis of Gleason score 7 prostate cancer.  Definitive radiation therapy was recommended and proton therapy was requested. 

The request was previously denied because it was considered not medically necessary. 

No, the proposed treatment was not medically necessary. 

Proton beam radiation therapy is not considered medically necessary due to availability of other standard available treatment modalities.  Proton therapy also has not been shown to be clinically superior in well-conducted randomized trials. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient. 

There is emerging data showing that proton beam radiation therapy is safe and effective for the treatment of prostate cancer.  However, there is insufficient clinical peer-reviewed literature that showed that proton therapy is safer or more effective than the standard therapies, which include intensity modulated radiation therapy (IMRT), prostate brachytherapy, surgery or combined modality.  Several studies have concluded that additional studies are necessary with proton beam radiation therapy for the treatment of prostate cancer. 

In a study, Mayahara and associates (1) evaluated 287 patients with prostate cancer treated with proton beam radiation therapy.  They concluded that "additional follow-up is warranted to elucidate the long-term safety and efficacy of proton therapy for prostate cancer". 

Another study by Zietman et. al. (2) investigated 393 patients with prostate cancer treated with a combination of photon and proton beam radiation therapy and concluded that "while the trial validates the use of proton-beam therapy, it did not test whether this modality is more or less efficacious than other more commonly available conformal techniques, brachytherapy or surgery". 

Another systematic review by Allen et al. (10) concluded that there is evidence for the efficacy of proton beam therapy for treating prostate cancer but no suggestion that it is superior to photon based approaches.  

A more recent study from University of Florida evaluated 1327 men with prostate cancer treated with proton therapy.  The five-year freedom from biochemical progression rates were 99%, 94%, and 74% in low-risk, intermediate-risk, and high-risk patients, respectively. The authors concluded that "Image guided PT (proton therapy) provided excellent biochemical control rates for patients with localized prostate cancer", but "Prospective clinical studies are needed to determine the comparative effectiveness of PT (proton therapy) and other radiation treatment strategies". 

In addition, the American Society for Radiation Oncology (ASTRO) states that "While proton beam therapy is not a new technology, its use in the treatment of prostate cancer is evolving.  ASTRO strongly supports allowing for coverage with evidence development for patients treated on clinical trials or within prospective registries". However, it also concludes that "The comparative efficacy evidence of proton beam therapy is still being developed". 

The National Comprehensive Cancer Network (NCCN) guidelines also state that proton therapy is an option for prostate cancer, but no clear benefit over the existing therapy of intensity-modulated radiation therapy has been demonstrated. 

In this case, there was no proton/intensity modulated radiation therapy (IMRT) comparison plan provided showing that the intensity modulated radiation therapy (IMRT) plan was inadequate in sparing the surrounding critical structures.  Intensity modulated radiation therapy (IMRT) with photon therapy is the standard of care for patients with prostate cancer that wish to undergo external beam radiation therapy.  Proton beam radiation therapy is not considered medically necessary due to availability of other available treatment modalities and non-superiority of proton beam radiation therapy compared to other standard options.