Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mucoepidermoid carcinoma.

Treatment: image-guided radiation therapy and proton beam radiation therapy.

The insurer denied coverage for image-guided radiation therapy and proton beam radiation therapy.

The denial is overturned.

This is a female patient who has been diagnosed with stage III T3N0 mucoepidermoid carcinoma of the left parotid gland that has been previously resected with a positive resection margin, perineural invasion, and 2+ lymph nodes. The submitted documentation states that this patient has been advised to have postoperative adjuvant radiation therapy to the parotid bed and ipsilateral lymph nodes in view of her findings.  The patient has been further advised to receive proton beam radiation in preference to conventional proton radiation using intensity-modulated radiation therapy (IMRT) techniques. The submitted documentation indicated that the patient initially presented with a parotid mass. After undergoing multiple tests, IMRT treatment was recommended. 

Based on the review of the medical record, this patient should be considered for radiation treatment, including proton beam radiation therapy (PBRT). The patient's treating physician is considering the delivery of a definitive dose to the tumor, which is located near the base of the patient's skull and other critical structures. As per the literature review, proton radiation is generally accepted as medically necessary for the following conditions: intracranial arteriovenous malformations (AVMs); ocular tumors, including intraocular/uveal melanoma (includes the iris, ciliary body, and choroid); or skull-based tumors (e.g., chordomas or chondrosarcomas). All other clinical situations are generally either medically unnecessary or investigational. Based on the clinical information provided, and the National Comprehensive Cancer Network (NCCN) and American Society for Radiation Oncology (ASTRO) guidelines, proton beam therapy for this patient with a tumor in the parotid/salivary gland head and neck region with an indication for postoperative radiation treatment of her current disease can be approved by the health plan.

The patient has left parotid cancer and is to be evaluated for postoperative treatment with proton radiation. Treatment to the tumor bed and surrounding tissues at risk postoperatively is reasonable to provide local control, and potentially impacts overall survival. The delivery of a postoperative dose is also reasonable. A plan with an image guidance technique is appropriate. Given the patient's anatomy, motion correction will be critical to limit the dose to these organs. As per ASTRO and NCCN guidelines, 3-D (and IMRT, if appropriate) with image-guided radiation therapy (IGRT) to establish accurate target positioning and treatment is a reasonable and accepted practice.  Without some type of image guidance, the risk of normal tissue damage is extremely high. There are available IGRT options that are approved for use for this patient. As per ASTRO and NCCN Guidelines, the service of IGRT would be appropriate and consistent with a diagnosis of a Head and Neck cancer. Guidance for localization of target volume for delivery of radiation treatment is, thus, medically necessary and can be approved in this clinical situation.

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 IGRT and PBRT should be overturned. The medical necessity is substantiated.