Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT) for treatment of a T12 
metastatic lesion. 
 
You asked the Plan to pre-approve the requested SBRT. You say that this SBRT would be optimal treatment 
due to excellent performance status. The Plan denied your request. The Plan says that this is not covered for 
metastatic prostate cancer. This treatment is only allowed for low to intermediate risk prostate cancer. 
 
The Plan follows Medicare rules. Medicare rules say that SBRT for treatment of metastatic spinal lesions is 
considered reasonable and necessary for enrollees with high performance status. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested SBRT. Our reviewer says 
that the requested treatment is considered medically reasonable and necessary based on LCD guidelines. Our 
physician reviewer found oligometastases are defined as a state of metastatic disease with metastases few in 
number and extent.  This patient, with a solitary metastasis of the retroperitoneal region would be considered to 
have an oligometastasis. The rationale for treating oligometastases with local therapy (i.e. radiation or surgery) 
is to prolong disease control, and potentially prolong life, as well as quality of life by improved cancer control. 
Single and multi-institutional studies have reported prolonged disease-free survival after SBRT, with ~20-30% 
of patients surviving many years.  
 
The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy, reflecting 
national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is medically 
necessary when the patients performance status justifies aggressive treatment, and for those whose tumor 
burden can be completely targeted with acceptable risks.  
 
This patient has a single lesion of the T12 spine, detected on Axumin PET imaging, and with rising PSA. He 
was offered standard 2-fraction spine SBRT. SBRT for 1-3 discrete metastases is an accepted standard of care 
as described above. The advantages of SBRT are to allow dose escalation while minimizing the volume of 
normal tissue exposed to high dose radiation. The LCD specifically indicates this treatment is indicated for 
metastatic spine lesions when performance status is high. 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested SBRT have been met. Therefore, we decided that the Plan has to 
pre-approve stereotactic body radiation therapy (SBRT) for treatment of a T12 metastatic lesion.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.