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 is the case of a patient with a history of right breast cancer. The patient was seen in the Radiation Oncologist's office for a consultation regarding radiation therapy. The patient had a double mastectomy and is interested in proton beam therapy (PBT). 

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes.

The treating provider has compared dose-volume histogram (DVH) for proton beam and intensity-modulated radiation therapy (IMRT). This treatment will reduce cardiac and lung morbidities.

"Proton beam radiation therapy (RT) for breast cancer has low toxicity rates and similar rates of disease control compared with historical data of conventional RT. No early cardiac changes were observed, which paves the way for randomized studies to compare proton beam RT with standard RT." (Jimenez, R. B. et al. 2019)

"Proton radiotherapy confers significant dosimetric advantages in the treatment of malignancies that arise adjacent to critical radiosensitive structures. To date, these advantages have been most prominent in the treatment of pediatric and central nervous system malignancies, although emerging data support the use of protons among other anatomical sites in which radiotherapy plays an important role. With advances in the overall treatment paradigm for breast cancer, most patients with localized disease now exhibit long-term disease control and, consequently, may manifest the late toxicities of aggressive treatment. As a result, there is increasing emphasis on the mitigation of iatrogenic morbidity, with particular attention to heart and lung exposure in those receiving adjuvant radiotherapy. Indeed, recent landmark analyses have demonstrated an increase in significant cardiac events that is linked directly to low-dose radiation to the heart. Coupled with practice-changing trials that have expanded the indications for comprehensive regional nodal irradiation, there exists significant interest in employing novel technologies to mitigate cardiac dose while improving target volume coverage." (Braunstein, et al., 2018)

Proton Beam Therapy - This treatment uses protons rather than x-rays. At high energy, protons can destroy cancer cells. The protons deposit the specific dose of radiation therapy to the targeted tissue. There is very little radiation dose beyond the tumor as compared to x-rays. This limits damage to nearby healthy tissue." (Majeed, H., & Gupta, V. 2021)

The requested proton treatment delivery codes, have final approval from the appropriate regulatory bodies for this diagnosis. PBT has been approved by the Food and Drug Administration (FDA). This patient is a good candidate for the requested codes.

Proton treatment delivery codes 77523 x 28, 77520 x 28, 77525 x 28, are the best available treatment for this patient at this time.

This suggested regimen is best treatment available, as it avoids cardiac and lung morbidity. It avoids secondary malignancy in this young patient, with curable disease.     
  
There are adverse risks increased over standard treatment. There are increased risks for heart and lungs, as well as secondary malignancy.     

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 the requested 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.