Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malignant neoplasm of cerebral meninges
Treatment: Special type of radiation procedure (proton beam radiation therapy)
The insurer denied coverage for a special type of radiation procedure (proton beam radiation therapy).
The denial is overturned.

This case involves an adult female seeking authorization for proton beam radiation therapy for treatment of secondary malignant neoplasm of cerebral meninges. The patient presented for an evaluation related to leptomeningeal metastases from metastatic breast cancer. Per the patient's history, she was found to have left breast cancer and underwent bilateral mastectomy with implant reconstruction. She did not receive adjuvant therapy. She was ultimately found to have metastatic disease to the lungs and ribs.  Biopsy of the lung revealed metastatic breast cancer. She has been receiving Taxol chemotherapy. She developed respiratory difficulty and was found to have a pericardial effusion. A pericardial window had to be performed. She had bilateral pleural effusions and bilateral pulmonary emboli. She then developed sciatic type right thigh discomfort. A Computed tomography (CT) scan showed multiple brain metastasis.  She was stabilized with dexamethasone and was taking Keppra. Lumbar puncture showed 31 circulating tumor cells in the cerebrospinal fluid. She presented to discuss proton therapy. Proton therapy would allow for delivery of radiation to the brain and spine while reducing the radiation to the anterior thoracic and abdominal structures which could reduce toxicity.  

The patient had brain metastasis and leptomeningeal disease with cerebrospinal fluid positive circulating tumor cells. The patient had malignant and benign primary central nervous system tumors. It was the treatment of choice for local control and minimizing toxicity for patient's tumors based on location and proximity to many critical organs. The proton therapy provided a two-fold decrease in secondary intracranial tumor incidents compared to conventional intensity modulated radiation therapy.  

Per Grosshans (2020), primary and metastatic brain tumors, radiation therapy remains one of the standard treatment modalities. The National Comprehensive Cancer Network states that proton therapy may be considered for glioma for patients with good long-term prognosis to better spare uninvolved brain and preserve cognitive function. To reduce toxicity from craniospinal irritation in adults, consideration should be given to proton therapy in patients with positive cerebrospinal fluid or known metastatic disease. 

In this case, the patient has metastatic breast cancer with brain metastasis and likely leptomeningeal disease. Proton therapy was recommended as it would allow delivery of radiation to the brain and spine while reducing the radiation which could reduce toxicity. Photon comparative estimation violated QUANTEC (Quantitative Analyses of Normal Tissue Effects in the Clinic) dose limits to the patient's hippocampus, brain, kidneys, lungs, and heart. The proton therapy provided a two-fold decrease in secondary intracranial tumor incidents compared to conventional intensity modulated radiation therapy. Given that the updated documentation indicated that the photon comparative estimation violated QUANTEC dose limits to multiple organs, the documentation supports that the intensity modulated radiation therapy or stereotactic would potentially damage critical structures when compared to the requested proton therapy.  

Based on the above, the insurer's denial must be overturned. The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. The medical necessity for a special type of radiation procedure (proton beam radiation therapy) is substantiated.