Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer

Treatment: Radiation Therapy for Breast Cancer

The insurer denied the Radiation Therapy for Breast Cancer. The denial was reversed. 

This is a female patient who had been diagnosed with locally advanced left breast cancer.  The patient was status post neoadjuvant chemotherapy followed by left mastectomy.  It was reported that she had residual disease in both breasts and lymph nodes after surgery. She required comprehensive left chest wall and regional lymphatic radiation to include the site close-out visit (SCV), axilla and internal mammary nodes.  A request was made for intensity modulated radiotherapy (IMRT) as it was reported that Helical Tomotherpy had a hotspot of 124.1% which was unacceptable; the patient would be at significantly increased risk for skin toxicity.  It was reported that the patient was young and there was concern that the 3D plan would place her at risk for significantly increased toxicity.  The request has been submitted for radiation therapy for the patient's breast cancer.

Radiation is indicated after lumpectomy or mastectomy for invasive and intraductal carcinoma (DCIS) of the breast to reduce recurrences and potentially improve overall survival.  The target volume will include the breast or residual skin/breast tissue, ribs and underlying chest wall. Factors that will complicate treatment planning include large chest/ breast size or separation distance, prior radiated tissue near the treatment field or prostheses near the field.  A history of cardiac disease or prior delivery of cardio-toxic chemotherapeutics will necessitate the lowest possible dose to the heart.  Large breast/chest wall separation distance can also deliver a large, possibly unacceptable dose to underlying lung with standard 3D techniques.  Studies have shown that IMRT/VMAT can deliver a more homogeneous plan than 3D.  

This patient also has left-sided disease, which may place the heart at greater potential exposure, necessitating a means to achieve the lowest possible dose to the heart.  The AP has indicated that some of these factors are present for this patient.  The AP has indicated his concerns regarding heart and lung dose and there is a 3-D comparison plan showing that the 3-D conformal plan is less effective at reducing dose then the IMRT plan.  The treatment volume encompassing the breast may be large enough that IMRT may be the modality that will deliver a homogeneous dose to the breast/chest wall target volume that a 3-D CRT plan cannot achieve.  With this 3-D versus IMRT comparison, it is possible to tell that IMRT will be able to deliver a clinically significant lower dose to the heart than a 3-D plan will. 

It is noted that for breast cancer, according to ASTRO coding guides, while IMRT is not routinely indicated in breast cancer, it may be indicated in selected cases of breast cancer where the target volume is near critical structures.  Evidence has been provided in the records to show that the 3-D plan would not be acceptable and that IMRT is inherently better than 3-D planning to maintain tolerance dose to the heart.  For these reasons IMRT/VMAT does meet guidelines for use in this situation.

The health plan did not act reasonably with sound medical judgment, in the best interest of the patient.

The carrier's denial of coverage for Radiation Therapy for Breast Cancer is reversed.  The medical necessity is substantiated.