Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for image-guided radiation therapy (IGRT) for inverse treatment planning followed by intensity-modulated radiation therapy (IMRT).Findings:  The physician reviewer found that IMRT is frequently utilized to treat certain body sites when normal tissue dose constraints cannot be met by other radiation techniques (NCCN Guidelines). It is also utilized if patient anatomy makes it impossible to safely treat using 3D-CRT. When treating the breast, the nearby critical organs that need to be monitored are the underlying lung, heart, opposite (contralateral) breast, as well as the arm. IMRT is more commonly utilized when treating the left breast due to the very close proximity of the heart. In this patients case, however, the right breast simply cannot be adequately treated without IMRT due to the patients inability to raise her right arm.IGRT refers to the image-guidance that is typically performed with each daily IMRT treatment. Multiple beam angles are utilized when treating patients with IMRT. There are typically at least 8 to 16 different radiation fields delivered in rapid succession with varying amounts of radiation dose from each beam. It is considered standard to have IGRT given with IMRT. IGRT is an umbrella term for various types of diagnostic imaging performed during the daily treatments which allow for accurately delivery the IMRT treatment. In fact, it would be unsafe to try to treat a patient with IMRT without proper IGRT guidance, as the risk of normal tissue toxicity has been found to be much higher when IGRT is not used. The risks of adjacent tissues exceeding the accepted dose constraints is well documented. Aside from the risk of grade 1 to 3 toxicities, there is also an increased risk of a new radiation-induced secondary cancer. In the case of healthy tissue receiving excess radiation dose there is strong evidence of increased cancer risk to that healthy tissue (Ramin, C., et al.; and Abo-Madyan, Y., et al.). There are also practical treatment setup considerations that need to be taken into account. Standard 3D-CRT can only treat the breast by aiming two lateral beams into the chest wall. This assumes that the patient is able to raise both arms far above her head and out of the way of the oncoming beams. Since this patient is unable to raise her right arm above her head, 3D-CRT cannot accurately target the right breast. As shown in the treatment planning images for this case, a standard radiation technique cannot avoid shooting through the right arm. IMRT technique with IGRT has the unique ability to adequately target the right breast while avoiding adjacent structures, including the right arm .In this case, this patients anatomy makes it impossible to properly target the right breast without irradiating the right arm. She is physically unable to raise her arm above her head. Under these circumstances, the requested image-guided radiation therapy (IGRT) for inverse treatment planning followed by intensity-modulated radiation therapy (IMRT) is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.