Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent optic nerve meningioma. 
Treatment: Proton beam radiation therapy.

The insurer denied coverage for proton beam radiation therapy.  The denial is overturned. 

This is a female patient with a diagnosis of recurrent optic nerve meningioma. She is to be considered for radiation, including proton radiation. The attending physician (AP) is considering delivery of a dose to the tumor 5400 centigray units (cGy).

Proton radiation is generally accepted as medically necessary for the following conditions:  1) intracranial arteriovenous malformations (AVMs); 2) Ocular tumors, including intraocular/uveal melanoma (includes the iris, ciliary body, and choroid); or 3) Skull-based tumors. All other clinical situations are generally either medically unnecessary or investigational. National Comprehensive Cancer Network (NCCN) guidelines version 3.2020 for Central Nervous System (CNS) Cancers describes appropriate postoperative radiation as intensity-modulated radiation therapy (IMRT) photons or other conformal techniques, including proton therapy. This update indicates that for proton beam therapy achieving highly conformal dose distributions is especially important for patients whose have primary tumors with good long-term prognosis to better spare un-involved brain and preserve cognitive function. Proton beam therapy is also to be used to treat patients with the most challenging disease, for which other radiation treatment (RT) options are not felt to be safe or of any benefit.  

This patient has good prognostic features with the potential for long-term survival and has specific anatomical areas such as hippocampus, eyes, retina, cochlea, optic nerves, chiasm, and temporal lobes that requires specific conformal dosing for them to be spared. 

The American Society for Therapeutic Radiation Oncology (ASTRO) Report on Emerging Technologies indicates the proton beam therapy for central nervous system tumors is a group 1 category. For this category, medical necessity requirements have been shown to be met, including for malignant primary CNS tumors. The 2014, June update indicates that for sites other than those listed above, excluding group 1 category, there is a continued need for clinical evidence development and comparative effective analysis for appropriate use of proton beam therapy for these various disease sites. The records do indicate an improvement of proton therapy over photon therapy. Regarding medical necessity, proton therapy for group 1 tumors may be considered a standard of medical practice. It may be safe and effective and may be considered more effective than standard photon therapy for this patient's condition. 

The AP has indicated that for a photon plan they are concerned with tolerances of multiple structures. They provide evidence that the proton plan can reduce the dose to the within acceptable limits, better than the photon plan. This will reduce short term toxicity and reduce significant long-term side effects. Records are provided which show that protons can meet normal tissue tolerances adequately and safely where photon therapy cannot adequately and safely meet these tolerances. The proton plan is essentially the best modality that will allow this patient to be safely treated. It is an appropriate level of service that can be safely provided. The provider can also deliver the appropriate treatment in a timely manner that is appropriate for the patient's clinical situation while the IMRT plan is unable to deliver the treatment while meeting appropriate tolerances. For these reasons, included from the clinical information provided, the NCCN and ASTRO guidelines, proton beam therapy for this patient should be approved by the health plan.

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

The insurer's denial of coverage for proton beam radiation therapy is overturned. Medical necessity is substantiated.