Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Grade I skull base meningioma

Treatment: Proton Beam Therapy

The insurer has denied coverage for Radiation Therapy for Primary Central Nervous System (CNS) Neoplasms (tumor) Phase 1: 30 Fractions (Treatment Sessions) of Proton Beam Therapy

The denial is overturned. 

This case involves a female who has been previously diagnosed with basal cell carcinoma, migraines, temporomandibular joint syndrome, glaucoma, and a World Health Organization grade 1 skull base meningioma. She has undergone total resection and indicated the recommendation has been made to initiate radiotherapy. Given tumor in this location in the orbit and cavernous sinus, the goal of initiating adjuvant therapy would be to prevent further growth and compression of the optic nerve, entrapment of the orbital rectus muscles and further extension into the cavernous sinus. Fractionated radiotherapy is preferred. She initially presented with left periorbital discomfort and headaches as well as increased lacrimation, blurry vision, worsening headaches, and left eye proptosis. A magnetic resonance imaging (MRI) did identify a mass centered at the lesser wing of the sphenoid bone with soft tissue in the orbit and middle cranial fossa. The documentation indicate she underwent surgical intervention and intraoperative findings did reveal a firm lobulated tumor involving the left axilla, optic canal and left lateral orbital wall. She developed episode of prolonged expressive aphasia and was placed on Keppra and Lamictal. A MRI demonstrated residual tumor extending from the superior lateral aspect of the left orbit to the optic canal into the left cavernous sinus. Given the bulk of the residual disease, the irregular shape of the tumor, the precarious location and current tumor in post-operative symptom burden, it has been recommended to utilize intensity modulated proton therapy to treat the residual tumor in postoperative bed to 54GY in 30 fractions. 

Proton radiation is generally accepted as medically necessary for the following conditions: 1) intracranial arteriovenous malformations; 2) Ocular tumors, including intraocular/uveal melanoma; or 3) Skull-based tumors.

National Comprehensive Cancer Network (NCCN) Guidelines for Central Nervous System Cancers describes appropriate post-operative radiation as intensity modulated radiation therapy photons or other conformal techniques, including proton therapy. Proton beam therapy is also to be used to treat patients with the most challenging disease. The American Society for Radiation Oncology Report indicates that 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. 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 condition. It is an appropriate level of service that can be safely provided. 

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

The carrier's denial of coverage for the Radiation Therapy for Primary Central Nervous System Neoplasms Phase 1: 30 Fractions of Proton Beam Therapy is overturned. The medical necessity is substantiated.