Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stage I metastatic breast cancer.

Treatment: Stereotactic body radiotherapy (SBRT).

The insurer denied coverage for: Stereotactic body radiotherapy (SBRT).

This case involves an adult patient diagnosed with stage I metastatic breast cancer who was status post bilateral modified radical mastectomy. Magnetic Resonance Imaging (MRI) of the right shoulder showed a low-grade intrasubstance tear at the junction of the infraspinatus and supraspinatus tendon with possible adhesive capsulitis in the appropriate clinical setting. The patient had multiple osseous lesions consistent with a history of multiple myeloma but no extraosseous soft tissue or pathologic fracture. The patient had refused hormonal treatment and presented for evaluation of bone metastases and was found to have Immunoglobulin G (IgG) kappa multiple myeloma. The patient was on induction carfilzomib and lenalidomide plus dexamethasone (KRd). The patient had been recommended to have a surgical fixation of the right humerus given her high risk for fracture. The report indicated the patient was being recommended for Stereotactic body radiation therapy (SBRT) the following day to treat pain in the right upper extremity. The patient underwent surgical fixation. The patient was seen following surgery. The patient was recovering well, with prior pain slowly improving. The patient stopped taking oxycodone and was not in a lot of pain when having radiation but was unsure if this had improved the pain. X-rays of the right humerus noted the clinical statement was multiple myeloma with unchanged lytic myeloma manifestations in the proximal humerus. The humeral rod and fixation screws were intact with material unchanged in position. The patient had decreased postsurgical swelling. The patient was recommended SBRT to treat the upper extremity for palliation of pain. The patient received a notice of adverse determination regarding the SBRT given that the patient received radiation to this area in the past. An appeal was submitted stating that the SBRT was for preoperative treatment before the patient underwent prophylactic fixation of the right humerus given her significant pain. This review pertains to the denial of coverage for stereotactic body radiotherapy.

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.

Current peer-reviewed medical literature notes that SBRT is a promising approach in treating painful bone metastases. However, the superiority of SBRT over conventional external beam radiotherapy (cEBRT) remains controversial. The information provided for the review noted that the patient received radiation therapy previously for the metastatic multiple myeloma, with use of oxycodone and then subsequent surgical fixation of the right humerus. The initial plan was for preoperative SBRT given the patient's significant pain. However, the superiority of SBRT over cEBRT for pain 
palliation in bone metastases has not been proven. cEBRT remains the standard of care for the palliative management of painful bone metastases. Given these findings, the requested service cannot be authorized. As such, SBRT was not medically necessary.
Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for stereotactic body radiotherapy (SBRT) is not substantiated.