Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left tonsil carcinoma

Treatment: The guidance for localization of target delivery of radiation treatment delivery; proton treatment delivery, simple, CPT codes 77387 and 77520

The insurer denied coverage for the guidance for localization of target delivery of radiation treatment delivery; proton treatment delivery, simple, CPT codes 77387 and 77520.

The denial is overturned.

This is a male patient who has been diagnosed with left tonsil carcinoma. The patient is to be considered for radiation treatment, including proton beam radiation therapy (PBRT). Proton radiation, per the American Society for Therapeutic Radiology and Oncology (ASTRO) Model Policy 2017, is generally accepted as medically necessary for group 1 tumors, including advanced or unresectable head and neck tumors. The National Comprehensive Cancer Network (NCCN) Guidelines version 2.2020 for Head & Neck Malignancies describes that appropriate postoperative radiation is 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 primary tumors are periocular in location and/or invade the orbit, skull base and/or cavernous sinus; extend intracranial weight or exhibit extensive perineural invasion; and who are being treated with curative intent and or will have long life expectancies following treatment. Proton beam therapy is also to be used to treat patients with the most challenging disease, for which other radiation therapy options are not felt to be safe or of any benefit. The guidelines further indicate that there are a few randomized and single institution reports and systemic comparisons demonstrating safety and efficacy of proton beam therapy in the above-mentioned specific clinical scenarios. 

In this case, this patient falls into the category described above. The patient has disease, located in a specific anatomical area such as base of skull, spinal cord or previously treated regions that require extremely specific and conformal dosing. The ASTRO Report on Emerging Technologies indicates the proton beam therapy for head and neck tumors while not necessarily a standard of care currently may be considered in appropriate situations. The 2014, June update indicates that for sites other than those listed above, 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, while proton therapy may not be 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 proton plan meets all the criteria listed from the ASTRO report and per the NCCN guidelines that it can be used over photon therapy in this situation.

The proton beam therapy is considered medically necessary for this patient with a tumor in the left tonsil/head and neck region with an indication for combination chemotherapy and radiation treatment of his current disease.

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 guidance for localization of target delivery of radiation treatment delivery; proton treatment delivery, simple, CPT codes 77387 and 77520 should be overturned. The medical necessity is substantiated.