Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate Cancer
Treatment: Phase II: 11 Fractional (treatment sessions) of Intensity Modulated Radiation Therapy (IMRT) 
Phase III: 1 Fractional (treatment sessions) of Intensity Modulated Radiation Therapy (IMRT)
The insurer denied the Phase II: 11 Fractional (treatment sessions) of Intensity Modulated Radiation Therapy (IMRT) 
Phase III: 1 Fractional (treatment sessions) of Intensity Modulated Radiation Therapy (IMRT)
The denial is overturned.

The patient is a male with a diagnosis of high-risk prostate cancer, stage T1cN0, Gleason score 4+3=7, and prostate specific antigen (PSA) of 31.56. Definitive radiation therapy was recommended and intensity modulated radiation therapy for 12 fractions (phase II of 11 fractions and phase III of 1 fraction) was requested. 

The health plan approved only 28 fractions, and the appeal is for the additional 12 fractions of IMRT initially planned/requested.

Yes, the proposed treatment is medically necessary.
There are several peer-review literatures that showed that intensity modulate radiation therapy (IMRT) is as effective, and safer compared to conventional conformal radiation therapy for the treatment of prostate cancer.  

In a study from Memorial Sloan-Kettering Cancer Center, a comparison was made for 1,100 patients with prostate cancer treated with three-dimensional (3-D) conformal or intensity modulated radiation therapy (IMRT).  The authors concluded that "treatment with IMRT (intensity modulated radiation therapy) significantly decreased the incidence of late grade-2 rectal toxicity," and concluded that "IMRT (intensity modulated radiation therapy) is associated with minimal rectal and bladder toxicity, and, hence, represents the treatment delivery approach with the most favorable risk-to-benefit ratio."  

Another study from Washington University School of Medicine evaluated 763 patients with prostate cancer treated with intensity modulated radiation therapy (IMRT) versus three-dimensional (3-D).  The authors concluded that "Intensity modulated RT (radiation therapy) is associated with a significant reduction in acute G2 (grade two moderate toxicity) + GI (gastrointestinal) / GU (genitourinary) toxicity. There is a trend for a clinically meaningful reduction in late G2 (grade two moderate toxicity + GI (gastrointestinal) toxicity with IMRT (intensity modulated radiation therapy)".  

In terms of the radiation fractionation for prostate cancer, the National Comprehensive Cancer Network (NCCN) guideline supports the use of either hypofractionation or standard fractionation for high-risk prostate cancer.  The recommended dose regimen is up to 28 fractions for hypofractionation regimen and 37-45 fractions for standard fractionation regimen.  According to RTOG 0415 randomized trial comparing different fractionation schedules, there is no difference in efficacy in the different fractionation regimens, however, there is increased late gastrointestinal (GI) and genitourinary (GU) effects with the hypofractionated regimen.  The requested 40 fractions (standard fractionation) of intensity modulated radiation therapy (IMRT), therefore, is medically necessary.