Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Stage IV Squamous Cell Lung Cancer

Treatment: Proton Beam radiotherapy and associated services: 77520 - Proton treatment delivery; simple, without compensation; 77523 - Proton treatment delivery; intermediate; 77525 - Proton treatment delivery; complex and coverage for the requested treatment

The insurer denied coverage for Proton Beam radiotherapy and associated services: 77520 - Proton treatment delivery; simple, without compensation; 77523 - Proton treatment delivery; intermediate; 77525 - Proton treatment delivery; complex and coverage for the requested treatment.

The denial is overturned. 

This is a patient who has been diagnosed with oligoprogressive stage four (IV) lung cancer. The patient has previously completed palliative radiotherapy 2 years ago. The patient now presents with progressive disease in the left thorax, for which the patient has been recommended to proceed with re-irradiation with palliative intent. Request is for approval of Proton Beam radiotherapy and associated services: 77520 - Proton treatment delivery; simple, without compensation; and 77523 - Proton treatment delivery; intermediate; 77525 - Proton treatment delivery; complex, which is under review.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.  

The treating provider supplied a proton/photon plan comparison, which supports an improved outcome; in light of the prior radiation, photon radiation is unable to provide adequate safety/precision. The photon radiation plan results in excessive and potentially dangerous exposure to the patient's brachial plexus, esophagus, and spinal cord. The proton radiation plan is able to significantly minimize the patient's risk for serious complications.

Proton Beam radiotherapy and associated services: 77520 - Proton treatment delivery; simple, without compensation; 77523 - Proton treatment delivery; intermediate; 77525 - Proton treatment delivery; complex does have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is a good candidate for Proton Beam radiotherapy and associated services: 77520 - Proton treatment delivery; simple, without compensation; 77523 - Proton treatment delivery; intermediate; 77525 - Proton treatment delivery; complex.  

Proton radiation is standard of care and widely utilized for re-irradiation in similar situations where it is shown that photon radiation planning is unable to meet nationally accepted treatment planning objectives and would result in excessive and potentially dangerous exposure to the patient.     

Proton Beam radiotherapy and associated services: 77520 - Proton treatment delivery; simple, without compensation; 77523 - Proton treatment delivery; intermediate; 77525 - Proton treatment delivery; complex is the best available treatment for this patient at this time.

The adverse risks are not increased over standard treatment/services. The adverse risks will be decreased with proton radiation.     

The proton radiation plan will significantly minimize the risk of serious complications to the patient's brachial plexus, esophagus, and spinal cord and should be approved.                                                    

In summary, the denial of Proton Beam radiotherapy and associated services: 77520 - Proton treatment delivery; simple, without compensation; 77523 - Proton treatment delivery; intermediate; 77525 - Proton treatment delivery; complex and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.