Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Anaplastic oligodendroglioma.
Treatment:  Proton beam radiation therapy.

The insurer denied coverage for proton beam radiation therapy.  The denial is upheld. 

This is a female patient, who has been recently diagnosed with anaplastic oligodendroglioma.  The recommendation has been made for the patient to undergo proton beam radiation therapy. 

As per medical literature, proton radiation is generally accepted as medically necessary for the following conditions: (1) intracranial arteriovenous malformations; (2) Ocular tumors, including intraocular/uveal melanoma (includes the iris, ciliary body and choroid); or (3) Skull-based tumors (e.g., chordomas or chondrosarcomas).  The National Comprehensive Cancer Network (NCCN) Guidelines for Central Nervous System (CNS) Cancers describes appropriate postoperative radiation as intensity-modulated radiation therapy 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 who have primary tumors with good long-term prognosis to better spare un-involved brain and preserve cognitive function.  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.  In this case, this patient has the potential to fit into the category described above.  The patient has good prognostic features with the potential for long-term survival and has specific anatomical areas such as hippocampus, eyes, retina, cochlea, and temporal lobes that require specific conformal dosing for them to be spared.  The records also reflect a comparison of photons versus protons planning where proton planning can meet the constraints appropriately.  However, the treating physician does not show that photon therapy will essentially fail to meet these constraints.

The American Society for Therapeutic Radiology and Oncology (ASTRO) Report on Emerging Technologies indicates the 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, including for malignant primary CNS tumors.  An update of that report indicates that for sites other than those listed above, excluding group 1 category, 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.  In this case, the records do indicate an improvement of proton therapy over photon therapy.  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 patient's condition.  The patient's treating physician has indicated that for a photon plan, they are concerned with tolerances of multiple structures, including the brainstem, cochlea, hippocampus, and temporal lobes.  They provide evidence that the proton plan can reduce the dose to the within acceptable limits, better than the photon plan.  This will reduce short term toxicity and reduce significant long-term side effects.  However, the records are provided that also show that photons can meet normal tissue tolerances adequately and safely.  The proton plan is not necessarily the best modality that will allow this patient to be safely treated.  Photon therapy is an appropriate level of service that can be safely provided.   

Proton beam therapy is not medically necessary for this patient.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for radiation therapy (proton beam radiation therapy) for primary CNS neoplasms (tumors) should be upheld.