Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brain Metastases.
Treatment: Image-Guided Radiation Therapy.
The insurer denied: Image-Guided Radiation Therapy.
The denial is upheld.

This patient is an adult female with limited stage small cell cancer in the right lung status post definitive chemoradiation treatment, completed last year. Positron emission tomography 
(PET) scan from 8 months ago showed progression in the right supraclavicular, mediastinal and retroperitoneal nodes and multiple skeletons including the thoracic (T) spine. Magnetic 
resonance image (MRI) of the brain recently showed multiple metastasis. Palliative three-dimensional (3-D) radiation therapy (RT) of 30 gray (Gy) on 10 fractions to the whole brain is planned with daily image-guided radiation therapy (IGRT). This is a review of daily image-guided radiation therapy (IGRT) for palliative three-dimensional radiation therapy of 30 gray on 10 fractions to the whole brain.

The proposed treatment is not medically necessary.

Image-guided radiation therapy (IGRT) is a procedure that refines the delivery of therapeutic radiation by applying image-based target re-localization to allow proper patient repositioning for the purpose of ensuring accurate treatment and minimizing the volume of normal tissue exposed to ionizing radiation. With proper applications of image-guided radiation therapy, the treatment will be delivered precisely and accurately according to the treatment plan approved by the radiation oncologist. The standard treatment technique of palliative radiation therapy to the whole brain for multiple metastatic lesions is three-dimensional radiation therapy with weekly post films. The American Society for Radiation Oncology's (ASTRO's) image-guided radiation therapy coding and physician supervision guidelines (2013) states that image-guided radiation therapy allows radiation oncologists to ensure that the target volume is treated with the planned dose of radiation. Whenever a target volume is located near or within critical structures and/or in tissue with inherent setup variation, image-guided radiation therapy may be indicated to further the therapeutic ratio. Such situations include where: 
1) The target volume is in close proximity to a critical organ at risk; 
2) The volume of interest must be covered with narrow margins to adequately protect immediately adjacent structures; 
3) Previous radiation has been delivered adjacent to the target volume and high precision is required to avoid overlapping; 
4) Dose escalation is required above and beyond that which is commonly used for the same tumors with conventional fractionation; 
5) The clinical target volume is expected to vary in its location within the patient beyond what would be appropriately covered with a standard planning target volume. 
Medical documents do not specify any critical organs in close proximity to target that requires narrow margins to adequately protect immediately adjacent structures. This patient had no 
previous radiation therapy to adjacent area to the whole brain and no dose escalation is planned. Target volume of whole brain does not vary in its location within the patient beyond what would be appropriately covered with a standard planning target volume. Therefore, image-guided radiation therapy for palliative radiation therapy to the whole brain in this case does not meet any of the above criteria.