Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Tonsil cancer

Treatment: Proton Beam Radiation Therapy (PBT)

The insurer denied coverage for Proton Beam Radiation Therapy (PBT)

The denial is overturned

The patient has been diagnosed with a history of oropharyngeal cancer. The patient has been recommended to proceed with radiotherapy with curative intent. The treating provider is requesting therapy with Proton beam radiation therapy (PBT); codes 77520, 77523 and 77525, which is under review.

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

As per the National Comprehensive Cancer Network (NCCN), "Either Intensity Modulated Radiation Therapy (IMRT) (preferred) or 3D-Conformal Radiation Therapy (CRT) is recommended for cancers of the oropharynx in order to minimize dose to critical structures. Use of proton therapy is an area of active investigation. Proton therapy may be considered when normal tissue constraints cannot be met by photon-based therapy."

In this patient dose comparison of photon vs proton supports the use of proton beam in this patient. 

Per Kim, J. K., et al., (2018), "The application of proton beam radiation therapy in the treatment of head and neck cancer has grown tremendously in the past few years. Globally, widespread interest in proton beam therapy has led to multiple research efforts regarding its therapeutic value and cost-effectiveness. The current standard of care using modern photon radiation technology has demonstrated excellent treatment outcomes, yet there are some situations where disease control remains suboptimal with the potential for detrimental acute and chronic toxicities. Due to the advantageous physical properties of the proton beam, proton beam therapy may be superior to photon therapy in some patient subsets for both disease control and patient quality of life. As enthusiasm and excitement for proton beam therapy continue to increase, clinical research and widespread adoption will elucidate the true value of proton beam therapy and give a greater understanding of the full risks and benefits of proton therapy in head and neck cancer."      

Per Kim et al 2022 in a comparison of head and neck cancers treated with IMRT or proton therapy found that "Proton therapy was associated with significantly reduced grade 2 dysgeusia and nonstatistically significant decrease in acute grade >=3 toxicities compared to IMRT."

Proton beam radiation therapy (PBT); codes 77520, 77523 and 77525 does have final approval from the appropriate regulatory bodies for this diagnosis.  

Proton radiation is Food and Drug (FDA) approved for management of solid tumor malignancies in general.     

This patient is a good candidate for proton beam radiation therapy (PBT); codes 77520, 77523 and 77525.

The adverse risks are not increased over standard treatment/services. 

In summary, the denial of proton beam radiation therapy (PBT); codes 77520, 77523 and 77525 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 risks are not substantially increased over standard treatments.