Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer.
Treatment: Y90 SIRT (selective internal radiation therapy).
The insurer denied: Y90 SIRT (selective internal radiation therapy).
The denial is overturned.

The patient is an adult female with a diagnosis of stage IV neuroendocrine carcinoma with liver metastasis status post prior liver radioembolization with Y-90 (Yttrium-90) with a good response. Another course of liver therapy was recommended and Y-90 radioembolization (selective internal radiation therapy) was requested.
The requested SIRT (selective internal radiation therapy) was denied because it does not meet selected guideline for coverage, therefore was not considered medically necessary. The denial is being appealed.

The requested health service is medically necessary.

The requested SIRT (selective internal radiation therapy) is medically necessary, because it has been shown to be safe and effective for the treatment of neuroendocrine cancer with metastasis to the liver.
Radioembolization or SIRT (selective internal radiation therapy) is a non-surgical therapy that uses radioactive spheres to deliver radiation directly to tumors in the liver. There are several trials that suggest that radioembolization provides better response rates, longer time to disease progression and longer survival intervals for primary liver cancers as well as liver metastasis. Radioembolization is an FDA (United States Food and Drug Administration) approved procedure, and it is not subject to IRB (institutional review board) approval. There is sufficient peer-reviewed literature showing that it is a safe and effective treatment.
The NCCN (National Comprehensive Cancer Network) guidelines for hepatobiliary cancers suggest that radioembolization is one alternative therapy for unresectable disease or for those who decline surgery. The Society of Interventional Radiology, using level 2A evidence, feels that there is sufficient evidence to support the safety and efficacy of Y-90 (Yttrium-90) microsphere therapy, with multidisciplinary management, adequate patient selection, and meticulous angiographic technique.
In a 2008 study from Northwestern University, a total of 137 patients underwent 225 administrations of Y-90 (Yttrium-90) microspheres. Radioembolization was shown to provide biological response in 87% of the patients with liver metastasis.
Another study from Washington University showed that after radioembolization, the overall survival for colorectal carcinoma with liver metastasis was 357 days versus 638 days for other primaries. The authors concluded that radioembolization produced promising survival rates with minimal toxicity, compared with systemic salvage options, for both colorectal primary and non-colorectal primaries. 
A 2009 meta-analysis from University Medical Center Utrecht for patients with primary and metastatic liver lesions treated with radioembolization was conducted. The authors concluded that for hepatocellular carcinoma (HCC), response was 89% for resin microspheres and 78% for glass microspheres.
The patient is an adult female with a diagnosis of neuroendocrine carcinoma with liver metastasis status-post prior SIRT (selective internal radiation therapy) with a good response. 
Local therapy to the remaining liver lesions was recommended, and radioembolization was requested. The patient was not a candidate for surgery, cryosurgery, microwave or radiofrequency ablation due to the size and extensive involvement of the liver lesions. The patient is young and functional and has stable disease outside of her liver. Without the radioembolization treatment, the patient's liver lesions would continue to progress, and her general condition would continue to deteriorate rapidly. She had essentially exhausted all other treatments options, and radioembolization is the best promising option that could improve her quality of life by preventing or delaying further disease progression. Radioembolization has been shown to be safe and effective for the treatment of the patient's diagnosis.