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. 

The patient is seeking 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.  The patient had stage 4 squamous cell carcinoma with Epidermal Growth Factor Receptor (EGFR) exon 19 deletion.  The patient was status carboplatin/Taxol/pembrolizumab with programmed death (PD) followed by afatinib with PD.  The patient was status post palliative thoracic radiotherapy and stereotactic radiation therapy to T (thoracic) 3 and left sacrum.  The patient had further PD and started gemcitabine.  The patient had multifocal greater than 10 brain metastasis status post stereotactic radiosurgery to larger metastasis. The patient was started on Osimertinib with response.  With recent oligoprogression at T1 status post stereotactic radiation therapy.  The patient now had oligoprogression in the previously radiated left lung.  The provider stated that radiation therapy for the oligoprogressive disease could improve the patient's progression free survival and allow the patient to continue on Tagrisso for a longer period of time.  As this area received prior radiation therapy, the patient was a candidate for proton reirradiation.  A plan comparison noted that the photon plan significantly added more toxicity to the patient's heart, spinal cord, esophagus, and breast tissue.  The photon-based toxicity profile was in modification of Radiation Therapy Oncology Group (RTOG)/Quantitative Analyses of Normal Tissue Effects in the Clinic (QUANTEC) dose guidelines.  The patient's organs at risk dose estimates were conservative as they had a history of prior radiation to the same lung.  There was full dose overlap.  Literature and guidelines were referenced in support of the requested treatment for the patient.  

It was stated that the requests for proton beam radiotherapy and associated services were denied.  The requests were denied as they were considered experimental and investigational.

In this case, the patient had stage 4 squamous cell carcinoma.  The patient now had oligoprogression in the previously radiated left lung.  The provider stated that radiation therapy for the oligoprogressive disease could improve the patient's progression free survival and allow the patient to continue on Tagrisso for a longer period of time.  As this area received prior radiation therapy, the patient was a candidate for proton reirradiation.  

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 risks are not substantially increased over standard treatments.