Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colon carcinoma with hepatic metastases. 
Treatment: Transcatheter embolization. 

The insurer denied the transcatheter embolization. 
The denial is overturned. 

The patient is a male with colon carcinoma with hepatic metastases. The patient has undergone a partial hepatectomy and left hemicolectomy with progression of the metastases after multiple lines of chemotherapy. His is ECOG (Eastern Cooperative Oncology Group) 0 and has mild epigastric discomfort. The patient is not a surgical or ablative therapy candidate due to the location of the liver metastases. The patient is requesting treatment with selective internal radiation therapy (SIRT) with Y-90 (Yttrium-90). 

Yes, the transcatheter embolization is medically necessary. 

The NCCN (National Comprehensive Cancer Network) Guidelines and peer-reviewed evidence support SIRT (selective internal radiation therapy) as efficacious for colorectal carcinoma in patients with chemorefractory liver metastases. 

The National Comprehensive Cancer Network (NCCN), Clinical Practice Guidelines in Oncology, v.2.2021, Colon Cancer states: "Arterially directed catheter therapy, and in particular yttrium 90 microsphere selective internal radiation, is an option in highly selected patients with chemotherapy-resistant/-refractory disease and with predominant hepatic metastases." This is a Category 2A recommendation. 

A search of the peer-reviewed medical literature finds many articles supporting the safety and efficacy of selective internal radiation therapy (SIRT) in the appropriate setting. A retrospective article of 36 patients by Jakobs, found that "Hepatic (90)Y radioembolization can be performed with manageable toxicity in patients with colorectal cancer liver metastases whose disease is refractory to chemotherapy." A prospective evaluation of 13 patients that failed first and second line therapy for colorectal metastases by Stuart, in 2008, found that "(90)Y microsphere therapy produced promising survival rates compared with systemic salvage options, with minimal toxicity." A prospective study by Sato in 225 Y-90 (Yttrium-90) administrations for unresectable chemorefractory liver metastases found that "(90)Y hepatic treatments are well tolerated with acceptable toxicities; tumor response and median survival are promising." A recent prospective, multicenter, randomized phase III trial of 44 patients by Hendlisz, found that "Radioembolization with (90)Y-resin microspheres plus FU [fluorouracil] is well tolerated and significantly improves TTLP (time to liver progression) and TTP (time to tumor progression) compared with FU [fluorouracil] alone. This procedure is a valid therapeutic option for chemotherapy-refractory liver-limited mCRC (metastatic colorectal carcinoma)." 

The American College of Radiology appropriateness criteria states that patients with unresectable liver or lung metastasis are candidates for local therapies, which include radioembolization. The patient is not a candidate for liver resection, ablation therapy or external beam radiation. The patient was previously treated with systemic chemotherapy and now is refractory. SIRT (selective internal radiation therapy) could be efficacious with least systemic toxicity. The Radioembolization Brachytherapy Oncology Consortium (REBOC) suggests that SIRT (selective internal radiation therapy) can successfully palliate the patient's disease in this situation.