Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hodgkin's Lymphoma.
Treatment: Radiation therapy for Hodgkin's Lymphoma.

The insurer denied coverage for radiation therapy for Hodgkin's Lymphoma. The denial is upheld. 

This is a female patient who was initially diagnosed with a bulky Hodgkin's lymphoma in the past. The patient was initially treated with Adriamycin, Bleomycin, Vinblastine, and Dacabazine but did not receive contact consolidative radiation therapy. In the initial follow-up, the patient was found to have a recurrence in the anterior mediastinal, subcarinal lymph node lesion, and high left paratracheal region. The patient's biopsy confirmed the presence of recurrent Hodgkin's lymphoma. Because of the initial bulky presentation and recurrent nature of the lymphoma, the patient was referred for consolidative radiation therapy. The provider opined the patient was appropriate for proton therapy for the treatment of lymphoma in order to maximize the likelihood of disease control.

Based on the review of the medical record and literature, the requested radiation therapy for Hodgkin's Lymphoma is not considered medically necessary. The patient has Hodgkin's Lymphoma. The patient's treating physician will need to consider the delivery of a moderate dose to the tumor in the mediastinum. The treatment field will involve mediastinal organs, including the breast, lung, and heart. Proton radiation is generally accepted as medically necessary for the following conditions: Intracranial arteriovenous malformations (AVMs); Ocular tumors, including intraocular/uveal melanoma (includes the iris, ciliary body and choroid); or Skull-based tumors (e.g., chordomas or chondrosarcomas). The National Comprehensive Cancer Network (NCCN) Guidelines version 2.2020 for Hodgkin's Lymphoma describes appropriate radiation as Intensity Modulated Radiation Therapy (IMRT) photons or other conformal techniques, including proton therapy to spare normal structures as needed. The American Society for Therapeutic Radiology and Oncology (ASTRO) Report on Emerging Technologies indicates the proton beam therapy for mediastinal Hodgkin's disease is a Group 2 classification, which may be considered in appropriate situations. The June 2017 update indicates that for sites other than those listed above; there is a continued need for clinical evidence development and comparative effective analysis for appropriate use of proton beam therapy for these various disease sites.  

In this case, regarding medical necessity, while proton therapy may not be a standard of medical practice, it may be safe and effective. A proton plan can reduce the dose to the normal tissues at risk, such as the rectum, and bladder, below tolerance, within acceptable limits sufficiently beyond the ability of a photon plan to do so for the required delivered dose for some situations. The records do reflect that the proton plan would limit the dose to normal tissue, maintaining dose tolerance of the critical tissues in the field. The photon plan comparison, however, shows that the photon plan is acceptable.  None of the tolerances for the organs listed, including lung and breast are exceeded.  The proton plan is not the best modality that will allow this patient to be safely treated.  The patient is young and has a significant life expectancy, so minimizing dose to surrounding tissues is critically important. However, the photon plan is reasonable and appropriate. It is an appropriate level of service that can be safely provided, compared to protons. For their complexity, protons are not shown to add a clinically significant benefit over photons for this patient.  

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the requested radiation therapy for Hodgkin's Lymphoma should be upheld. The medical necessity is not substantiated.