Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer
Treatment Intensity-modulated radiation therapy (IMRT) for breast cancer.
The insurer denied coverage for Intensity-modulated radiation therapy (IMRT) for breast cancer.
The denial is overturned.

This case involves a female diagnosed with breast cancer who was being recommended for intensity modulated radiation therapy, initial phase: 25 fractions. The patient underwent right breast sentinel lymph node mapping with the surgical pathology report noting that the patient had ultrasound positive biopsy for cT2-3 N1 (clinical stage invasion of adjacent organs regional nodal spread) invasive mammary carcinoma of the right breast. The visit note stated the patient presented for right breast cancer regarding radiation therapy options. The report stated that the patient underwent bilateral mastectomy with reconstruction. She was well-healed at the time of the visit with no palpable masses or lesions and had no palpable regional adenopathy appreciated. The treatment plan at that time included postmastectomy radiation therapy given the locally advanced disease. The physician explained that PMRT (post mastectomy radiation therapy) in the patient's clinical scenario, with evidence of axillary lymph nodes, positive prechemotherapy, and residual nodal disease, post neoadjuvant chemotherapy (NAC) had been shown to decrease local regional recurrence and might improve other disease outcomes. The practice was to target the reconstructed chest wall as well as the regional lymph nodes including the axillary bed at risk, the supraclavicular and infraclavicular lymph nodes as well as the internal mammary lymph node chain to a total dose of 50 Gy (gray: a derived unit of ionizing radiation dose). The physician also stated that an IMRT technique may be implemented to reduce the dose to the surrounding critical organs. 

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

Literature has stated that 3D (3-dimentional) conformal radiation therapy (CRT) and intensity-modulated radiation therapy (IMRT) are two of the most common treatment techniques used for postmastectomy radiotherapy. The patient had received support to undergo 3D-CRT (3-dimentional-conformal radiation therapy). The treating physician explained the reasoning behind the IMRT treatment, as it would reduce the dose to the surrounding critical organs. Given the provided information, IMRT has been found to be effective for treating postmastectomy patients and would be suitable for the individual in question as the technique/system prevents overexposure of radiation to vital organs. This is essential in maintaining the patient's health and lowering her risk of radiation to areas of the body unassociated with the breast cancer. Therefore, while 3D CRT is a common treatment for breast cancer patients, it has been determined that IMRT is more appropriate in this scenario to avoid damage to surrounding tissues and overall toxicity. The Intensity-modulated radiation therapy (IMRT) for breast cancer is considered a medical necessity for this patient.

The insurer's denial of coverage for Intensity-modulated radiation therapy (IMRT) for breast cancer is overturned. Medical Necessity is substantiated.