Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Metastatic Pheochromocytoma with skull, lung and sacral metastases.
Treatment:  Stereotactic body radiation therapy.

The insurer denied the Stereotactic body radiation therapy.  The denial is overturned.

This is a woman with history of pheochromocytoma of right adrenal gland status
post right adrenalectomy.  She had no evidence of disease recurrence when she
presented with symptoms consistent with pheochromocytoma.  Work-up showed a
recurrent tumor in the right perinephric area, consistent with recurrence and lesion
in the skull, right 9th rib, T12 vertebral body, sacrum and right lung.  Biopsy of 12th
vertebral body showed hemangioma with compression fracture of T12 spine.  She
underwent resection of recurrent pheochromocytoma in the right perinephric area
and right 9th rib.  Stereotactic body radiation treatment is being requested to treat
metastatic pheochromocytoma in the skull, right lung and sacrum.

This member has good performance status of ECOG 1 (Eastern Cooperative
Oncology Group - Strenuous physical activity restricted; fully ambulatory and able to
carry out light work).

Yes, the health plan should cover the proposed treatment.

Stereotactic body radiation treatment (SBRT) is a technique of delivering highly conformal radiation treatment to the target with sparing of adjacent normal tissues,
and it enables delivery of high dose RT (radiation therapy) in a few fractions.  Published evidence has demonstrated its efficacy and safety for treatment of
solitary/oligometastatic lesions in extra-cranial sites, such as bone and lung.  Published evidence from phase I/II trials (6, 7 and 8) have demonstrated high local control rates over 90% with low toxicity.

Multiple peer reviewed publications including ones from prospective trials have
reported on high response rates with stereotactic body radiation treatment (SBRT)
with acceptable toxicities in selected patients with limited metastatic disease in the
liver.  ASTRO (American Society for Radiation Oncology) model policy for SBRT (1) states that SBRT is indicated for primary tumors of and tumors metastatic to the lung, liver, kidney, adrenal gland or pancreas as well as for pelvic and head and neck tumors that have recurred after primary irradiation when and only when each of the following criteria are met, and each specifically documented
in the medical record:  1) The patient's general medical condition (notably, the
performance status) justifies aggressive treatment to a primary cancer or, for the case of metastatic disease, justifies aggressive local therapy to one or more discrete deposits of cancer within the context of efforts to achieve total clearance or clinically beneficial reduction in the patient's overall burden of systemic disease; and 2)  The tumor burden can be completely targeted with acceptable risk to critical normal structures.

This member had a good performance status with ECOG 1 with the only 3 sites of
metastasis (skull, right lung and sacrum) with no effective systemic therapy
available, currently.  Complete eradiation of three remaining metastatic lesions in the skull, right lung and sacrum is important for quality of life and durable survival, and three metastatic lesions in the skull, right lung and sacrum can be completely targeted with acceptable risk to critical normal structures with SBRT.

In this member's clinical condition, SBRT is consistent with the ASTRO (American Society for Radiation Oncology) model policy for SBRT and is a medically appropriate treatment for quality of life and durable survival.