Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left frontal meningioma
Treatment: Proton Beam Therapy (PBT)
The insurer denied: Proton Beam Therapy (PBT)
The denial is overturned

This is an adult female patient with a World Health Organization (WHO) grade III anaplastic meningioma in the left frontal lobe of brain status post resection. Proton beam therapy of 60 gray (Gy) in 30 fraction is being requested for adjuvant therapy.

The proposed treatment is medically necessary.

This adult female has World Health Organization (WHO) grade III anaplastic meningioma in the left frontal lobe in close proximity to the optic chiasm, orbit, frontal/temporal lobe and pituitary gland. Thus, it is critical to achieve sharp radiation dose gradient between the targeted tumor volume and optic chiasm/pituitary gland/brain in order to avoid radiation complications to these critical normal tissues. The dose of radiation (60 gray) required to control meningioma has high risks of damage to optic nerve/chiasm and brain and can result in permanent visual loss, and brain necrosis. Proton beam with superior dose conformity can deliver a high dose to the tumor with maximum sparing of adjacent optic chiasm, pituitary gland and brain and will decrease risks of such complications in this patient. Compared to photon beam radiation therapy, proton beam radiation therapy can achieve significantly sharper dose gradient due to its Bragg peak patterns of energy release and thus can deliver therapeutic high dose to target with significantly better dose conformity and sparing of adjacent normal tissues. Proton beam therapy, therefore, can be considered as a form of delivering superior conformal radiation therapy. Thus, proton beam therapy in this case can reduce risks of radiation induced blindness and hormonal dysfunction of pituitary gland in this patient with good prognosis.
There are several single institutional studies of proton radiotherapy for meningioma and these studies demonstrate at least equivalent tumor control with minimum complications.
The American Society for Radiation Oncology (ASTRO) states that proton beam therapy is an advanced type of external-beam radiation therapy that uses proton rather than photon beams to deliver radiation doses to a tumor. Proton therapy offers a high degree of precision, which allows radiation oncologists to target an escalated dose of radiation directly on a tumor and spare nearby healthy tissue. Proton therapy is particularly beneficial for patients with tumors that are near critical structures, such as lung tumors near the heart. Based on new evidence published since the original policy was issued in 2014, the updated model policy outlines two categories of appropriate clinical indications, or diagnoses, for proton beam therapy. For indications in Group 1, coverage is recommended; for Group 2, coverage is recommended if additional requirements (outlined below) are met. Disease sites were assigned to one of the two categories based on evidence in published clinical data and current Medicare coverage.
Group 1 indications, or the clinical scenarios that frequently support the use of proton therapy based on medical necessity and published clinical data, were updated with five additions and one modification. Group 1 indications, with additions marked by asterisks, include:
Malignant and benign primary central nervous system (CNS) tumors, which includes skull base meningioma, as in this case.
Therefore, the use of proton beam therapy with its superior dosimetric conformity in order to maximize sparing of optic nerve/chiasm and pituitary gland, is consistent with the 2107 American Society for Radiation Oncologists (ASTRO) guideline for proton beam therapy.
In addition, the National Comprehensive Cancer Network (NCCN) clinical practice guideline on central nervous system cancer 2022 includes proton beam therapy for treatment of brain tumor in patients with good long-term prognosis to better spare un-involved brain and preserve cognitive function.