Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stage IIC adenocarcinoma of the prostate gland.
Treatment: Partially denied coverage for 44 units of intensity modulated radiation therapy (IMRT).

The insurer partially denied coverage for 44 units of IMRT.  The denial is overturned.

This case involves a male diagnosed with stage IIC adenocarcinoma of the prostate gland, who was being recommended for 44 units of intensity modulated radiation therapy (IMRT).  Records indicated the patient's National Comprehensive Cancer Network (NCCN) staging was unfavorable for intermediate risk disease with Gleason equaling 7 (4+3), and pretherapy prostate-specific antigen (PSA) equaling 10.49 ng/mL (nanogram per milliliter).  The treating physician discussed treatment options with the patient and recommended a standard of 44 sessions of hypofractionation over a period of up to 20 sessions.  The physician acknowledged that the patient received a notice of adverse determination and noted that standard fractionation of up to 45 fractions is considered the standard of care for the treatment of prostate cancer.  This dose regimen is supported by the NCCN, the American Society for Clinical Oncology (ASCO), and the American Society for Radiation Oncology (ASTRO) and is currently one of the standard regimens.  The physician noted that available treatment options were discussed with the patient including radical prostatectomy, prostate brachytherapy, external beam radiation therapy, active surveillance, and hormonal therapy.  The physician explained the different approaches to treatment along with the relative risks and benefits.  The physician noted that while the patient received a notice of adverse determination indicating that coverage would not be approved for the 44 standard/conventional fractions and then limited treatment to 28 sessions, the determination regarding the issue failed to acknowledge that the requested services fell directly within the excepted standard of care for the patient's condition.  

Current medical literature notes that hypofractionated prostate radiotherapy has the potential to shorten the duration of prostate cancer treatment while increasing the biologically effective dose delivered to the prostate by delivering larger daily doses of radiation.  Additionally, IMRT, an advanced form of three-dimensional conformal radiation therapy (3D-CRT), is the most common type of external beam radiation therapy for prostate cancer. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the beams and aiming them at the prostate from several angles, the intensity (strength) of the beams can be adjusted to limit the doses of radiation reaching nearby normal tissues. This lets doctors deliver an even higher radiation dose to the cancer.  The information provided for the review confirmed the patient was being treated for stage IIC adenocarcinoma of the prostate gland and had been recommended 44 units of intensity modulated radiation therapy (IMRT).  Despite the final adverse determination that a modified approval was given for 28 units of IMRT, given that standard of care is typically 44 units to thoroughly treat the site, the 44 units of IMRT are medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for 44 units of intensity modulated radiation therapy (IMRT) services is substantiated.