Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Small Cell Lung Cancer
Treatment: Intensity-modulated radiation therapy
The insurer denied the Intensity-modulated radiation therapy
The denial is overturned.

The patient is a female with a diagnosis of stage IIIB small cell lung cancer status post chemotherapy and radiation therapy. Prophylactic brain radiation therapy was recommended, and hippocampal avoidance whole brain radiation therapy with IMRT (intensity-modulated radiation therapy) was requested.

Yes, the requested intensity-modulated radiation therapy is medically necessary.
There are numerous studies that showed that IMRT (intensity-modulated radiation therapy) is superior compared to conventional conformal radiation therapy for the treatment of brain and spinal cord tumors.

A MD Anderson Cancer Center study evaluated GBM (glioblastoma multiforme) patients treated with radiation therapy and performed a dosimetric comparison of IMRT (intensity-modulated radiation therapy) vs. 3D (three dimensional).  The study showed that the dose to the normal tissues was reduced significantly with IMRT (intensity-modulated radiation therapy).  Dose reduction with IMRT (intensity-modulated radiation therapy) was 19.8% to the brain stem, 25.3% to the optic chiasm, and approximately 37% to the optic nerves.  The authors concluded that "IMRT [intensity-modulated radiation therapy] treatment for high-grade gliomas allows for improved target conformity, better critical tissue sparing, and importantly does so without increasing integral dose and the volume of normal tissue exposed to low doses of radiation."

Another study evaluated patients with brain metastasis treated with hippocampal sparing whole brain radiation therapy with IMRT (intensity-modulated radiation therapy).  The authors, "HA-WBRT [whole-brain radiation therapy - hippocampal avoidance] with SIB [simultaneous integrated boost] to metastases is a safe and tolerable regime that shows favorable LTC [local tumor control] for patients with multiple brain metastases, while it has the potential to minimize the side-effect of cognitive deterioration."

The patient is young, and care must be taken to minimize additional radiation exposure to the surrounding normal brain.  IMRT (intensity-modulated radiation therapy) is the best option for this patient in sparing the normal brain, especially the hippocampus, and preventing neurologic deficits.  IMRT (intensity-modulated radiation therapy) has been shown to be a safe and effective procedure, and in this case, is an appropriate treatment.

The health plan, in offering complex isodose treatment as an alternative, was stating that the treatment was for lung cancer, not prophylactic brain radiation. The health plan used Lung cancer criteria instead of CNS (central nervous system) criteria (for brain Mets).

Therefore, given the above the requested intensity-modulated radiation therapy is medically necessary.

There are numerous studies that showed that IMRT (intensity-modulated radiation therapy) is superior compared to conventional conformal radiation therapy for the treatment of brain and spinal cord tumors.  The patient is young, and care must be taken to minimize additional radiation exposure to the surrounding normal brain.  IMRT (intensity-modulated radiation therapy) is the best option for this patient in sparing the normal brain, especially the hippocampus, and preventing neurologic deficits.  IMRT (intensity-modulated radiation therapy) has been shown to be a safe and effective procedure, and in this case, is an appropriate treatment, and medically necessary.