Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Lung cancer.
Treatment:  Radiation therapy.
The insurer denied the radiation therapy.  The denial is overturned.

The Radiation therapy is medically necessary.

The patient is a male with a diagnosis of loco-regionally advanced lung cancer s/p (status post) neoadjuvant chemotherapy and surgery.  Adjuvant radiation therapy was recommended, and IMRT (intensity-modulated radiation therapy) was requested. 

IMRT is a technique of conformal radiation planning and delivery that is used to treat tumors that have close proximity to vital organs and structures.  It allows for the radiation dose to conform more precisely to the three-dimensional (3-D) shape of the tumor by modulating, or controlling, the intensity of the radiation beam.  IMRT also allows higher radiation doses to be focused to regions within the tumor while minimizing the dose to surrounding normal critical structures.  It is the standard of care for cancers/tumors of the prostate, head and neck, CNS (central nervous system), pediatric tumors and other sites where standard radiation planning and delivery is suboptimal in terms of adequate tumor coverage or critical structure sparing.
			
A 2007 M. D. Anderson Cancer Center study (7) evaluated 151 lung cancer patients treated with IMRT.  The study showed that "Despite the IMRT group's larger gross tumor volume, the rate of Grade greater than or equal to 3 TRP [treatment-related pneumonitis] at 12 months was 8% (95% confidence interval 4%-19%), compared with 32% (95% confidence interval 26%-40%) for 3D-CRT (p = 0.002)."  Other studies have shown that IMRT is effective in reducing V20 of the lung (volume of the lung receiving greater than 20 Gy) compared to conventional conformal radiation therapy.  

In a 1999 Washington University article (1), the authors concluded that the risk of developing radiation pneumonitis is 36% if V20 for lung is greater than 40%.  The risk of pneumonitis is 0% if V20 is less than 22%, and only 7% if V20 is 22-31%.  Another study compared dose-volume-histograms of IMRT plan with 3D plan for patients with lung cancer.  The results showed that there is an average dose reduction of the mean values by 73% to the heart, 69% to the right lung and 74% to the left lung, with respect to the GTV (gross tumor volume) could be achieved with IMRT. 

A more recent 2013 study from MD Anderson Cancer Center evaluated 223 patients with lung cancer treated with either 3DCRT (three-dimensional conformal radiotherapy) or IMRT.  The authors concluded that "IMRT was not associated with worse oncologic outcomes than those of 3DCRT. IMRT was associated with a lower rate of esophagitis-related percutaneous feeding tube placements."  

According to NCCN guidelines, "more advanced technologies are appropriate when needed to deliver curative RT [radiotherapy] safely. These technologies include 4D-CT and/or PET/CT simulation, IMRT/VMAT [volume modulated arc therapy], IGRT [image guided radiation therapy], motion management, and proton therapy."
			
This patient is a male with a diagnosis of loco-regionally advanced lung cancer s/p neoadjuvant chemotherapy and surgery.  Adjuvant radiation therapy was recommended, and IMRT was requested.  In this case, the target is very extensive, and care must be taken to minimize radiation exposure to the heart, spinal cord and normal lung with IMRT.  According to the patient's physician, a 3D/IMRT comparison plan was done, and the IMRT plan was able to reduce dose to the surrounding critical structures.  3D radiation therapy would not be adequate in sparing these structures.  IMRT is an appropriate and medically necessary treatment for this patient at this time.