Appeal type: Medical necessity
Decision: Overturned

Diagnosis: stage IV breast cancer and brain involvement

Treatment: Stereotactic Radiosurgery (procedure codes 61796 and 61797)

The insurer denied coverage for Stereotactic Radiosurgery (procedure codes 61796 and 61797)

The denial is overturned


According to the medical records, the patient is an adult female with stage IV breast cancer and brain involvement, 7-10 lesions of 1 centimeter (cm) or less. Stereotactic radiation was recommended.

Stereotactic radiosurgery (SRS) is more appropriate than whole brain radiation therapy (WBRT) for this patient. When 7-10 small brain metastases are detected in a young patient with a Karnofsky of 90 there is an agreement for medical necessity of stereotactic radiation due to less cognitive deterioration, while maintaining disease control.

"Conclusions: The task force has proposed recommendations to inform best clinical practices on the use of radiation therapy for brain metastases with strong emphasis on multidisciplinary care." (Gondi, V. et al.2022).

"Stereotactic radiosurgery (SRS) is an effective treatment for patients with multiple brain metastases. Three decades of increasingly powerful scientific studies have shown that SRS improves outcomes and reduces toxicity when it replaces whole-brain radiation therapy (WBRT). Expert opinion surveys of clinicians have reported that the total intracranial tumor volume rather than the number of brain metastases is related to outcomes. As a result, an increasing number of treating and referring physicians have replaced the reflex use of WBRT with SRS, unless the patient has miliary disease or carcinomatous meningitis. In the current era of immunotherapy and targeted therapies with potentially increased systemic disease survival, 10 or more tumors are routinely treated with SRS alone at most academic medical centers. In a single SRS session we routinely treat patients with cumulative tumor volumes of 25 cm3 even if they have >=10 metastases." (Niranjan, A. et al. 2019).

"Stereotactic radiosurgery (SRS) uses many precisely focused radiation beams to treat tumors and other problems in the brain, neck, lungs, liver, spine and other parts of the body.

It is not surgery in the traditional sense because there's no incision. Instead, stereotactic radiosurgery uses 3 Dimensional (3D) imaging to target high doses of radiation to the affected area with minimal impact on the surrounding healthy tissue. Like other forms of radiation, stereotactic radiosurgery works by damaging the DNA of the targeted cells. The affected cells then lose the ability to reproduce, which causes tumors to shrink.

Stereotactic radiosurgery of the brain and spine is typically completed in a single session. Body radiosurgery is used to treat lung, liver, adrenal and other soft tissue tumors, and treatment typically involves multiple (three to five) sessions." (Mayo Clinic Stereotactic Radiosurgery 2019).
 
Based on the above, the insurer's denial must be reversed. 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 stereotactic radiosurgery (procedure codes 61796 and 61797) is substantiated.