Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer

Treatment: Proton beam radiation therapy (PBRT) (procedure codes 77520, 77295, 77301, 61800, 77338, 61796, 63620, 77432, 77435, S8030, 77470, 77370, and 77387)

The insurer denied coverage for PBRT 

The denial is overturned

This case involves a female with a diagnosis of breast cancer. The patient is being seen and treated for biopsy proven breast cancer. The treating provider is requesting plan approval for treatment with PBRT, procedure codes 77520, 77295, 77301, 61800, 77338, 61796, 63620, 77432, 77435, S8030, 77470, 77370, and 77387.

According to the clinical documentation provided for review, the patient has the medical diagnosis of breast cancer. The patient is being seen and treated for biopsy proven breast cancer. The patient's breast cancer is stage II T1N1M0, invasive carcinoma of the left breast, with positive axillary nodal metastasis. The patient is status post (s/p) lumpectomy and left axillary dissection, followed by adjuvant chemotherapy of Adriamycin, Cytoxan, Taxol, Herceptin, and Pertuzumab. The Proton beam therapy is being requested to treat the left breast and regional nodes on Radiotherapy Comparative Effectiveness (RADCOMP) Consortium Trial: ClinicalTrials.gov Identifier: NCT02603341). The treating provider recommends therapy with PBRT, procedure codes 77520, 77295, 77301, 61800, 77338, 61796, 63620, 77432, 77435, S8030, 77470, 77370, and 77387. 

The requested proton beam therapy is provided as part of National Cancer Institute (NCI) approved clinical trial (Phase III Pragmatic Randomized Trial of Proton vs. Photon Therapy for Patients With Non-Metastatic Breast Cancer: A Radiotherapy Comparative Effectiveness (RADCOMP) Consortium Trial, ClinicalTrials.gov Identifier: NCT02603341).

Therefore, the requested proton beam therapy is consistent with the 2017 American Society for Radiation Oncology (ASTRO) model policy for proton beam therapy.      

Medical documents provided comparison of proton beam therapy plan and photon RT plan in this member. Proton beam therapy plan resulted in significantly lower dose to the heart in this woman with good long-term prognosis. Published studies suggest that proton beam radiation offers superior dosimetry to photon radiation treatment dosimetry, and the sparing of the heart would be better achieved with proton beam therapy compared to photon-based radiation therapy. Proton beam therapy in this case is provided on an NCI approved phase III clinical trial, (Phase III Pragmatic Randomized Trial of Proton vs. Photon Therapy for Patients With Non-Metastatic Breast Cancer: A Radiotherapy Comparative Effectiveness (RADCOMP) Consortium Trial, ClinicalTrials.gov Identifier: NCT02603341). In this patient's clinical situations of being treated with Adriamycin chemotherapy, photon radiation therapy to the left breast carries significant risks of radiation treatment induced cardiac complications due to synergistic cardiac toxicity of radiation and Adriamycin. Therefore, the requested proton beam therapy is consistent with the group 2 indication on the 2017 ASTRO model policy for proton beam therapy.  
                                            
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage Proton beam radiation therapy (PBRT) (procedure codes 77520, 77295, 77301, 61800, 77338, 61796, 63620, 77432, 77435, S8030, 77470, 77370, and 77387) is overturned. Medical Necessity is substantiated.