Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensity modulated radiation therapy (IMRT). IMRT is standardly utilized to treat certain body sites when normal tissue dose constraints cannot be met by other radiation techniques. In the case of lung cancer, IMRT is commonly utilized to spare areas of normal lung. This is particularly important in patients who have chronic obstructive pulmonary disease (COPD), as is the case with this patient. Toxicities such as radiation pneumonitis and esophagitis can cause significant morbidity leading to hospitalization. There is strong evidence in the literature demonstrating a correlation between normal lung sparing and the rates of treatment-related complications. When compared with three-dimensional conformal radiation therapy (3D-CRT)  Boyle and colleagues note that IMRT significantly decreased unnecessary dose to critical organs with equivalent coverage of planning target volumes. The National Comprehensive Cancer Network (NCCN) guidelines for non-small cell lung cancer outline the importance of treating the primary lung target in a safe manner while respecting the established dose constraints of surrounding organs. In this case, the patients radiation dosimetric treatment planning parameters indicate that IMRT is necessary to meet the acceptable dose constraints of the normal lung. The 3D-CRT comparison plan showed a mean lung dose of 41 Gy and a V20 of 37%, which exceed acceptable NCCN dose constraints. Bradley and colleagues report that the mean lung dose and V20 are two key indicators that predict the rate of radiation pneumonitis, and that when the dose constraints of these two indicators are exceeded, then the risk of pneumonitis increases exponentially. This is especially true if the patient is receiving concurrent chemotherapy, as in this case. In this case, the provider is using a dose of 42 Gy to the lung tumor, which is in line with recent dosing regimens for lung palliation. Lewis and colleagues report that such higher doses have been associated with better outcomes, especially in patients presenting with superior vena cava symptoms. In this case, the patient exhibited class superior vena cava syndrome with upper extremity swelling. He is undergoing a concurrent chemoradiation treatment to a large, locally advanced and metastatic lung cancer. Given that the dosimetry data shows that the treating provider is unable to meet acceptable lung tissue constraints using 3D-CRT, the requested service is medically indicated to adequately treat the tumor while maintaining acceptable normal tissue toxicity. Therefore, IMRT is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.