Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atypical meningioma
Treatment: Proton Beam Radiation Therapy (77387, 77525, G6002)
The insurer denied: Proton Beam Radiation Therapy (77387, 77525, G6002)
The denial is overturned

This is an adult male with history of WHO (World Health Organization) grade 2 meningioma of bifrontal lobe and the mid falx invading skull status post (s/p) subtotal resection 18 months ago. He has been evaluated with serial surveillance MRI (magnetic resonance imaging). The MRI (magnetic resonance imaging) showed increase in size of anterior falcine and olfactory grove meningioma. Proton beam therapy is being requested to treat this member's recurrent meningioma in the anterior falcine and olfactory grove to 60-66 Gy (gray).

The proposed treatment is "medically necessary". 

This adult male has an unresectable recurrent meningioma in the anterior cranial fossa in close proximity to the optic chiasm, orbit, frontal/temporal lobe and pituitary gland. Thus, it is critical to achieve sharp radiation dose gradient between targeted tumor volume and optic chiasm/pituitary gland/brain in order to avoid radiation complications to these critical normal tissues. 
This member's clinical condition is similar to skull base chordoma with tumor located in the base of skull near optic nerve. The dose of radiation (greater than 60 Gy [gray]) required to control meningioma has high risks of damage to optic nerve/chiasm and dysfunction of pituitary gland and can result in permanent visual loss, hypopituitarism with hormonal deficiency and brain necrosis. Proton beam with superior dose conformity can deliver high dose to tumor with maximum sparing of adjacent optic chiasm, pituitary gland and brain and will decrease risks of such complications in this member. Compared to photon beam RT (radiation therapy), proton beam RT (radiation therapy) can 
achieve significantly sharper dose gradient due to its Bragg peak patterns of energy release and thus can deliver therapeutic high dose to target with significantly better dose conformity and sparing of adjacent normal tissues. Proton beam therapy, therefore, can be considered as a form of delivering superior conformal RT (radiation therapy). Thus, proton beam therapy in this case can reduce risks of radiation induced blindness and hormonal dysfunction of pituitary gland in this patient with good prognosis. There are several single institutional studies of proton radiotherapy for meningioma and these studies demonstrate at least equivalent tumor control with minimum complications. 
The American Society for Radiation Oncology (ASTRO) states that proton beam therapy is an advanced type of external-beam radiation therapy that uses proton rather than photon beams to deliver radiation doses to a tumor. Proton therapy offers a high degree of precision, which allows radiation oncologists to target an escalated dose of radiation directly on a tumor and spare nearby healthy tissue. Proton therapy is particularly beneficial for patients with tumors that are near critical structures, such as lung tumors near the heart. Based on new evidence published since the original policy was issued in 2014, the updated model policy outlines two categories of appropriate clinical indications, or diagnoses, for proton beam therapy. 
For indications in Group 1, coverage is recommended; for Group 2, coverage is recommended if additional requirements (outlined below) are met. Disease sites were assigned to one of the two categories based on evidence in published clinical data and current Medicare coverage. 
Group 1 indications, or the clinical scenarios that frequently support the use of proton therapy based on medical necessity and published clinical data, were updated with five additions and one modification. Group 1 indications, with additions marked by asterisks, include: 
Malignant and benign primary central nervous system (CNS) tumors, which includes skull base meningioma, as in this case. 
Therefore, the requested proton beam therapy with its superior dosimetric conformity in order to maximize sparing of optic nerve/chiasm/pituitary gland and normal brain is consistent with the 2107 ASTRO (American Society for Radiation Oncology) guideline for proton beam therapy. 
The NCCN (National Comprehensive Cancer Network) clinical practice guideline on CNS (central nervous system) cancer 2022 includes proton beam therapy for treatment of brain tumor in patients with good long-term prognosis to better spare un-involved brain and preserve cognitive function.