Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Angiosarcoma
Treatment: Photon based radiation therapy service codes 77523 x 8 and its associated radiation codes 77290, 77295, 77300 x10, G6002 x 8, 77427 x2, 77334 x11 and 77336 x2
The insurer denied the coverage for service codes 77523 x 8 and its associated radiation codes 77290, 77295, 77300 x10, G6002 x 8, 77427 x2, 77334 x11 and 77336 x2.
The denial was upheld.   

This male patient has a history of multiply recurrent lymph node positive angiosarcoma of his left upper back status post (s/p) multiple surgical resections and delivery of systemic chemotherapy and biological therapy. The patient subsequently presented with another recurrence, for which he was treated with sorafenib, and recommended to proceed with definitive external beam radiotherapy with curative intent. The recommendation is for proton beam radiation therapy.

Per the NCCN guidelines, "[radiation therapy (RT)] can be administered either as primary, preoperative, or postoperative treatment. Total RT doses are always determined based on the tissue tolerance. Newer RT techniques such as brachytherapy, intraoperative RT (IORT), and intensity-modulated RT (IMRT) have led to the improvement of treatment outcomes in patients with [soft tissue sarcoma (STS)]. The main advantage of IMRT is its ability to more closely contour the high-dose radiation to the surrounding normal tissues. Additionally, image-guided techniques may allow for reduced target volumes, further minimizing toxicity."

As per review of the American Society for Radiation Oncology (ASTRO) Model Policy, proton radiotherapy for this patient's clinical condition is not supported outside the context of a prospective clinical trial.
              
Proton radiotherapy has the ability to reduce the volume of low dose radiation exposure to surrounding normal critical tissues, but it cannot reduce the high dose exposure. Since it is the volume of high dose normal tissue exposure which has traditionally been correlated with radiation-induced morbidity, it remains unclear as to whether the use of proton radiotherapy in this patient's condition would offer clinically meaningful improvements in outcomes. The treating provider has not supplied a detailed slice by slice proton/photon plan comparison in color format (it is not possible to interpret black/white images that were provided) to justify the need for proton radiotherapy in this patient's clinical scenario. Typically a photon-based plan would be associated with a high level of safety/efficacy, and this is supported by high quality outcomes published in the peer reviewed medical literature. Based on the review of the medical record, there are not any extenuating circumstances present in this patient's case that would necessitate the use of proton beam radiotherapy (such as prior receipt of radiation to the same site or genetic/comorbid condition which increases normal tissue radiosensitivity).      

As per the current peer reviewed medical literature, there are insufficient high quality clinical outcomes reported to allow one to make definitive conclusions regarding the relative safety/efficacy of proton beam radiotherapy for management of recurrent angiosarcoma, as compared to standard of care photon-based radiation therapy. 

Thus, the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient
                                        
The carrier's denial of service codes 77523 x 8 and its associated radiation codes 77290, 77295, 77300 x10, G6002 x 8, 77427 x2, 77334 x11 and 77336 x2 should be upheld.