Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for stereotactic body radiation therapy (SBRT) for
the enrollee.
You asked the Plan to provide coverage for stereotactic body radiation therapy (SBRT). You say that this
treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are
not met. Maximus overturned the Plans denial. The Plan requested a reopen and stated that Maximus did not
apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for stereotactic body
radiation therapy (SBRT) for an enrollee with ventricular tachycardia. The Maximus Physician Reviewer
determined that the requested services are considered medically reasonable and necessary in this case. The Plan
requested a reopen and argues that it is unclear why this request for SBRT, in a situation where the
documentation does not clearly delineate that conventional therapy has actually failed, including possible
revascularization of ischemic tissue, and given the lack of documentation of the current post ablation frequency
of VT event, warrants an off label use of a technology that is not part of a clinical trial where the procedure and
subject could provide beneficial data to move science forward.
The medical records show the enrollee is a 61-year-old woman with coronary artery disease who has
undergone coronary bypass surgery as well as stent placement 7 times. The enrollee's course has been
complicated by uncontrolled tachyarrhythmias. The enrollee has been treated with routine medications and
cardiac catheter ablations, both endocardial and epicardial, without success. A physician specialist caring for
the enrollee writes that an internal defibrillator is shocking the enrollee numerous times per day in response to
uncontrolled ventricular tachycardia numerous times per day.
The physician notes that patients in this category have extremely reduced survival in comparison to those with
controlled tachyarrhythmias. The physician writes, "The consensus is that the patient should be offered ablation
using stereotactic radiosurgery." Published data is cited which indicates that radiosurgery is highly effective in
treating refractory ventricular tachycardia due to aberrant conductivity through a pre-existing cardiac scar.
Our Medical Director has concluded that the Plan is correct in this case. There are insufficient data in the
medical literature to support that SBRT for the management of refractory ventricular tachycardia meets
medically reasonable and necessary criteria as defined by Medicare. Specifically, the published literature on
this topic supports that SBRT may be considered experimental or investigational at this time, and there are
insufficient data to demonstrate that the procedure is safe and effective for the treatment of refractory
ventricular tachycardia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of stereotactic body radiation therapy (SBRT) have not been met. Therefore, we
decided that the Plan does not have to provide coverage for stereotactic body radiation therapy (SBRT) for the
enrollee.