Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that SBRT is medically reasonable and necessary for this 
patient. The Plan denied your request. The Plan says that the requested SBRT services are not medically 
reasonable because research does not show that Intensity-modulated radiation therapy (IMRT) services would 
not be not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found oligometastases are defined as a state of metastatic disease with metastases few in number and 
extent.  This patient has recurrence of resected cancer that recurred previously and then was irraadated. 
Therefore, this patient has oligorecurrence of cancer in a site that was previously irradiated. i.e. one site of 
recurrence that developed after standard systemic therapy (as opposed to oligometastases as this does not 
appear to have metastasized). The rationale for treating oligorecurrence with local therapy (i.e. radiation or 
surgery) is to prolong disease control, and potentially prolong life. The patient has already received standard 
chemotherapy. It is relatively well-established that SBRT is superior to other forms of radiation in treating 
discrete cancerous lesions.  It allows dose escalation while minimizing the volume of normal tissue exposed to 
high dose radiation, and as a result yields high tumor control rates.  
 
The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy does not 
specifically address pelvic recurrences, though does address the need for SBRT in suitable patients who had 
undergone prior radiotherapy. The ASTRO model policy does address the need of good performance status 
(patient with KPS=60, so borderline) and need to encompass the entire target (which seems to apply for this 
case based on the records provided). While IMRT would also be an option for this patient, SBRT would be 
within accepted standards of care (and likely more cost effective than a 10-15 fraction IMRT course). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
stereotactic body radiotherapy (SBRT).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.