Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve stereotactic body radiation therapy (SBRT). You say that the requested 
stereotactic body radiation therapy (SBRT) is medically necessary. The Plan denied your request. The Plan 
says that the requested stereotactic body radiation therapy (SBRT) is not medically necessary. 
 
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 stereotactic body radiation therapy 
(SBRT). Our reviewer says that the requested stereotactic body radiation therapy (SBRT) is medically 
necessary. Our physician reviewer found SBRT, delivering high fractional doses in 3-5 fractions, is an 
established approach for the treatment of discrete lesions from cancer. The advantages of SBRT are the ability 
to escalate the dose while using novel technologies to minimize the exposure of the surrounding normal tissues 
and do so in a short course of treatment. As the case records suggest, SBRT is likely a more cost-effective 
approach than many weeks of radiation +/- concurrent chemotherapy. 
 
Unresectable, recurrent, ureteral cancer, is a relatively uncommon scenario for which there are no National 
Comprehensive Cancer Network (NCCN) guidelines or much published literature on optimal radiation dosing. 
To my knowledge (and after searching PubMed), there are no published studies on SBRT for ureteral cancer 
outside of one retrospective study of 16 patients (Khriguian. Stereotactic Ablative Radiation Therapy for the 
Treatment of Upper Urinary Tract Urothelial Carcinoma. Pract Radiat Oncol. 2022 Jan-Feb;12(1):e34-e39.). 
The authors conclude that SBRT is safe and well-tolerated, with good radiographic tumor response to ablative 
doses of radiation therapy. 
 
In contrast there are emerging studies on SBRT for unresectable renal cancers (Siva S et al.. 5-year outcomes 
after stereotactic ablative body radiotherapy for primary renal cell carcinoma: an individual patient data meta-
analysis from IROCK (the International Radiosurgery Consortium of the Kidney). Lancet Oncol. 2022 
Dec;23(12):1508-1516). 
 
Based upon extrapolation from the experience with unresectable kidney cancer, SBRT for unresectable ureteral 
cancer seems like a reasonable approach if it can be delivered safely with tumoricidal doses. 
 
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 been met. Therefore, we 
decided that the Plan has to pre-approve stereotactic body radiation therapy (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.