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 SBRT. You say that you would like the plan to reconsider their denial. The
Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that SBRT is covered for certain indications.
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
documentation supports that the requested services are medically reasonable and necessary. Our physician
reviewer found The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage
policy, reflecting national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney
lesions is medically necessary when the patients performance status justifies aggressive treatment, and for those
whose tumor burden can be completely targeted with acceptable risks (which does not apply in the setting of
oligoprogression- i.e. one or few lesions growing in setting of widespread progression). A study specifically
addressed the use of SBRT for "oligoprogression" of disease (i.e. limited growth of lesion(s)) in enrollees with
ALK+ or epidermal growth factor receptor mutated non-small cell lung cancer (a different scenario than for
enrollees receiving immunotherapy) in an effort to enable the enrollees to continue systemic therapy and treat
the disease that has progression; they demonstrated greater than six months of additional tumor control with
SBRT. It is acceptable to consider SBRT or hypofractionated (6-15 treatments) stereotactic radiotherapy for
enrollees with metastatic sites that are generally accepted as safe to treat per NCCN guidelines. For this
enrollee, another rationale to offer SBRT is the prior thoracic radiation. SBRT to the growing hilar lesion can allow for minimizing dose overlap. Based on the location of the site to be treated (near prior site of disease) in
setting of oligoprogression, SBRT would be an accepted standard of care. It is unclear what is meant by "the
tumor burden cannot be completely targeted" as the active tumor burden would be completely targeted with the
proposed treatment, while the other sites within the lung are not clearly active disease. Therefore, the enrollee
meets criteria for the requested services.
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 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.