Appeal type: Other
Decision: Favorable

 
We decided that the Plan has to pre-approve 4 fractions of Stereotactic Body Radiation Therapy (SBRT.) 
 
You asked the Plan to pre-approve the 4 fractions of SBRT. You say that the records provided support the need 
for SBRT. The Plan denied your request. The Plan says that the requested services are not medically reasonable 
and 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 the 4 fractions of SBRT. Our reviewer 
says that the requested services are considered medically reasonable and necessary in this case. Our physician 
reviewer found SBRT, delivering high fractional doses in 2-5 fractions is an established approach for the 
treatment of discrete lesions from cancer.  There is abundant data on the use of SBRT for oligometastases (few 
lesions) to the lung. With stereotactic radiation, technologies to improve targeting accuracy are used to allow 
for higher dose delivery in 5 or fewer fractions. The combination of proximity of critical structures to the 
target, as well as the very high dose delivered per treatment fraction necessitates many fields to deliver a more 
conformal dose. Generally, for lung cancer, the goal with SBRT is to maximize dose delivery to the target, and 
minimize dose delivery to the normal lung, heart (for left sided tumors), liver (for right sided tumors), chest 
wall, trachea, esophagus and spinal cord without compromising lung tumor dose. The recent American Society 
for Therapeutic Radiology and Oncology (ASTRO) model coverage policy states that SBRT for primary lung 
cancer and for metastases to the lung is considered medically necessary. This model policy reflects not only 
expert opinion, but is also evidence-based, based upon published literature. SBRT is only considered medically 
necessary for patients with good medical condition/performance status and for those whose tumor burden can 
be targeted, which appears to apply for this case. For this case, the patient has multiple nodules stable over 
many years with growth of one lesion that is biopsy proven carcinoid. This is therefore a stage I lung cancer for 
which SBRT would be standard of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the 4 fractions of SBRT have been met. Therefore, we decided that the Plan has 
to pre-approve 4 fractions of 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.