Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) for recurrent 
glioblastoma multiforme (GBM). 
 
You asked the Plan to pre-approve the requested PBRT. You say that the enrollee has a history of a 
glioblastoma multiforme. At the time of initial diagnosis, he underwent surgery followed by chemotherapy and 
external beam radiation therapy. He developed a local recurrence. He recently underwent repeat craniotomy 
with resection of the tumor. In order to provide the best chance of first for local control in the brain, it is felt 
that proton therapy would be ideal. The Plan denied your request. The Plan says there is not sufficient support 
for this treatment plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 requested PBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the use of proton therapy is an accepted radiation technology, that has proven 
efficacy and tolerability. Certain conditions- such as base of skull chordomas and chondrosarcomas, and 
pediatric central nervous system malignancies are probably best treated with proton therapy, due to the sharp 
dose fall off, allowing high dose delivery to the tumor, while relatively sparing the neighboring normal tissue.  
 
However, our reviewer is not aware of any data which describe proton therapy as necessary superior to photon 
therapy with respect to outcomes for gliomas. Most studies are small dosimetric studies and were done on 
mostly low-grade glioma patients.  
 
For this patient, undergoing reirradiation for glioblastoma, there is a plan comparison of proton therapy to a 
non-proton-based plan, but no demonstration that proton therapy is needed to avoid exceeding the cumulative 
tolerance dose of nearby normal tissue.  Two plans are provided but no appeal that specifically addresses why 
the proton plan is better with respect to a plausible, clinically meaningful benefit. Reirradiation for 
glioblastoma is quite feasible with intensity modulated radiation therapy (IMRT).  
 
In summary, proton therapy can be considered medically necessary for recurrent glioblastoma when the need is 
sufficiently supported. Simply providing 2 plans with no context of how or why one is better, with no plan 
composite plan does not justify the need for proton therapy as ASTRO model policy specifies demonstration 
that proton therapy is needed to avoid exceeding the cumulative tolerance dose of nearby normal tissue. 
There is also no justification for a more protracted (6 week) course in a patient whose cancer recurred relatively 
quickly and for which the treatment is palliative in nature. As such, the requested treatment is not considered 
medically reasonable and necessary. 
 
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 requested PBRT have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy (PBRT) for recurrent glioblastoma multiforme 
(GBM).