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 necessary due to the patient's two 
brain metastases. This is the only site of metastatic disease. The patient will experience known cognitive and 
neurological side effects if she was to be treated with whole brain radiation therapy. The Plan denied your 
request. The Plan says that SBRT is not generally accepted for the patient's current condition. Other therapies 
are more 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 SBRT is an accepted standard of care for limited metastases from small cell lung cancer. The 
American Society for Radiation Oncology (ASTRO) model policy for radiosurgery lists no restrictions on 
SBRT based upon primary cancer type or number of lesions, or prior treatment (i.e. having undergone prior 
SBRT) but rather emphasizes the need of SBRT in patients with good performance status, and who are 
expected to have a reasonably long life expectancy warranting treatment.   
 
Perhaps more compelling (in that it is not from a Radiation Oncology society) are the National Comprehensive 
Cancer Network (NCCN) guidelines, which state (and have stated since at least 2014) that radiosurgery can be 
considered for patients with multiple brain metastases with low-volume burden of disease. The guidelines 
actually recommend whole brain radiation therapy (WBRT) or SBRT for these patients, and in a footnote, 
states that SBRT can be considered for patients with good performance status and low overall tumor volume. 
The guidelines explicitly state: The definition of limited brain metastases in terms of number of metastases 
or total intracranial disease volume is evolving and may depend on the specific clinical situation.  The NCCN 
guidelines explicitly state: While brain metastases from small cell lung cancer have historically been treated 
with WBRT, an international retrospective study suggested SBRT alone may be suitable in some cases. The 
guidelines do not limit their recommendation based on prior SBRT.  
 
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.