Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT) (77373, 77470). 
 
You asked the Plan to pre-approve SBRT. You say that the requested treatment is medical necessary for this 
type of cancer. The enrollee is not a candidate for surgery. The Plan denied your request. The Plan says that 
there is no good evidence the SBRT treatment is safe or effective for the enrollee's cancer. 
 
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, delivering high fractional doses in 1-5 fractions is an established approach for the 
treatment of discrete lesions from cancer. The most recent American Society of Radiation Oncology (ASTRO) 
model SBRT coverage policy, reflecting national expert opinion, states that SBRT is indicated for primary 
tumors of and tumors metastatic to the lung, liver, kidney, adrenal gland or pancreas is medically necessary 
when the enrollees performance status justifies aggressive treatment, and for those whose tumor burden can be 
completely targeted with acceptable risks. For metastatic disease, SBRT is generally only indicated for 
enrollees with oligometastatic disease for those undergoing palliation after prior radiation. Oligometastases are 
defined as a state of metastatic disease with metastases few in number and extent. This case is challenging 
because the enrollee arguably has oligoprogression, i.e., one or few lesions growing in setting of widespread 
progression, which does not strictly fulfill the ASTRO model policy criteria of tumor burden that can be 
completely targeted with acceptable risks. Yet, the enrollee has had very prolonged (decades) disease course 
such that it is not a far reach to assert that the pancreatic tumor is the only site of viable cancer and that ablating 
it could be helpful. Even if that was considered a reach, palliative radiation would be an accepted standard of 
care, and in the setting of re-irradiation, which applies for this enrollee who had another pancreatic lesion 
treated such that dose overlap would be minimized with SBRT.  
 
On the basis of standard medical necessity criteria, the reviewer believes that the treatment offered to this 
enrollee could be considered to be furnished in accordance with accepted standards of medical practice, 
acknowledging that the data supporting this treatment continue to arise and data specific for this situation 
would be limited due to the rarity of such a long-term survivor of metastatic cancer who has had indolent/active 
disease for many years. 
 
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) (77373, 77470).  
 
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.