Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT) (G0339, G0340). 
 
You asked the Plan to pre-approve SBRT. You say that SBRT is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the requested service is not covered by Medicare of the health plan. 
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 stereotactic body radiotherapy, delivering high fractional doses to the prostate in 3-5 fractions 
is an emerging approach to the treatment of prostate cancer. Some published studies have included enrollees 
with high-risk disease, for which SBRT has been controversial in recent years. SBRT is included in the latest 
version of National Comprehensive Cancer Network (NCCN) (April 2023) treatment guidelines for early-stage 
prostate cancer. The Principles of Radiation Therapy section in these NCCN guidelines now state for patients 
with high and very high-risk prostate cancer: SBRT combined with androgen deprivation therapy (ADT) can 
be considered if delivering longer courses of external beam radiation therapy (EBRT) would present a medical 
or social hardship. and that ADT is recommended unless medically contraindicated. The guidelines also state 
that SBRT is acceptable in practices with appropriate technology, physics and clinical expertise. The 
discussion in the NCCN guidelines summarizes published data and concludes that for SBRT Longer follow-
up and prospective multi-institutional data are required to evaluate longer term results, especially because late 
toxicity theoretically could be worse. Arguably SBRT is more cost-effective (which would benefit the insurer), 
and perhaps equivalent or superior to conventionally fractionated intensity-modulated radiation therapy 
(IMRT)/image-guided radiotherapy (IGRT), though for high-risk disease, is still somewhat controversial. 
Nevertheless, based upon NCCN guidelines, SBRT with ADT would be furnished in accordance with 
accepted standards of medical practice. Therefore, the decision is favorable. 
 
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) (G0339, G0340).  
 
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.