Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 42-year-old female who presented to her provider on 10/26/22 with a diagnosis 
of squamous cell carcinoma in situ. The patient has requested reimbursement for high dose rate 
electronic brachytherapy, skin surface application, per fraction, including basic dosimetry, when 
performed, from 11/15/22 through 12/13/22. The Health Insurer has denied this request and 
reported that the services at issue were not medically necessary for the treatment of this patient. 
The physician reviewer found that the submitted documentation supports the medical necessity 
of the services at issue. Squamous cell carcinoma in situ is a precursor to squamous cell carcinoma 
that should be treated. There are a variety of modalities for the treatment of basal cell carcinoma 
and squamous cell carcinoma including surgery, radiation therapy, and topical agents. Although 
surgical excision is the primary treatment approach for curative treatment of non-melanoma skin 
cancers, radiation therapy can play an integral role in both the definitive and adjuvant settings. 
In  patients  who  cannot  undergo  or  decline  surgical  resection,  definitive  radiotherapy  is 
recommended as a curative treatment modality. Radiation treatment is a non-invasive treatment 
with similar cure rates to surgery. Radiation therapy, including external beam and brachytherapy 
techniques, has been used as primary and post-surgical adjuvant therapy for non-melanoma skin 
cancers. High dose rate brachytherapy (HDR-BT) using skin surface applicators or surface molds 
has several advantages over electron beam radiotherapy, particularly for irregular surfaces and 
difficult  areas  such  as  in  and  around  the  nose  or  earlobe,  including:  (1)  Electron  beam 
radiotherapy for irregular surfaces and facial areas, such as the nose, may be associated with 
setup errors and difficulty in planning, (2) HDR-BT provides a rapid dose fall-off outside the target 
volume,  (3)  HDR-BT  provides  important  potential  advantages  by  reducing  the  number  of 
treatments and the duration of the treatment schedule, and (4) in addition to excellent local 
control, HDR-BT has an appealing cosmetic outcome, with some series reporting excellent 
cosmetic outcomes in 98% of patients treated. In this case, the patient had a very small lesion on 
her nose. Given the size and location of the lesion, a very small electron field would have been 
required  to  treat  this  lesion  if  electron  beam  radiotherapy  is  used.  Significant  dosimetry 
challenges and uncertainties exist when small field electron beam radiotherapy is utilized to treat 
skin cancers or superficial lesions. Complex dosimetric measurements would have been required 
for accurate treatment planning using small field electron beam radiotherapy due to physical and 
dosimetric characteristics of small radiotherapy electron beams. In this clinical setting, HDR 
electronic brachytherapy was the preferred radiation treatment option and was medically 
indicated. Therefore, high dose rate electronic brachytherapy, skin surface application, per 
fraction, including basic dosimetry, when performed, from 11/15/22 through 12/13/22, was 
medically necessary for the treatment of this patient.