Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 62-year-old male who presented to his provider on 9/12/22. The patient has 
requested authorization and coverage for stereotactic body radiation therapy. The physician 
reviewer found that at issue is whether the requested stereotactic body radiation therapy is 
medically necessary for the treatment of this patient. The submitted documentation supports 
the medical necessity of the requested service. Historically, the management of metastatic 
tumors  was  focused  on  systemic  therapies  such  as  chemotherapy.  The  advent  of  newer 
molecular sequencing techniques and targeted therapies has allowed clinicians to provide very 
tailored systemic therapies to metastatic cancer patients. Patients who respond well to these 
targeted systemic therapies demonstrate very good disease response throughout most of their 
body. However, it is still common for certain localized metastatic tumor deposits to continue to 
grow despite good overall disease control in the rest of the body, as is the case in this patient. 
This disease state is referred to as oligometastatic disease and the role of stereotactic body 
radiation therapy (SBRT) in this setting is a very active area of research. There is strong evidence 
showing improved overall survival and progression-free survival with the addition of SBRT to 
systemic therapies in an oligometastatic setting. SBRT technique allows for higher doses to be 
delivered with greater precision, allowing for very high local control when treating localized 
lesions. SBRT also allows for very rapid radiation dose falloff outside of the treated lesion, 
meaning less exposure to surrounding normal tissues and resulting in less normal organ toxicity. 
Navarria and colleagues report that SBRT has promising results in terms of local control, survival, 
and toxicity. There are very few grade 3 or higher toxicities seen with the administration of SBRT 
to the thoracic area and lung. This improved toxicity profile is only achievable with SBRT 
technique  and  not  with  standard  radiation  techniques.  Further  improvements  in  targeted 
systemic therapy will require equal improvements in local disease control. The clinical implication 
of oligometastatic disease is that cure or long-term survival can be achieved for this subset of 
patients with metastatic disease, so minimizing treatment toxicity is critical. In this case, the 
patient had a previous course of radiation therapy to the adjacent chest wall. It is not uncommon 
for patients with oligometastatic cancers to undergo several courses of local radiation therapy as 
their oligometastatic state evolves over time. SBRT allows for very high ablative radiation doses 
to be delivered to small areas of disease while avoiding previously irradiated tissue. Some of the 
toxicities of overlapping reirradiation include chronic ulcers, fibrosis, rib fracture, and chronic 
pain. Each of these toxicities may be debilitating, so it is critical to utilize highly focused radiation 
techniques. In this case, as the records note that the patient already had a wedge resection of 
the lung, reducing his functional lung capacity, it is critical to spare normal lung volume from 
excess  radiation  exposure.  In this  clinical  setting,  given  this patients  previously  irradiated 
adjacent chest wall and history of lung resection, the requested service is medically indicated. 
Therefore, stereotactic body radiation therapy is medically necessary for the treatment of this 
patient.