Cyberknife Radiosurgery denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient is a 59-year-old male who presented with stage IV non-small cell lung cancer in August 2004. He received external beam radiation therapy for metastatic disease to his spine. This was followed by Cyberknife radiosurgery and then surgical resection. This was then followed by systemic chemotherapy for progressive disease. Recently, the patient was diagnosed with a single right parietal brain metastatic lesion. The options discussed were Cyberknife radiosurgery alone versus whole brain radiation therapy with Cyberknife boost. The patient wishes to proceed with Cyberknife radiosurgery without whole brain radiation. The Health Plan has denied authorization for the requested procedure on the basis that it is not medically necessary in this clinical setting.This patient with stage IV lung cancer has been treated aggressively to date, especially for the spinal metastatic disease.

A 49-year-old male enrollee has requested authorization and coverage for radiosurgery via CyberKnife for treatment of the enrollee’s acoustic neuroma. Findings: The physician reviewer found that stereotactic radiosurgery has become a well-established treatment modality in the management of selected patients with acoustic neuromas. According to German, et al., among neurotologists, 42% perform stereotactic radiosurgery (approximately 58% of those use Gamma Knife, and 44% use CyberKnife) and 37% percent of patients seen by neurotologists receive radiation. Results are better than with those obtained using whole-brain radiotherapy and comparable to the best selected surgery-radiation series. However, review of the relevant peer-reviewed evidence does not reveal adequate data that CyberKnife is superior to conventional radiosurgery in this setting.

Where the denial was upheld

A 57-year-old female enrollee has requested CyberKnife radiosurgery for the treatment of her acoustic neuroma. Findings: The physician reviewer found that the three major treatment options for acoustic neuromas are observation, surgery, and radiation therapy. Observation is usually reserved for patients whose symptoms and/or tumor size are stable or progressing only slowly. Stereotactic radiosurgery (SRS) is a technique that utilizes multiple convergent beams to deliver a single high dose of radiation to a radiographically discrete treatment volume, thereby minimizing injury to adjacent structures. This can be accomplished with either the gamma knife or a linear accelerator. Radiosurgery is a viable treatment option for selected patients with smaller tumors (less than 3 cm) or for enlarging tumors in patients who are not candidates for surgery.

A 63-year-old male enrollee has requested CyberKnife radiosurgery for the treatment of his unresectable hilar cholangiocarcinoma. Findings: Three physician reviewers found that locally advanced, metastatic gallbladder cancer has a poor prognosis. Radiation is used primarily for palliation of symptoms from local progression, such as biliary obstruction, bowel obstruction and splanchnic nerve pain. Decades of literature indicates that radiotherapy with unresectable gallbladder cancer is medically indicated. Chemotherapy also is used for palliation, and the standard treatment in patients with reasonably good performance status is to offer both chemotherapy and radiation. With newer technology, newer tools are available to deliver the radiation.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Cyberknife Radiosurgery, then check the rights and deadlines that apply to your plan.