Cyberknife Stereotactic Radiosurgery denials: what the review data shows

Where the denial was overturned

Physician 1: The patient is a 47-year-old male diagnosed with a high-grade pleomorphic sarcoma of the left supraclavicular fossa. The recommendation of the treating oncologist was for a dose of 60 Gy delivered in 30 fractions to the left supraclavicular area. A post-treatment note from April 2005 indicated the PET and CT scan revealed no solid evidence of recurrence, however, a note dated July 2006 indicated a locally recurrent high-grade pleomorphic sarcoma interposed between the left scapula, clavicle and chest wall, occurring two years after neoadjuvant chemotherapy, surgical resection and post-operative radiation therapy. According to the radiation oncologist, the superior aspect of the patient’s recurrence was clearly within his prior radiation therapy portal, with the inferior aspect of it appearing to extend beneath the inferior margin on the portal.

A 60-year-old male enrollee has requested CyberKnife stereotactic radiosurgery (or intensity modulated radiation therapy, in the alternative) for treatment of his hepatocellular carcinoma. Findings: Two physician reviewers found that the patient was seen at a center of excellence by an international expert on the use of stereotactic radiosurgery (SRS) for brain and spine tumors. The records have demonstrated that he has a solitary site of residual metastatic disease at present. He had 1 known site of disease over the past 15 months, and has done well with aggressive therapy. In general, conventional radiation for treatment of spinal tumors is difficult to control given the radiation sensitivity of the adjacent spinal cord, preventing doses that are likely to provide a sustained response.

Where the denial was upheld

A 71-year-old male enrollee has requested for CyberKnife stereotactic radiosurgery for treatment of his prostate cancer. Findings: Three physician reviewers found that the guidelines are developed through an explicit review of the evidence integrated with expert medical judgment by multidisciplinary panels from NCCN member institutions. Treatment recommendations are specific and are implemented through performance measurement. In reviewing current NCCN guidelines, this patient would be deemed a low recurrence risk. Based on a life expectancy of greater than ten years, options regarding initial therapy would be active surveillance, radiation therapy or radical prostatectomy. Additionally, these guidelines state that 3D conformal or IMRT technique should be employed.

A 32-year-old female enrollee has requested for Cyberknife stereotactic radiosurgery for treatment of her metastatic non-small cell lung cancer. Findings: Two physician reviewers found that the patient has stage IV lung cancer that was treated aggressively with resection of brain metastatic disease followed by Cyberknife radiosurgery. She then received aggressive treatment for lung primary cancer and further treatment with Cyberknife. The patient presented with stage IV lung cancer and despite aggressive chemoradiation and further systemic treatment with Tarceva, she still has persistent systemic disease. Conventional palliative radiotherapy is appropriate in this setting. There is no data to suggest that Cyberknife treatment is likely to be superior to standard radiotherapy.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Cyberknife Stereotactic Radiosurgerywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.