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Stereotactic Body Radiation Therapy denials: what the review data shows
Independent reviewers have decided 20 published cases where an insurer denied Stereotactic Body Radiation Therapy — and they overturned the insurer 50% of the time. A denial for Stereotactic Body Radiation Therapy is a starting position, not a final answer.
Published decisions
20
2001–2026
Overturned
50%
10 denials reversed
Conditions behind stereotactic body radiation therapy denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Prostate Cancer | 7 | 14.3% |
What the insurer actually argued
Denials fall into different categories, and they don’t succeed equally — so the reason on your letter changes how you should answer it.
| Reason given | Decisions | Overturned |
|---|---|---|
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 15 | 40% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 5 | 80% |
Typical time to a decision
6 days
Most land between 5 and 7 days
Handled as urgent
85%
Expedited when a delay would cause harm
What the reviewers wrote
Excerpts from the independent reviewers’ published findings — the actual reasoning, quoted, not summarised.
Where the denial was overturned
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for stereotactic body radiation therapy (SBRT). Historically, the management of patients with metastatic prostate cancer was focused on systemic therapies such as hormonal therapy, chemotherapy, or immunotherapy. The advent of newer molecular sequencing techniques and targeted systemic treatments has allowed clinicians to provide tailored systemic therapies to metastatic prostate cancer patients. Patients who respond well to these targeted systemic therapies demonstrate 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.
Findings: The physician reviewer found that the patient has requested reimbursement for stereotactic body radiation therapy (SBRT). Historically, the management of patients with metastatic tumors was focused on systemic therapies such as chemotherapy. The advent of newer targeted and systemic therapies has allowed clinicians to provide more effective treatment to metastatic cancer patients. Patients who respond well to these systemic therapies demonstrate 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, which was the case with this patient. This disease state is referred to as oligometastatic disease.
Where the denial was upheld
Worth reading too — these show what an appeal has to overcome.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stereotactic body radiation therapy for treatment of the enrollee who has a history of lung cancer. Findings: The physician reviewer found that The requested services are not medically necessary for treatment of this patient’s medical condition. SBRT, delivering high fractional doses in 4-5 fractions, is an established approach for the treatment of discrete lesions from cancer. SBRT systems use fiducials, bony anatomy or external markers as a coordinate system to map the delivery of radiation to increase the precision and accuracy of radiation delivery. SBRT can be considered in select patients with oligometastatic bone metastases.
Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for stereotactic body radiation therapy (SBRT).Radiation treatment in both the pre-operative and post-operative setting has played a significant role in the treatment of soft tissue sarcomas of the extremities. Per the National Comprehensive Cancer Network (NCCN guidelines), there is a benefit to pre-operative radiation treatment of extremity sarcomas as compared to post-operative treatment. SBRT delivers high doses of radiation treatment in fewer sessions. It has found a significant role in certain disease sites, such as brain metastases and early-stage lung cancers. However, the role of SBRT in the setting of soft tissue sarcoma of the extremity is still an active area of research.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California outcomes — every state runs an equivalent external review, but the rates here are California’s. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
How to use this in your appeal
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 Stereotactic Body Radiation Therapywhen you appeal: reviewers routinely find that denials like yours didn’t hold up.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · DERIVED AGGREGATE STATISTICS ONLY · METHODOLOGY
Not legal or medical advice. Coverage Rights is a self-help tool that helps you prepare your own appeal. For advice about your specific situation, talk to a licensed attorney or your doctor.