Stereotactic Body Radiation Therapy denials in California external review

What the reviewers wrote

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

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.

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 Stereotactic Body Radiation Therapy, then check the rights and deadlines that apply to your plan.