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Stereotactic Body Radiotherapy denials: what the review data shows
Independent reviewers have decided 20 published cases where an insurer denied Stereotactic Body Radiotherapy — and they overturned the insurer 35% of the time. A denial for Stereotactic Body Radiotherapy is a starting position, not a final answer.
Published decisions
20
2001–2026
Overturned
35%
7 denials reversed
Conditions behind stereotactic body radiotherapy denials
What insurers denied — and how those fights ended.
| Category | Decisions | Overturned |
|---|---|---|
| Prostate Cancer | 7 | 0% |
| Pancreatic Cancer | 5 | 60% |
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. | 17 | 29.4% |
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 3 | 66.7% |
Typical time to a decision
7 days
Most land between 6 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 radiotherapy (SBRT). Historically, the management of metastatic breast 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 breast 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 metastatic tumor deposits to continue to grow despite good overall disease control in the rest of the body.
A 64-year-old male enrollee has requested for stereotactic body radiotherapy (SBRT) or in the alternative, external beam radiation therapy (EBRT) for treatment of the his pancreatic cancer. Findings: The physician reviewer found that stereotactic body radiotherapy (SBRT), delivering high fractional (8-20 Gy) doses in 1-5 fractions, with image guidance or other means to improve precision, is an established approach for the treatment of discrete lesions from cancer. In addition, there are several publications describing improved health outcomes in patients treated with SBRT for pancreatic cancer. In 2004, Koong and colleagues conducted a Phase I trial in which 15 patients with unresectable pancreatic cancer received single fraction SBRT, escalated from 15 to 25 Gy. No acute grade 3 toxicity was observed.
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 reimbursement for stereotactic body radiotherapy for treatment of the enrollee’s prostate cancer. Findings: The physician reviewer found that The physician reviewer found the medical evidence has not established the superior effectiveness of stereotactic body radiotherapy in this clinical setting. Outcome data for stereotactic body radiotherapy at this time is limited to five-year to six-year follow-up. The study by Katz and colleagues evaluated prostate cancer patients treated with stereotactic body radiotherapy (total patient number was 304, and 81 were intermediate-risk). The five-year biochemical disease free survival was 90.7% for intermediate-risk, and toxicity was also acceptable.
Nature of Statutory Criteria/Case Summary: An enrollee has requested stereotactic body radiotherapy (SBRT) for treatment of the enrollee’s metastatic pancreatic neuroendocrine tumor and breast cancer. Findings: Two physician reviewers found that external beam radiation therapy (EBRT) remains a conventional and efficacious method of palliative radiation therapy for patients with spine metastases. By comparison, SBRT has resulted in comparable rates of pain relief and late treatment related toxicity. SBRT continues to show promise as an emerging modality in selected patients with spine metastases.
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 Radiotherapywhen 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.