Stereotactic Body Radiotherapy 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 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

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.

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 Radiotherapy, then check the rights and deadlines that apply to your plan.