This is a patient with a left tonsil squamous cell carcinoma. He had a resection with neck dissection that revealed a stage tumor (T) 2 nodes (N) 1 metastasis (M) 0 squamous cell carcinoma with negative margins with large cervical lymph node metastases with extra capsular extension. Radiation therapy with concurrent chemotherapy are recommended to attempt long term control and the proton beam approach is requested. At issue is the medical necessity of proton beam radiation therapy.
The health plan's determination is upheld.

The requested health service or treatment of proton beam radiation therapy for head and neck cancer is not considered medically necessary for this patient. This is a patient with a left tonsil squamous cell carcinoma. He had a resection with neck dissection and radiation therapy with concurrent chemotherapy are recommended to attempt long term control. There is a lack of any significant randomized trials published in peer reviewed literature supporting the benefits of proton beam radiation over photon beam radiation or the safety of proton beam radiation for this diagnosis. Additional randomized trials are needed as recommended by the cited literature below to determine the efficacy and safety of proton radiation for this patient's clinical scenario. Therefore, the requested service/treatment is not medically necessary.