Diagnosis: Cancer/Breast Cancer
Treatment: Radiation Therapy
The health plan denied the requested procedure as not medically necessary. The health plan's determination is overturned.

This is a female with history of recurrent left-sided breast cancer. She was previously treated with breast conserving lumpectomy and hypo fractionated whole breast radiotherapy for pT2N0 left breast cancer. She presented with multifocal recurrence of her left breast cancer and was treated with a left mastectomy, lymph node dissection, and implant removal showing 3 out of 10 involved lymph nodes and a close anterior margin. She then received postoperative systemic chemotherapy. She has been recommended to proceed with a course of reirradiation to her left chest wall and regional lymph nodes (including her internal mammary lymph nodes), with curative intent. The request is for approval of proton beam radiotherapy.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested proton beam radiotherapy is medically necessary in this patient's case. Proton beam radiotherapy is standard of care and the most appropriate radiation modality in this patient's unique clinical situation requiring reirradiation in close proximity to her heart and left lung. The treating provider performed a proton/photon plan comparison which revealed that the patient cannot be treated safely/effectively with the use of photon-based radiotherapy (including volumetric arc therapy (VMAT) planned intensity modulated radiation therapy (IMRT)) as this resulted in excessive exposure to the patient's heart tissue. Photon-based planning would lead to an unacceptable risk for cardiac morbidity/mortality. The proton radiation therapy plan was able to significantly reduce this exposure to within known safe tolerance limits for the patient's heart. The ASTRO Model Policy for proton radiation therapy supports its use in this patient's unique clinical situation because she cannot be treated safely with photon-based radiotherapy. There are numerous high quality prospective clinical outcomes published in the peer reviewed medical literature that support the use of proton beam radiotherapy for reirradiation of recurrent breast cancer.