Diagnosis: Left lateral oral tongue squamous cell carcinoma

Treatment proton beam radiation therapy

The insurer denied coverage for proton beam radiation therapy

The denial is overturned

This case involves a female patient who has been diagnosed with left lateral oral tongue squamous cell carcinoma status post left partial glossectomy and left neck level 2-4 dissection with close medial tongue margins of 7.5 mm (millimeter) who is being seen regarding adjuvant radiotherapy. The documentation indicated the presence of multiple intermediate risk factors on surgical pathology warrants of the requested adjuvant radiation therapy to reduce the risk of local primary or neck recurrence. The request has been received for coverage for proton beam radiation therapy.
Additional submitted documentation does include radiation oncology consult note where she was seen for consultation. The documentation indicated her history began when she first noticed an area of irritation to the left posterior lateral portion of the tongue. There are no other associated symptoms present. She underwent biopsy with pathology consistent with squamous cell carcinoma. She then underwent a left partial glossectomy and neck dissection. The documentation indicated the patient did feel well, overall. She denied any pain and does not utilize any medication. Her speech was overall understandable, and the physician indicated once again, given the presence of multiple intermediate risk factors on surgical pathology it was recommended; she receive adjuvant radiation therapy.
The medical records include a comparison plan for this specific patient between intensity-modulated radiation therapy (IMRT) photons and proton therapy. The dose to several critical structures are significantly lower for the proton plan. In particular, the radiation dose to both left and parotid gland are remarkably lower with the proton plan. The parotid gland doses for the IMRT photon plan are unusually high, but even if the mean dose of 26 Gy [(Gray) unit to measure radiation a patient is exposed to] is met for both glands, the proton plan is clinically significantly superior. For this reason, proton therapy is medically necessary in this case to spare these critical adjacent structures and because the treatment is part of a protocol.
The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.
The insurer's denial of coverage for proton beam radiation therapy is reversed. Medical necessity is substantiated.