Diagnosis: Cancer.
Treatment: Radiation Therapy.

The insurer denied Proton Beam Therapy.
The denial is upheld.

This patient is a male, who presented with locally advanced Prostate cancer. He is being evaluated by his provider, with curative intent radiation using Proton beam.
At issue is the medical necessity of Proton Beam Therapy.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Proton Beam Therapy is not medically necessary for this patient.

The treatment of prostate cancer in the United State which is in accordance with generally accepted standards of medical practice in the United States is intensity modulated radiation therapy (IMRT). Proton beam treatment is being evaluated under National Cancer Institute (NCI) sponsored trials.

The use of Proton Beam radiation therapy as definitive treatment for prostate cancer has medical literature with relatively short follow up with proton beam therapy as monotherapy for prostate malignancies. These studies show equivalent control rates to other types of radiation therapy for the shorter follow up periods. There are also retrospective studies with large numbers of patients that have shown worse gastrointestinal (GI) side effects as compared to photon beam radiation therapy with IMRT. There is a lack of randomized studies regarding proton beam radiation therapy alone as treatment for prostate cancer that show equivalent outcome or any improvement over other forms of radiation therapy such as photon IMRT. Until the current randomized trials ongoing are published in peer reviewed medical literature, this treatment for prostate cancer is considered investigational and not medically necessary.

Therefore, the requested health service/treatment of Proton Beam Therapy is not medically necessary.