Diagnosis: Synovial sarcoma
Treatment: Proton Beam Radiation Therapy
The insurer denied the Proton Beam Radiation Therapy
The denial is overturned

The paring is a male with a diagnosis of synovial sarcoma involving the right supraclavicular region. The plan is neoadjuvant chemotherapy followed by surgical resection and adjuvant radiation therapy, and proton therapy was requested.

The initial proton therapy request was denied because it does not meet eviCore criteria for coverage and is not considered medically necessary.

Yes, the proposed treatment with proton beam radiation therapy is medically necessary.
The requested proton therapy is medically necessary because it is consistent with generally accepted standards of good medical practice in the United States, is clinically appropriate and considered effective for patient's illness and is not for the personal comfort or convenience of the patient, family or provider.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
A photon/proton comparison plan was done. The Dmax spinal cord dose (spinal cord point maximum doses) was 55 gray (Gy) with photon (which exceeded tolerance) and 1.5 gray (Gy) with proton therapy (within tolerance). The brachial plexus Dmax (spinal cord point maximum doses) was 114 gray (Gy) with photon therapy (exceeded tolerance) and 59.1 gray (Gy) with proton therapy (within tolerance). If photon based radiation was utilized, there is a significantly high risk of spinal cord and brachial plexus injury. The proton plan was able to reduce the radiation dose to those structures with acceptable levels.