Diagnosis: Anal Cancer
Treatment: Proton Beam Therapy
The insurer denied the Proton Beam Therapy.
The determination is upheld.

The patient has a prior history of acute myelogenous leukemia (AML) status/post (s/p) chemotherapy and stem cell transplantation and now presents with clinical (c) tumor (T) 2 nodes (N) 1 metastasis (M) 0 invasive squamous cell carcinoma of her anal canal. She has been recommended to proceed with a course of definitive chemoradiotherapy with curative intent. At issue is whether the proton beam therapy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The requested proton beam radiotherapy. is not likely to be more beneficial than standard of care photon-based intensity modulated radiation therapy (IMRT) in the patient's setting. Proton radiation is not proven to yield superior clinical outcomes for management of invasive anal cancer per the current peer reviewed medical literature and expert consensus national guidelines. The treating provider did not supply a customized proton/photon plan comparison to justify necessity of proton radiation in the patient's situation (the provided comparison was a representative case example and not specific to the patient). The patient had not previously received pelvic radiotherapy in the past, and she does not have a comorbid/genetic condition that increases her risk for normal tissue toxicity. Proton radiation in the member's setting is not supported by the American Society for Radiation Oncology (ASTRO) Model Policy outside the context of a prospective clinical trial. Therefore, the requested proton beam radiotherapy is not likely to be more beneficial than standard of care photon-based IMRT in the member's setting.