Diagnosis: Rectal adenocarcinoma
Treatment: Proton Beam Radiation
The insurer denied: Proton beam therapy
The denial is: Upheld

The patient is a male who presented with tumor (T)3 node (N)1 metastasis (M) 0 adenocarcinoma of rectum. The patient was treated with neoadjuvant chemotherapy with complete response. The patient is planned with radiation therapy (RT) using proton beam. The subject under review is the medical necessity for the proton beam therapy.

The requested treatment with proton beam therapy is not medically necessary for this patient. Medically necessary treatment is defined as those treatments which are In accordance with generally accepted standards of medical practice in the United States.
In this case, radiation treatments which are in accordance with generally accepted standards of medical practice in the United States for rectal cancer are three dimensional (3D) conformal radiation therapy (CRT) or intensity modulated radiation therapy (IMRT) using photon.
National Comprehensive Cancer Network (NCCN) guidelines do not recommend proton beam for this clinical scenario. There are no published data to support proton beam for curative intent without surgery.
Proton treatment is not in accordance with generally accepted standards of medical practice in the United States for treatment of rectal cancer.