Diagnosis: Prostate Cancer
Treatment: Stereotactic body radiation therapy
The insurer denied stereotactic body radiation therapy.
The determination is overturned.

This is a male patient with a history of a prostate adenocarcinoma Gleason 7 (seven) disease treated with radiation therapy as definitive treatment. He then had a rise in his prostate-specific antigen (PSA). He had restaging scans and was found to have disease at the bilateral internal iliac nodes, right common iliac and left acetabulum. Palliative radiation therapy is recommended for this oligometastatic disease and stereotactic body radiation therapy (SBRT) for 5 (five) fractions to each lesion is recommended. At issue is the medical necessity of the stereotactic body radiation therapy.
The requested treatment of SBRT (stereotactic body radiation therapy) is medically necessary for this patient.
The statement on the denial information that there are more than five treatments for the course of treatments is not correct. The primary site of disease has been treated and in control. Because the pelvis has had previous radiation is also another reason to treat these oligometastases with SBRT (stereotactic body radiation therapy) to protect critical vital structures adjacent to the target volumes that have received some radiation dosing from primary radiation to the prostate. The medical policy states only up to 3 (three) lesions can be treated with no clinical trials stating the exact number of oligometastases that can be treated successfully and safely. The SABR - COMET trials [Stereotactic Ablative Radiotherapy for the Comprehensive Treatment of Oligometastatic Cancers] have shown excellent improvement in survival with no stated limits of the number of oligometastases treated with SBRT. The requested 4 (four) lesion to be treated with 5 (five) fractions of SBRT (stereotactic body radiation therapy) per course of treatment is considered medically appropriate and necessary.