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202304-161964

2023

Empire Healthchoice Assurance Inc.

PPO

Cancer

Radiation Therapy

Medical necessity

Overturned

Case Summary

Diagnosis: Pituitary Adenoma.
Treatment: Stereotactic body radiotherapy (SBRT); procedure codes 77373 and 77435.

The insurer denied coverage for stereotactic body radiotherapy (SBRT); procedure codes 77373 and 77435.

The denial is overturned.

Radiation therapy (RT) in pituitary adenoma should be offered only to patients with residual, recurrent, progressive, or high-risk tumors with careful assessment of the benefit-risk ratio by an experienced multidisciplinary neuro-oncology team.
The choice of RT technique should be based on size, site, and availability of infrastructure and expertise, with no significant differences between fractionated approaches and stereotactic radiosurgery (SRS).

This patient has a slowly growing pituitary tumor which can be treated with single shot Gamma knife, fractionated intensity modulated radiation therapy (IMRT) or fractionated stereotactic radiosurgery (SRS). Although the patient has no visual symptoms, it is better to treat now rather than waiting for symptoms as the tumor is in a critical location.
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for stereotactic body radiotherapy (SBRT); procedure codes 77373 and 77435 is substantiated.

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