Diagnosis: Cancer.
Treatment: Proton beam therapy.

The insurer denied proton beam therapy. The health plan's determination is upheld.

This patient is a male with a Thymoma post resection. Radiation therapy is recommended to this region to decrease its risk of recurrence and proton beam approach is requested. The request is for proton beam radiation therapy.

No, the proposed health service or treatment of proton beam therapy is not likely to be more beneficial than any standard treatment for the insured's life threatening or disabling condition or disease.

The health plan's determination is upheld. Based on the provided clinical information and the provided Aetna CPB 0270 on proton beam radiotherapy, the requested proton beam therapy is considered not medically necessary. There is a lack of any significant clinical trials published in peer reviewed journals supporting the benefits and safety of proton radiation over conventional standard of care photon beam radiation therapy with intensity modulated radiation therapy (IMRT). In this clinical scenario only case controlled comparison plans were provided, not a comparison of the actual patient and his unique anatomy and tumor location. This treatment is also not supported by National Comprehensive Cancer Network (NCCN) Guidelines with category 2a support. There are small dosimetric studies that show potential for improved outcomes with decreased side effects. However, additional phase III clinical trials are needed to determine the exact benefits and safety of proton beam radiation therapy for this patient's clinical scenario. The requested proton beam radiation therapy should be denied.