IpubMD - Appeal Review
Title: Appeal of Denial for Prostate Cancer Treatment
Subject: Appeal of Denial for Prostate Cancer Treatment Template
Author: Mr. Monteagudo Al



To:     Insurance Company  

Re:      Appeal of Denial for Prostate Cancer Treatment
Patient Name
    Patient ID Number

Dear Sir or Madam:

I am writing to request an appeal of the denied request for the prostate cancer treatment of .

Early prostate cancer can be treated in many ways. It is clear that in addition to the efficacy of any particular treatment, the duration and side effects of that treatment massively influence choice. Stereotactic Body Radiation Therapy (SBRT, Cyberknife) with image guidance and motion tracking/compensation is what we recommend for many patients with clinically localized low-risk to intermediate-risk prostate cancer for the following reasons:

Efficacy – Recently published abstracts for American Society for Radiation Oncology (ASTRO) 2010 show 5-year disease-free survival of 96-98% with continued low rates of late toxicity (0-3% Grade 3+ urinary and 0% Grade 3+ rectal toxicity). The two charts below represent a summary of publications from peer reviewed journals that show the Cyberknife (SBRT) is performing with lower toxicities, including erectile function preservation, and effectively eliminating the cancer compared to other radiation modalities.

This is a summary of the aggregate data that includes erectile function.

Cost – Add something here about cost comparison from your institutions that illustrate the CK is more effective over traditional therapies offered to patient.

Quality of life – Cyberknife treats prostate cancer in 5 or fewer fractions. Conventional radiation treatment requires 43 days, over a 9 week period while Cyberknife takes 5 days in one week.  This is important to the patient because he is still employed.

Side effects – Cyberknife uses a real time imaging system thus compensating for movement of the prostate and other organs; it is able to aim the radiation from significantly more angles than other radiation technologies thus resulting in potentially less damage to the surrounding tissue and organs, including the bladder, rectum and neurovascular bundle.

Pain free and no anesthesia – Apart from the introduction of gold fiducials for motion compensation, Cyberknife is non invasive and completely pain free. Cyberknife does not require anesthesia and there is no recovery time in contrast to other invasive treatments such as bracheotherapy and surgery.

The Cyberknife received FDA 510(k) clearance in 1999 to provide treatment planning and image-guided robotic radiosurgery for tumors in the head and neck.  And in 2001, the Cyberknife received 510(k) clearance to treat tumors anywhere in the body where radiation treatment is indicated.

Thus, coverage should be provided by for a delivery system that administers a traditional and well-recognized form of cancer treatment that can be of benefit to patient and insurer alike. We respectfully request that fund this procedure and consider it to be the most appropriate and medically necessary treatment for the prostate cancer treatment of .

Clinical articles have been included for your review and due-diligence process.  Please contact us at if you require additional information.


1. ||Medicare and CyberKnife||Blue Shield SRS Policy||HDR Brachytherapy by Martinez MD||First 1000 cases||Rationale, conduct, and outcome using hypofractionated radiotherapy in prostate cancer Mark Ritter, M.D., Ph.D. [Professor]
Supporting Articles:
1. Medicare and CyberKnife
2. Blue Shield SRS Policy
3. HDR Brachytherapy by Martinez MD
4. First 1000 cases
5. Rationale, conduct, and outcome using hypofractionated radiotherapy in prostate cancer Mark Ritter, M.D., Ph.D. [Professor]