Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve IMRT in 15 fractions. We decided that the Plan does not have to 
pre-approve additional fractions of IMRT beyond 15.  
 
You asked the Plan to pre-approve IMRT in 15 fractions. You say that the enrollee needs this treatment. The 
Plan says that 3D conformal radiation would be appropriate. IMRT exceeds the enrollee's medical needs. 
 
We decided that the Plan has to pre-approve IMRT in 15 fractions.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IMRT in 15 fractions. Our reviewer 
says that the documentation supports that up to 15 fractions of IMRT as noted in the treatment plan is 
considered medically reasonable and necessary in this case. Our physician reviewer found IMRT is a tool that 
clinicians can use when there is concern about sparing normal tissues from high dose exposure.  IMRT 
generally implies inverse planning algorithms, i.e. the physician determines radiation treatment parameters to 
maximize dose to the target and minimize dose to normal tissues, and the planning algorithm maximizes the 
adherence to these parameters by modifying the beam spatially and/or temporally.   Usually, multiple fields 
(>5) are delivered. IMRT for abdominal cancers is used to reduce dose to the small bowel, rectum, bladder, 
pelvic bone marrow and femoral heads.  
 
This case is complicated by the unknown origin of the cancer and the widely metastatic disease (with peritoneal 
implants). The treatment with radiotherapy is therefore palliative. Certainly IMRT can be considered in 
exceptional circumstances. This patient with a visceral malignancy representing the bulk of her disease could 
be considered an exceptional circumstance for which escalating the dose and considering IMRT is warranted. 
Two plan comparisons are provided, comparing IMRT with 3D conformal radiation. One plan comparison is 
for 3 Gy x15 while the other is for 2.5 Gy 20. In both, the IMRT plan better spares the rectum and bladder in a 
clinically meaningful manner. Both are fairly comparable with respect to calculated biologically effectiveness.  
 
As the intent is palliation, it is generally in the best interest of the patient to undergo a less protracted course of 
treatment in an effort to not delay systemic therapy as well as to shorten the duration of treatment in a patient 
with anticipated poor prognosis in the setting of metastatic disease. Therefore, if one is to consider IMRT 
medically necessary in this patient, accepting that escalating the dose beyond typical palliative regimens, then 
the standard would be to use the treatment with shorter duration. As an acceptable 15-fraction plan was 
submitted (which meets all of the criteria in the dose intent) and as the case records do not document the need 
for a >15-fraction approach, our reviewer finds that 15 fractions of IMRT falls within the accepted standards 
for aggressive palliative care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT in 15 fractions have been met. Therefore, we decided that the Plan has to 
pre-approve IMRT in 15 fractions.  
 
We also decided that the Plan does not have to pre-approve additional fractions of IMRT beyond 15. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary. 
 
As noted above, our reviewer finds that more than 15 fractions is not supported for the goal of palliative 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional fractions of IMRT beyond 15 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve additional fractions of IMRT beyond 15. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.