Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approveradiation therapy to treat esophageal cancer.You asked the Plan to pre-approvethe requested services. The Plan denied your request. The Plan says that there is no current research showing that the enrollee's cancer responds better to the requested treatment over the type the plan can approve.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. The file shows that rotational arc therapy (IMRT) with image guided radiation therapy (IGRT) was requested. 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 the requested services. 
Our physician reviewer found that This patient is being treated to a relatively low dose of 41.4 Gy whereas most patients with esophageal cancer receive higher doses -on the order of 45-50.4 Gy. This case is further complicated by the fact that the patient has Stage IVB disease, specifically due to nodal involvement. The treatment field appears to encompass the thoracic and upper abdominal nodal regions and not the supraclavicular nodal regions, though it is a relatively large field.this case is complicated, and it is reasonable to be more aggressive than offering palliative doses of 30 Gy in an effort to better control the cancer which has responded well to chemotherapy.A large field would be necessary to include the primary tumor site (which was 9 cm prior to chemotherapy) and regional nodes. With a dose of 41.4 gy (higher than palliative doses but lower than standard doses) risks to the spinal cord, liver and heart would be low such that the IMRT plan would not afford an appreciable clinical benefit.However, because of the large field, critical dose measures for the lung are improved in a clinically meaningful manner.IMRT would be furnished in accordance with accepted standards of care, conceding that the dose and treatment field are chosensuch thatan IMRT plan is necessary, and that a lower dose or small field may be readily treatable with a non-IMRT plan. These types of decisions (dose and treatment field) are not straight-forward and even in the setting of metastatic disease, with the disease confined to the primary sites and nodes, a larger field and higher dose are clinically appropriate and within accepted standards of clinical practice.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have been met.Therefore, we decided that the Plan has to pre-approveradiation therapy to treat esophageal cancer.If the Plan does not agree with our decision,they can ask us to open a caseagain. 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/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.