Appeal type: Other
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 12 fractions of 3D conformal radiation therapy. We decided that 
the Plan does not have to pre-approve the additional 3 fractions of 3D conformal radiation therapy.  
 
You asked the Plan to pre-approve 15 fractions of 3D conformal radiation therapy. You say that the requested 
3D conformal radiation therapy for endometrial cancer is medically necessary. The Plan says that the requested 
3D conformal radiation therapy for endometrial cancer is not medically necessary. 
 
We decided that the Plan has to pre-approve 12 fractions of 3D conformal radiation therapy.  
 
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 15 fractions of 3D conformal radiation 
therapy. Our reviewer says that 12 fractions of 3D conformal radiation therapy for endometrial cancer is 
medically necessary. Our physician reviewer found for most cases of palliative treatment of metastases -- even 
when a CT scan is used for treatment planning purposes, and when a 3D dose matrix generated -- for billing 
purposes, it is the accepted standard to bill 2D radiation and not 3D radiation. Generally, 3D radiation is 
necessary when the 2D radiation plan results in unacceptable normal tissue dose exposure and toxicity risks 
(uncommon with palliative treatment). It usually implies the need to spare normal tissues in a manner that 
cannot be achieved with 2D radiation. Generally, for simple bone metastases, 1-10 fractions of 2D radiation is 
used to alleviate pain. When treating metastases that are not bone metastases, or the primary site for palliation, 
higher doses, higher fractional doses, and longer treatment courses can be considered to control bleeding, 
reduce mass effect and/or provide prolonged tumor control. 
  
For this case, the goal is to palliate vaginal bleeding from endometrial cancer. Radiation is being offered to stop 
the bleeding (a vascular effect that can result in quick symptom control) and control the cancer growth. While 
some small retrospective studies suggest that short course treatment is effective (<10 fractions) in controlling 
bleeding, there is no accepted standard dose-fractionation for this clinical scenario. Short course (1-5 fractions) 
is most appropriate for urgent/emergent treatment where immediate symptom control is needed (which does 
not apply to this patient). NCCN guidelines do not discuss palliative radiation for symptomatic bleeding from 
gynecologic cancers. She was prescribed 3.7 Gy twice daily, twice a week, for 3 weeks using IGRT (already 
approved). In an effort to control bleeding and afford cancer control, this aggressive dose-fractionation is 
reasonable and in accordance with standard of care for palliation. 
  
Given the high dose to be delivered, and high dose per fraction, 3D conformal radiation would be standard to 
reduce the dose exposure to the rectum bladder and bowel. For this enrollee, the request was for 15 fractions, 
but the treatment recommended was for 12. 
  
Based on the documentation provided, 3D conformal radiation in 12 fractions is medically reasonable and 
necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 fractions of 3D conformal radiation therapy have been met. Therefore, we 
decided that the Plan has to pre-approve 12 fractions of 3D conformal radiation therapy.  
 
We also decided that the Plan does not have to pre-approve the additional 3 fractions of 3D conformal 
radiation therapy. 
 
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. 
  
Given the high dose to be delivered, and high dose per fraction, 3D conformal radiation would be standard to 
reduce the dose exposure to the rectum bladder and bowel. For this enrollee, the request was for 15 fractions, 
but the treatment recommended was for 12. 
 
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 additional 3 fractions of 3D conformal radiation therapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the additional 3 fractions of 3D conformal 
radiation therapy. 
 
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.