Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for five fractions of SBRT. We decided that the Plan does not have to pay 
for the other five fractions of SBRT.  
 
You asked the Plan to pay for ten fractions of SBRT. You say that this is not medically necessary for this 
diagnosis. The Plan says that this is medically necessary. 
 
We decided that the Plan has to pay for five fractions of SBRT.  
 
The Plan follows Medicare rules. Medicare rules say that services are covered when they are 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 for SBRT. Our reviewer says that five fractions of 
SBRT are medically reasonable and necessary. Our physician reviewer found that oligometastases are defined 
as a state of metastatic disease with metastases few in number and extent.  This enrollee, with a metastatic bone 
lesion would be considered to have oligometastases. The rationale for treating oligometastases with local 
therapy (i.e. radiation or surgery) is to prolong disease control, and potentially prolong life, as well as quality of 
life by improved cancer control. Given that melanoma is relatively radiation resistant requiring the escalated 
dose that SBRT can deliver, and there are no other sites of metastatic disease (all had been resected), SBRT 
would be furnished in accordance with accepted standards of care. Five fractions of SBRT would be favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of five fractions of SBRT have been met. Therefore, we decided that the Plan has 
to pay for five fractions of SBRT.  
 
We also decided that the Plan does not have to pay for the other five fractions of SBRT. 
 
The Plan follows Medicare rules. Medicare rules say that services are covered when they are 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 for the other five fractions of SBRT. Our reviewer says 
that the other five fractions are not medically reasonable or necessary. Our physician reviewer found that it 
appears that ten fractions were requested, perhaps to treat the enrollee in a sequential manner. However, to be 
considered for SBRT (per the ASTRO coverage policy), all lesions should be targeted in five or few fractions. 
 
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 other five fractions of SBRT have not been met. Therefore, we decided that 
the Plan does not have to pay for the other five fractions of SBRT. 
 
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.