Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve IMRT treatment with 10 fractions. We decided that the Plan does 
not have to pre-approve the additional requested fractions.  
 
You asked the Plan to pre-approve IMRT treatment with 10 fractions. You say that it is felt that this is 
medically necessary. The Plan says that IMRT for this cancer is not proven safe and effective, it is considered 
experimental for this indication. 
 
We decided that the Plan has to pre-approve IMRT treatment with 10 fractions.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
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 treatment with 10 fractions. Our 
reviewer says that the documentation supports that medical necessity of up to 10 fractions of IMRT for 
treatment of the enrollee's condition.  
 
 
 
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. SBRT, delivering high fractional doses in 2-5 fractions is an established 
approach for the treatment of discrete lesions from cancer, though perhaps relatively risk for an abdominal 
metastasis. SBRT is an accepted standard of care for oligometastatic disease. This patient appears to have 
limited/oligo- metastatic disease for which dose escalation is warranted. If SBRT is considered too risky, IMRT 
would be an accepted standard of care. 
 
However, the use of 28 fractions for the treatment of an oligometastasis is not in accordance with accepted 
standards of care. I know of no studies, consensus guidelines, or other source to support such a protracted 
course of treatment (particularly in the midst of a pandemic). There are studies using 8-10 fraction courses of 
hypofractionated image guided IMRT for oligometastases. The case records provide no plausible rationale, or 
evidence based of published data, to support a 28-fraction course of 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 IMRT treatment with 10 fractions have been met. Therefore, we decided that 
the Plan has to pre-approve IMRT treatment with 10 fractions.  
 
We also decided that the Plan does not have to pre-approve the additional requested fractions. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
As noted above, our physician reviewer finds that fractions in excess of 10 are not supported as medically 
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the 
additional requested fractions have not been met. Therefore, we decided that the Plan does not have to pre-
approve the additional requested fractions. 
 
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.