Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT) (77014, G6012, 
G6015). 
 
You asked the Plan to pre-approve IMRT. You say that the requested therapy is medically necessary. The Plan 
denied your request. The Plan says that the request does not meet the Medicare or health plan coverage criteria. 
 
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. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT is a technique used to improve the dose conformality. The use of IMRT for the treatment 
of breast cancer is becoming more widely used. In general, IMRT is not an experimental technique, but rather a 
radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose 
distribution, and therefore minimize the dose to normal structures. Advantages of IMRT are to reduce the dose 
to the heart, lungs, skin and contralateral chest.  IMRT can also improve the dose homogeneity of the treatment 
volume, and therefore reduce the hot spots. From the NCCN practice guidelines, for the section on 
optimizing delivery of individual therapy: Greater target dose homogeneity and sparing of normal tissues 
can be accomplished using compensators such as tissue wedges, forward planning using segments and intensity 
modulated radiation therapy (IMRT). A randomized study showed that IMRT (not specifically for the boost 
phase) improved target conformality. In summary, it is safe to say that IMRT is not experimental, but rather a 
useful tool available to radiation oncologists to potentially reduce toxicity and improve the lung, heart and skin 
dose distributions. While a plan comparison is not provided. published evidence suggests that IMRT is needed 
to spare normal tissues. The decision is favorable as the following LCD criteria appear to be met, the target 
volume is concave or convex, and the critical normal tissues are within or around that convexity or concavity 
and the target volume is in close proximity to critical structures that must be protected. 
 
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 have been met. Therefore, we decided that the Plan has to pre-approve 
intensity modulated radiation therapy (IMRT) (77014, G6012, G6015).  
 
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.