Appeal type: Practitioner Services
Decision: Partially Favorable

 You asked the Plan to pre-approve 3D conformal IGRT. You say that protecting critical organs at risk is of paramount importance, so ten fractions of 3D conformal radiation therapy is medically necessary. The Plan says that the denial of authorization for these services is correct, because there is no research showing that the enrollee's cancer will respond better to this treatment plan than to the Plan's recommendation of complex isodose treatment.  We decided that the Plan has to pre-approve IGRT.   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 3D conformal IGRT. Our reviewer says that the requested IGRT is medically reasonable and necessary. Our physician reviewer found that IGRT is a means to improve set-up accuracy. IGRT uses daily image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows accuracy of treatment delivery, so when generating a planning target margin the margins can be reduced and thus allow reduction in the volume of normal tissues exposed to radiation. The records describe the target being between the kidneys and the need to use narrow margins for possible radiation in the future. Ensuring accurate set-up can ensure sparing of the kidneys. Therefore, IGRT could be considered necessary as a potential benefit.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3D conformal IGRT have been met. Therefore, we decided that the Plan has to pre-approve IGRT.   We also decided that the Plan does not have to pre-approve 3D conformal radiation.  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 3D conformal radiation. Our reviewer says that the requested 3D conformal radiation is not medically reasonable and necessary. Our physician reviewer found that 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. For this case, the goal is to control pain from bone metastases, and the plan is to use simple AP-PA fields.  This generally constitutes 2D radiation even when DVHs are generated. For bone metastases with soft tissue involvement, billing for 3D radiation is an accepted standard per Evicore guidelines, due to more complex treatment planning to not only cover the bone, but also the soft tissue component and the added complexity of sparing normal tissue when targeting bone plus soft tissues. For this patient, there is no indication of an extensive soft tissue component. The case file incudes several template/boiler plate forms which indicate that the plan was reviewed in 3 dimensions and that normal tissues were spared with radiation. This generally applies to all treatments in radiation oncology in which CT based planning is used (which is the vast majority of patients) but does not necessarily mean that 3D radiation would be billed over a complex treatment plan, especially when simple AP-PA fields are used. Therefore, 3D conformal radiation is not necessary as the treatment plan seems most consistent with what would be billed, in standard, as 2D radiation.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 3D conformal radiation have not been met. Therefore, we decided that the Plan does not have to pre-approve 3D conformal radiation.  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.