Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity modulated radiation treatment delivery (IMRT), includes 
guidance and tracking, when performed; simple (77385, 77387, G6002, 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 there is no current research showing that your type of cancer responds 
better to the requested type of treatment than the type of treatment they can approve. 
 
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 both 3D RT and IMRT deliver radiation to the breast or chest wall. 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 that are often seen in the lateral chest wall. For 
enrollees with an intact breast after resection, IMRT has been shown to improve skin and breast toxicity.  
When treating regional lymph nodes, IMRT can markedly reduce heart and lung exposures. 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). For this enrollee, with 
3D conformal radiation, the lung and heart exposure are excessive, and IMRT with IGRT reduces the exposure 
to acceptable. 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. In 
light of the dosimetric improvement with IMRT in this enrollee, as well as ASTROs most recent update of its 
Choosing Wisely list, the decision is favorable as IMRT would be furnished in accordance with accepted 
standards of medical practice. The LCD specify: "Other malignancies not delineated in the above can be 
supported with submission of documentation for medical necessity should a denial occur. The determination of 
appropriateness and medical necessity for IMRT for any site shall be found in the documentation from the 
radiation oncologist and must be available when requested or submitted in the appeals process." This is 
therefore met. 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 treatment delivery (IMRT), includes guidance and tracking, when performed; 
simple (77385, 77387, G6002, 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.