Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT) x30 (77014, 
77386, 77387). 
 
You asked the Plan to pre-approve IMRT. You say that you will need to utilize IMRT because there are 
important structures. The Plan denied your request. The Plan says that there is no high-quality evidence to 
support IMRT use for small cell lung cancer. 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 with IMRT, often full dose can be delivered to the target, while minimizing dose to the normal 
organs. IMRT can be considered necessary when a 3D plan is unacceptable and the IMRT plan results in a 
clinically meaningful reduction in normal tissue dose-volume delivery and/or improved target coverage. The 
literature supports using IMRT for select enrollees with advanced lung cancer- generally definitive treatment 
with concurrent chemotherapy and doses of at least 60 Gy. Clear indications for IMRT include unfavorable 
tumor geometry, proximity of the tumor to critical organs (i.e., paraspinal location), and/or small lung volumes 
and prior thoracic radiation. A retrospective National Cancer Data Base study of 2543 enrollees with locally 
advanced NSCLC (T3-T4), of whom 16.6 % received IMRT showed that IMRT was associated with 
significantly improved survival (HR 0.80, p=0.048 on Cox regression). While this enrollee has SCLC as 
opposed to NSCLC, the principles of organ/tissue sparing when delivering 60 Gy with concurrent 
chemoradiation apply to both diseases. From the most recent NCCN guidelines (3.2023) for SCLC state: 
IMRT is preferred over 3D conformal EBRT on the basis of reduced toxicity in the setting of concurrent 
chemotherapy/RT while the most recent NCCN guidelines for NSCLC state: To minimize potential lung and 
heart toxicities IMRT is preferred over 3D conformal radiation for locally advanced for non-small cell lung 
cancer. The decision is 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 IMRT have been met. Therefore, we decided that the Plan has to pre-approve 
Intensity Modulated Radiation Therapy (IMRT) x30 (77014, 77386, 77387).  
 
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.