Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation treatment (77014, G6002, G6015). 
 
You asked the Plan to pre-approve radiation treatment. You say that the requested radiation therapy is for 
cancer treatment for the enrollee. The enrollee was diagnosed on September of 2022, and needs therapy as soon 
as possible as it detrimental if not treated. The Plan denied your request. The Plan says the enrollee has a 
history of metastatic sarcoma. The provider plans 10 fractions of palliative RT to the extremity. IMRT and 
IGRT would be considered not generally accepted in these circumstances, not backed by national guidelines, 
and outside UHC policy. Based on the additional information available, the request does not meet the Medicare 
or health plan coverage criteria. 
 
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 radiation treatment. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. 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.  This enrollee with widely metastatic leiomyosarcoma, is being offered palliative radiation 
to the right humerus in 10 fractions and is planned to undergo immunotherapy for his systemic disease. 
Palliative IMRT for bone or soft tissue is uncommonly needed. There are records from medical oncology, but 
no records from radiation oncology, no planning records, and no dosimetric rationale for IMRT or explanation 
for why IMRT would be needed over 2D or 3D radiation. IMRT can be considered medically necessary (even 
for palliation and/or non-standard indications) when justified by quantitative dose measures- when the dose-
volume exposure of critical structures in unacceptable without IMRT. The need for IMRT is not justified based 
upon quantifiable dosimetric measures or a plausible rationale.  ASTRO model policy emphasizes the need to 
support IMRT with dosimetry; this would be of particular importance for clinical scenarios for which IMRT is 
not considered standard. The decision is unfavorable for this case as IMRT would not be furnished in 
accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation treatment have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiation treatment (77014, G6002, G6015).