Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a multi-leaf collimator (MLC) device for intensity modulated radiation therapy (IMRT) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the stereotactic body radiation therapy (SBRT) codes that were requested can be approved, but the MRT planning service codes cannot be authorized.
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 the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found SBRT, delivering high fractional doses in 2-5 fractions is an established approach for the treatment of discrete lesions from cancer. There are abundant data on the use of SBRT/hypofractionated radiation for oligometastatic prostate cancer, and this treatment is not explicitly disputed here. With stereotactic radiation, technologies to improve targeting accuracy are used to allow for higher dose delivery. The combination of proximity of critical structures to the target, as well as the very high dose delivered per treatment fraction necessitates a more conformal dose. Generally, the goal with SBRT is to maximize dose delivery to the target, and minimize dose delivery to the normal tissues without compromising tumor dose. IMRT is often used with SBRT in order to more tightly conform the radiation dose to the target to minimize high dose exposure to normal tissues. Many published studies of outcomes after SBRT employed IMRT planning. Rationales to use IMRT would be for ease of planning (inverse algorithms allow for optimally weighted beams) and more conformal delivery of high doses of radiation. For this case, planning with IMRT (and therefore the planning codes for IMRT) would be in accordance with accepted standards of care. IMRT planning with spine SBRT would be standard of care given the complex shape of the target wth close proximity to the cord and other critical structures. IMRT may not be needed for the treatment of the rib metastasis, though can be used, and for this case would be billed in conjunction with the spine metastasis (i.e. one planning and one MLC code for the treatment of both lesions). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-approve a multi-leaf collimator (MLC) device for intensity modulated radiation therapy (IMRT) for the enrollee.
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