Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve IGRT. You say that IGRT is medically appropriate in this case. The Plan 
denied your request. The Plan says image-guided radiation therapy is not medically necessary. The patient's 
records show that they have a condition or disease that is known to respond well to RT (radiation therapy). 
However, picture studies are not supported to guide the patient's radiation treatment. 
 
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 IGRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found 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. Usually IGRT is used when critical structures are abutting or in close 
proximity to the target that is being treated to high doses. This situation does not apply to this patient for which 
the target lesion can be seen on the skin to assist in daily set up.  
When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. The 
Definitive and Postoperative Radiation Therapy for Basal and Squamous Cell Cancers of the Skin: Executive 
Summary of an American Society for Radiation Oncology Clinical Practice Guideline states: For local 
treatment of skin targets, the task force emphasizes the importance of regular and frequent visual confirmation 
of surface coverage by the treating radiation oncologist (ie, biweekly see-on-table verification). Daily 
imaging is neither necessary nor useful when treating with electron beam, ELS, or skin surface brachytherapy. 
(with ELS= Electronically generated low-energy sources being offered to this patient). IGRT for superficial 
electronic brachytherapy is not specifically endorsed by the ACRASTRO Practice Parameter for Image-
Guided Radiation Therapy. Using ultrasound on a daily basis is not unreasonable to offer but not necessary. 
Therefore, to bill for daily simple simulations and/or IGRT for a technology for which need has not been 
established by published data or supported by consensus guidelines (many of which recommend against 
treatment with these devices in general- citations below) is not necessary.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve image-guided radiation therapy (IGRT).