Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve IMRT planning and 35 fractions. We decided that the Plan does 
not have to pre-approve 5 fractions.  
 
You asked the Plan to pre-approve Intensity Modulated Radiation Therapy (IMRT) and 40 fractions (77014, 
77386, 77470). You say that the enrollee has been diagnosed with non-small cell lung cancer, at least stage 
IIIA, and been recommended concurrent chemotherapy and radiotherapy as definitive treatment management. 
This recommendation is consistent with NCCN guidelines. The Plan says that the requested service does not 
meet the Medicare or the Plan coverage criteria. The reason for offering the service as outlined in the records 
aren't medically necessary. There is no good medical evidence the special radiation is needed. 
 
We decided that the Plan has to pre-approve IMRT planning and 35 fractions.  
 
The Plan follows 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 for IMRT and 40 fractions. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found IMRT is a radiation planning and delivery tool available to the radiation oncologist to better 
shape the radiation dose distribution, and therefore minimize the dose to normal structures. A secondary 
analysis of RTOG 0617 (in which IMRT was allowed) randomizing enrollees to receive 60 Gy vs 74 Gy, 
showed that IMRT (despite having larger target volumes) had similar normal lung exposure (slightly lower 
lung V20 and higher V5 for IMRT), and a lower heart V20-V60; IMRT was associated with less grade 3+ 
pneumonitis (7.9% vs 3.5%, p=.039). In addition to IMRT technique, lung V20 and Stage IIIB disease were 
associated with pneumonitis risks while mean lung dose and lung V5 were not. The decision is favorable for 
IMRT planning as IMRT would be furnished in accordance with accepted standards of medical practice based 
on NCCN guidelines and published evidence. For the request for 40 fractions, the standard treatment approach 
utilizes 30 fractions to a dose of 60 Gy. The ongoing phase III NRG Oncology RTOG 1308 trial uses 70 Gy in 
2 Gy daily fractions as its standard dose. However, there should be some selectivity with close attention to 
normal tissue constraints. In general, there is no evidence basis to use 40 fractions at 1.8 Gy per fraction. The 
appeal letter states that 1.8 Gy fractions were chosen to spare uninvolved lung, which does not make sense and 
not supported by any evidence or guidelines. IMRT is plausibly used to spare lung but not non-standard 
fraction sizes. Our physician reviewers decision is partially favorable for 35 fractions which adheres to NCCN 
guidelines and ASCO Guidelines. Therefore, we decided that the Plan has to pre-approve IMRT planning and 
35 fractions.  
 
We also decided that the Plan does not have to pre-approve 5 fractions. 
 
The Plan follows 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 for 40 fractions. Our reviewer says that the requested 
items/services are partially considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no evidence basis to use 5 fractions at 1.8 Gy per fraction. The appeal letter states that 1.8 Gy 
fractions were chosen to spare uninvolved lung, which does not make sense and not supported by any evidence 
or guidelines. This decision is contingent upon the enrollee having non-metastatic disease, which the PET/CT scan suggests is possible (with right axillary nodal and chest wall sites that are worrisome, though non-specific 
for cancer involvement. Therefore, we decided that the Plan does not have to pre-approve 5 fractions. 
 
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.