Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity modulation radiation therapy (IMRT) of the right breast 
(77301, 77338, 77370, 77385). 
 
You asked the Plan to pre-approve IMRT of the right breast. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says that the requested treatment is for the 
head, neck, brain, or paraspinal regions. The notes provided do not show a tumor in these regions. Criteria 
include a tumor in another location but has received maximum treatment. Notes do not show the enrollee has 
had this treatment. 
 
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 of the right breast. Our reviewer 
says that the requested items/services are 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. 3D conformal radiation for breast cancer generally implies the use of tangential chest wall 
fields that are forward planned. i.e., the fields are designed and optimized (i.e., beam weighting, beam shaping, 
beam modifiers such as wedges) by the dosimetrist and clinician (as opposed to IMRT in which the 
optimization is performed by a computer algorithm), plus additional fields to include the supraclavicular nodes 
or axilla. Often, segmented fields are used to improve dose homogeneity and organ sparing. Both 3D RT and 
IMRT deliver radiation to the breast or chest wall.  For enrollees with an intact breast after resection, IMRT has been shown to improve skin and breast toxicity. For post-mastectomy radiation. It is plausible that with this 
enrollees obesity (BMI >42) IMRT would be necessary for dose homogeneity. In summary, it is safe to say 
that IMRT is not experimental, but rather a useful tool available to radiation oncologists to potentially reduce 
toxicity and improve the lung, heart, and skin dose distributions. In light of the dosimetric improvement with 
IMRT in this enrollee, as well as ASTROs most recent update of its Choosing Wisely list, the decision is 
favorable as IMRT would 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 IMRT of the right breast have been met. Therefore, we decided that the Plan has 
to pre-approve intensity modulation radiation therapy (IMRT) of the right breast (77301, 77338, 77370, 
77385).  
 
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.