Appeal type: Practitioner Services
Decision: Partially Favorable

 
You asked the Plan to pre-approve 33 fractions of intensity-modulated/image-guided radiation therapy 
(IMRT/IGRT).. You say that this is medically necessary and supported by Medicare rules. The Plan says that 
IMRT for routine breast cases is unproven. 
 
We decided that the Plan has to pre-approve 16 fractions with a 5 fraction boost for a total of 21 
fractions of IMRT/IGRT.  
 
The Plan follows Medicare rules. Medicare rules state that IMRT may be covered under certain conditions. 
 
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/IGRT. Our reviewer says that 
the enrollee meets criteria for 16 fractions plus a 5 fraction boost (21 fractions total). Our physician reviewer 
found 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. It is plausible that with 
this enrollee's obesity (body-mass index above 40) IMRT would be necessary for dose homogeneity. In light of 
the dosimetric improvement with IMRT in this enrollee, as well as the American Society For Radiation 
Oncology's (ASTRO's) most recent update of the Choosing Wisely list, 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/IGRT have been met. Therefore, we decided that the Plan has to pre-
approve 21 fractions of IMRT/IGRT.  
 We also decided that the Plan does not have to pre-approve the 12 additional requested fractions of 
IMRT/IGRT. 
 
The Plan follows Medicare rules. Medicare rules state that IMRT may be covered under certain conditions. 
 
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/IGRT. Our reviewer says that 
the enrollee does not meet criteria for the 12 additional requested fractions of IMRT beyond the 16 fractions 
and 5 fraction boost that the Plan already must approve. Our physician reviewer found standard treatment for 
early stage breast cancer is that the whole breast should receive a hypofractionated dose of 40 to 42.5 Greys in 
15 to 16 fractions; in selected cases 45 to 50.4 Greys in 25 to 28 fractions may be considered. The records do 
not describe why more than 15 or 16 fractions would be considered in this enrollee or why this would be a 
selected case for a protracted course of radiation when not treating regional lymph nodes.  
 
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/IGRT have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 12 fractions of IMRT/IGRT. 
 
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.