Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT). 
 
You asked the Plan to pre-approve Intensity Modulated Radiation Therapy (IMRT). You say that the requested 
Intensity Modulated Radiation Therapy (IMRT) is medically necessary. The Plan denied your request. The 
Plan says that the requested Intensity Modulated Radiation Therapy (IMRT) is not medically necessary. 
 
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 Intensity Modulated Radiation Therapy 
(IMRT). Our reviewer says that the requested Intensity Modulated Radiation Therapy (IMRT) is medically 
necessary. Our physician reviewer found in general, IMRT is not an experimental technique, but rather 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. 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. There are abundant data which support the use of IMRT 
with head and neck cancer. For early stage glottic cancer, historically opposed lateral fields were used, with 
more modern approaches using dynamic wedges to generate more homogeneous dose delivery. A study from 
MDACC compared 151 patients treated with conventional radiation and 62 with IMRT. While outcomes 
between conventional radiation and IMRT were similar, the authors concluded: Because the oncologic 
outcomes for patients treated with IMRT were excellent and IMRT allows for carotid sparing, we have 
transitioned to IMRT as our standard for most patients with T1 glottic cancer. Mohamed ASR, et al. 
Outcomes of carotid-sparing IMRT for T1 glottic cancer: Comparison with conventional radiation. 
Laryngoscope. 2020 Jan;130(1):146-153. 
 
A 2016 review concludes: Standardization of IMRT planning for early glottic cancers including target 
volumes and carotid dose constraints is clearly desirable. The data using both surrogate markers for and direct 
evidence of carotid toxicity suffices as evidence, in our view, for the importance of avoidance of the carotid 
arteries when irradiating the glottis. Thus, it is our conclusion that high-quality IMRT should be adopted as a 
new standard of care for the treatment of early glottic cancers. Samuels MA, Freedman LM, Elsayyad N. 
Intensity-modulated radiotherapy for erly glottic cancer: transition to a new standard of care? Future Oncol. 
2016 Nov;12(22):2615-2630 
 
Conceding that the published data supporting need for IMRT for T1N0 glottic cancer are limited, IMRT would 
be within accepted standards of medical practice and therefore meet standard medical necessity criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intensity Modulated Radiation Therapy (IMRT) have been met. Therefore, we 
decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT).   
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.