Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT) 
(G6001). 
 
You asked the Plan to pre-approve ultrasound guided radiation therapy. You say that the enrollee is scared of 
his skin cancer diagnosis and would like to start treatment. The Plan denied your request. The Plan says the 
plan is to treat the enrollee with superficial orthovoltage radiation and use US-IGRT as well. The superficial 
radiotherapy has been approved. The US-IGRT has not been approved. The ACR-ASTRO Practice Parameter 
for IGRT states: "IGRT is used in conjunction with highly conformal radiation therapy techniques."Superficial 
orthovoltage x-ray therapy is not and is incapable of being highly conformal. The medical policy states that 
US-IGRT is not medically necessary for superficial radiation therapy. 
 
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 ultrasound guided radiation therapy. 
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 enrollee 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. Certainly, using 
ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is FDA approved 
for use with ultrasound though that in and of itself does not mean that daily imaging is necessary but simply 
that the device was designed to incorporate this functionality. 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) is not 
necessary. The decision is unfavorable as billing for daily IGRT which would not 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 ultrasound guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve ultrasound guided radiation therapy (US-IGRT) (G6001).