Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve IMRT with 15 fractions. We decided that the Plan does not have to 
pre-approve IMRT with 13 fractions.  
 
 
 
 
 You asked the Plan to pre-approve Intensity Modulated Radiation Therapy (IMRT) with 28 fractions (77300, 
77301, 77336, 77338, 77386).. You say that the treatment was medical necessary and should have been 
covered. The enrollee has renal cell carcinoma with a pancreatic mass, metastatic disease that was being 
treated. Attached you will find all the documents necessary to review the appeal. The Plan says that the 
enrollee has a history of renal cell carcinoma with spread to pancreas. The provider's course of action seems to 
be "aggressive palliation." The request does not meet the Medicare or health plan coverage criteria. 
 
We decided that the Plan has to pre-approve IMRT with 15 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 28 fractions. Our reviewer says that the 
requested items/services are partially considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is being offered palliative radiation to sites a pancreatic mass. The 
consultation note does not describe any staging studies that describe the extent of the enrollees disease outside 
of this lesion. A planning CT report is provided that describes only this mass as being present. The clinic note 
mentions a pancreatic head mass and it is not being treated apparently and is not mentioned in the planning CT 
report. IMRT palliation of metastases is uncommonly needed. For this case, while there are planning records, 
there is no specific dosimetric rationale for IMRT or explanation for why IMRT would be needed over 2D or 
3D radiation. The decision is partially favorable for 15 fractions of IMRT/IGRT which is more in line with 
what would be offered for palliation. A 15-fraction IMRT approach would facilitate normal tissue sparing 
while allowing some escalation of the dose to normal structures. IMRT would arguably be furnished in 
accordance with accepted standards of medical practice for aggressively treating metastatic disease abutting 
normal tissues.  Excess of 15 fractions for palliation would not be in accordance with accepted standards of 
care. Therefore, we decided that the Plan has to pre-approve IMRT with 15 fractions.  
 
We also decided that the Plan does not have to pre-approve IMRT with 13 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 28 fractions. Our reviewer says that the requested 
items/services are partially considered medically reasonable and necessary in this case. Our physician reviewer 
found that generally a plan comparison is needed to justify IMRT when using IMRT for non-standard 
indications. The records state that a more protracted course of radiation was offered because of the concern of 
toxicity with hypofractionated radiation. However, in this enrollee, risks of toxicity are more related to the total 
dose prescribed (56 Gy in 28 fractions) with 3D vs IMRT. With IMRT, there is the ability to spare normal 
tissues and dose paint such toxicity risks can be mitigated, so it is unclear why if IMRT is necessary, 28 
fractions of IMRT are necessary. This seems excessive for palliation (and the records are explicit about the 
palliative intent of treatment). It is my opinion that IMRT can be considered medically necessary (even for 
palliation and/or non-standard indications) when justified by quantitative dose measures, when the dose-
volume exposure of critical structures in unacceptable without IMRT. Even in the absence of a plan 
comparison, it is plausible that IMRT could reduce toxicity risks based on the location of the target relative to 
normal tissues. However, there is no evidence-based rationale for 13 fractions of treatment with palliation. 
 Therefore, we decided that the Plan does not have to pre-approve IMRT with 13 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.