Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve IMRT planning and 20 fractions. We decided that the Plan does 
not have to pre-approve IMRT planning and 25 fractions.  
 You asked the Plan to pre-approve Intensity Modulated Radiation Therapy (IMRT) and 45 fractions (77014, 
G6015). You say that your local MAC supports and reimburses for a 45-dose treatment for enrollees with 
prostate cancer. The health plan is supposed to cover the same as traditional Medicare plans. The Plan says that 
the request does not meet the Medicare or health plan coverage criteria.  
 
We decided that the Plan has to pre-approve IMRT planning and 20 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 45 fractions. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found 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. Several retrospective studies have investigated the addition of pelvic radiation therapy to the 
primary site in enrollees with metastatic prostate cancer. A major limitation of these studies includes the 
retrospective nature of the studies, such that enrollees chosen to receive radiation may have had other criteria 
(i.e., lower disease bulk, better functional status) possibly accounting for favorable outcomes. Likewise, those 
chosen to receive higher doses of radiation may have been selected based upon anticipation of those enrollees 
faring better. The decision for IMRT would be partially favorable for 20 fractions. Therefore, we decided that 
the Plan has to pre-approve IMRT planning and 20 fractions. 
. 
We also decided that the Plan does not have to pre-approve 25 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 25 fractions. Our reviewer says that the requested 
items/services are partially considered medically reasonable and necessary in this case. Our physician reviewer 
found the NCCN v1.2023 guidelines recommend external beam radiotherapy to the primary site for enrollees 
with intact prostate and low volume disease. They specify low-volume castration naive metastatic disease with 
ADT required unless medically contraindicated. High-volume disease is specified as visceral metastases 
and/or 4 or more bone metastases with at least one metastasis beyond the pelvis vertebral column. The 
guidelines emphasize minimizing toxicity from radiotherapy and not dose escalating. The delivery of >20 
fractions of radiation in the metastatic setting seems outside of the standard of care based on NCCN guidelines. 
The case file does not document the need for going outside of the standard of care. IMRT is appropriate for this 
patient though there is no justification for 45 fractions. Therefore, we decided that the Plan does not have to 
pre-approve 25 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.