Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve IMRT planning and 15 fractions. We decided that the Plan does 
not have to pre-approve 18 fractions.  
 
You asked the Plan to pre-approve Intensity Modulated Radiation Treatment (IMRT) with 33 fractions (77014, 
G6002, G6015).. You say that the requested treatment is needed to treat the enrollee's metastatic non-small cell 
lung cancer involving the hilar and mediastinal lymph nodes. 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 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 40 fractions. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee has oligometastatic stage IV disease (and would have had Stage III NSCLC 
without distant metastases due to mediastinal nodal involvement. For enrollees with an RTOG cooperative, a 
group study showed that with stage III NSCLC, there was no advantage to escalating the dose beyond 60 Gy in 
30 fractions with respect to survival outcomes, and enrollees treated to higher doses fared worse. In the 
aforementioned studies of consolidative radiotherapy, 5 or 15 fractions of radiotherapy were used. For this 
enrollee, there is no rationale provided for the need of >15 fractions, and in fact 33 fractions would be outside 
the standard of care. With no benefit in stage III enrollees to treating with >30 fractions, doing so in stage IV 
enrollees is even less likely to be of benefit and possibly could cause harm. Also, prolonging the thoracic 
radiotherapy in this enrollee with metastatic disease would not be standard treatment. With no rationale for why 
33 fractions were requested, the decision ultimately would be partially favorable for 15 fractions, as treating 
with more fractions without a plausible rationale for why is not standard. 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 planning with 18 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 40 fractions. Our reviewer says that the requested 
items/services are partially considered medically reasonable and necessary in this case. Our physician reviewer 
found this case becomes challenging as the NRGLU002 suggests that the treatment proposed for this enrollee is 
investigational as it is being tested in a randomized trial, yet the NCCN guidelines and ASTRO model policy 
suggest that it is an accepted standard.  One caveat is that in the NRGLU002 trial, enrollees randomized to not 
receive radiation can receive it at a later date if there is progression of disease. Nevertheless, based on NCCN 
guidelines the thoracic radiotherapy would be furnished in accordance with accepted standards of care. 
Therefore, we decided that the Plan does not have to pre-approve IMRT with 18 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.