Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional radiation treatment (G6015, 77014). 
 
You asked the Plan to pre-approve additional radiation treatment. You say that the additional fractions are 
needed for standard treatment. The Plan denied your request. The Plan says that the enrollee has localized 
prostate cancer. Based on this information, the extra treatments beyond 28 treatments, is not reasonable and 
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 additional radiation treatment. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee, with intermediate risk prostate cancer, was offered definitive 
radiotherapy with intensity-modulated radiation therapy (IMRT)/image-guided radiotherapy (IGRT) in 45 
fractions. At issue is the number of fractions requested. Conventional fractionation remains an acceptable 
alternative 1.8-2 gray (Gy) for 37-45 fractions. The National Comprehensive Cancer Network (NCCN) 
guidelines summarize the data on hypofractionation as moderately hypofractionated image guided IMRT 
regimens (2.4-4 Gy per fraction over 4-6 weeks) have been tested in randomized trials, and their efficacy has 
been similar or non-inferior to conventionally fractionated IMRT, with on trial showing fewer treatment 
failures with a moderately hypofractionated regimen. Toxicity was similar between moderately 
hypofractionated and conventional regimens in some but not all of the trials. In addition, efficacy results varied 
among the trials, with some showing noninferiority or similar efficacy and others showing that 
hypofractionation may be less effective than conventional fractionation schemes. These safety and efficacy 
differences are likely a result of differences in fractionation schedules. In addition, results of a large cohort 
study showed no differences in quality of life of urinary or bowel function between those that received 
hypofractionated versus conventional regimens. Overall, the panel believes that hypofractionated IMRT 
techniques, which are more convenient for enrollees, can be considered as an alternative to conventionally 
fractionated regimens when clinically indicated. So, for this case, the issue is the appropriateness of 44 
fractions versus moderate hypofractionation. Treatment with more fractions is costlier, which is the root of the 
dispute. 45 fractions is considered acceptable (albeit not preferable) by NCCN guidelines and American 
Society for Radiation Oncology (ASTRO), American Society of Clinical Oncology (ASCO), and American 
Urological Association (AUA) Evidence-Based Guideline, with the expert guidelines acknowledging some 
limitations in the data. As such, the reviewer believes that 45 fractions of IMRT would be within accepted 
standards of medical practice. The decision is therefore favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional radiation treatment have been met. Therefore, we decided that the 
Plan has to pre-approve additional radiation treatment (G6015, 77014).  
 
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.