Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the provided comparison plans do not show clinically meaningful differences. 
 
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 the therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that IMRT for rectal cancer can be used to reduce dose to the small bowel, bladder and femoral heads, 
and iliac bone marrow. This enrollee is to receive a dose of 50.4 Gy to the pelvis (with a boost after 45 
Gy). Rectal cancer can often be treated with conventional radiation, while maintaining acceptable dose 
constraints to the bladder, although IMRT can reduce the volume of bladder receiving 45-50 Gy. The dose to 
the femurs (tolerance of 45-50 Gy) and small bowel (tolerance of 40-45 Gy) can be effectively reduced with 
IMRT, though the need for IMRT is generally determined by a quantitative dosimetric rational documenting a 
clinically meaningful reduction in bowel or femur dose. The case file includes data from comparison that does 
show that the 3D conformal radiation cannot meet accepted dosimetric constraints. Specifically, the bladder 
constraints are high, with the 3D plan exceeding the RTOB 0822 recommendations and the IMRT plan 
lowering the exposures. In a case like this, it cannot be determined if a better designed 3D plan or better 
designed target volumes would make the 3D plan acceptable. Even the IMRT plan exceeds some RTOG 0822 
constraints suggestive of a difficulty planning objective. The plan comparison is suggestive of a clinically 
meaningful benefit with IMRT. The case records did adequately demonstrate the need for IMRT using 
plausible dosimetric evidence (i.e. to what extent IMRT reduced the dose-volume exposure of critical normal 
tissues).  This is important in justifying the need for IMRT in clinical scenarios for which IMRT is not always 
standard. Simply asserting that IMRT is necessary does not constitute sufficient documentation for medical 
necessity of IMRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy have been met. Therefore, we decided that the Plan has to pre-
approve intensity-modulated radiation therapy (IMRT).  
 
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.