Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve nineteen (19) additional treatments of intensity-modulated 
radiation therapy (IMRT) (77385, 77386, 77387, G6002, G6015, G6016). 
 
You asked the Plan to pre-approve additional treatments of IMRT. You say that you disagree with the denial 
and request reconsideration. The Plan denied your request. The Plan says that prostate radiation is not 
considered necessary for the enrollee's stage of cancer. 
 
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 treatments of IMRT. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found this enrollee, with node-positive prostate cancer, was offered definitive 
radiotherapy with IMRT/IGRT in thirty-nine (39) fractions. At issue is the number of fractions requested. For 
prostate cancer, National Comprehensive Cancer Network (NCCN) guidelines (v4.2023) offer as preferred 
dose fractionations the following for N1 disease, 3 gray (Gy) x 20, 2.7 Gy x 26 and 2.5 Gy x 28.  
 
Conventional fractionation remains an acceptable alternative 1.8-2 Gy for 37-45 fractions. The issue is the 
appropriateness of 44 fractions versus moderate hypofractionation. Treatment with more fractions is costlier, 
which is the root of the dispute. For localized prostate cancer, 39 fractions in considered acceptable (albeit not 
preferable) by NCCN guidelines (and this applies to N1 disease) and American Society for Radiation Oncology 
(ASTRO), American Society of Clinical Oncology (ASCO), and American Urological Association (AUA) 
Evidence-Based Guideline (applying only to N0 disease)  with the expert guidelines acknowledging some 
limitations in the data. As bowel exposure would necessarily be higher with treating regional nodes due to the 
larger field as well as escalating the dose to the pelvic lymphatics (which are either not treated or treated to 
lower doses for N0 disease) our reviewer believes that 39 fractions of IMRT would be within accepted 
standards of medical practice (and acceptable per NCCN guidelines). 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 treatments of IMRT have been met. Therefore, we decided that the 
Plan has to pre-approve nineteen (19) additional treatments of intensity-modulated radiation therapy (IMRT) 
(77385, 77386, 77387, G6002, G6015, G6016).  
 
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.