Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve daily image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve daily image-guided radiation therapy. You say that this service is medically 
necessary. The Plan denied your request. The Plan says image-guided radiation therapy is considered 
experimental/investigational for the patient's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 daily image-guided radiation therapy. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found radiation is a standard approach to the treatment of skin cancer and is 
often preferred over surgery when resection is likely to result in unacceptable morbidity or cosmesis.  
 The use of superficial radiotherapy (SRT) or electronic brachytherapy for skin cancers that would be well-
treated with standard radiotherapy modalities such as electron therapy or orthovoltage radiotherapy.  The most 
recent guidelines for basal cell and squamous cell skin cancers explicitly state There are insufficient long-term 
efficacy and safety data to support routine use of electronic surface brachytherapy. However, the treatment 
itself is not disputed in this case but rather the need for image guidance. At issue is the need for daily image 
guidance; it appears that the request is for IGRT. IGRT is a means to improve set-up accuracy. IGRT uses daily 
image guidance to help localize the target so as to minimize normal tissue dosing. Specifically, IGRT allows 
accuracy of treatment delivery, so when generating a planning target margin, the margins can be reduced, and 
thus allow reduction in the volume of normal tissues exposed to radiation. Usually, IGRT is used when critical 
structures are abutting or in close proximity to the target that is being treated to high doses. This situation does 
not apply to this patient for which the target lesion can be seen on the skin to assist in daily set up. When 
treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. 
 
Certainly using ultrasound on a daily basis is not unreasonable to offer but not necessary. The device itself is 
FDA approved for use with ultrasound though that in and of itself does not mean that daily imaging is 
necessary but simply that the device was designed to incorporate this functionality. Therefore, to provide daily 
simple simulations and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines (many of which recommend against treatment with these devices in general- 
citations below) is not necessary.  Daily IGRT which would not be furnished in accordance with accepted 
standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of daily image-guided radiation therapy have not been met. Therefore, we decided 
that the Plan does not have to pre-approve daily image-guided radiation therapy (IGRT).