Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve radiation therapy for bladder cancer.  
 
You asked the Plan to pre-approve radiation therapy for bladder cancer. You say that radiation therapy for 
bladder cancer is medically necessary. The Plan denied your request. The Plan says that the National 
Comprehensive Cancer Network (NCCN) guidelines do not recommend Intensity Modulated Radiation 
Therapy (IMRT) for all bladder cancer patients. 
 
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 radiation therapy for bladder cancer. 
Our reviewer says that the requested radiation therapy is considered medically reasonable and necessary in this 
case. Our physician reviewer found that in general, radiation is used in the setting of bladder preservation after 
gross disease has been surgically removed (via TURBT). IMRT is a tool that clinicians can use when there is 
concern about sparing normal tissues from high dose exposure. IMRT generally implies inverse planning 
algorithms, i.e., the physician determines radiation treatment parameters to maximize dose to the target and 
minimize dose to normal tissues, and the planning algorithm maximizes the adherence to these parameters by 
modifying the beam spatially and/or temporally. The most recent NCCN guidelines for bladder cancer do not 
address IMRT as they do for other cancers. For this enrollee, there is a comparison plan provided 
(3D arc vs IMRT). Most of the institutions constraints (which are more detailed than the SWOG constraints) 
are met with the exception of the bowel D0.03 cc.  While the 3D arc plan is an outstanding plan that would be 
acceptable to treat the patient, the maximum bowel (D0.03 cc) is higher than recommended in the SWOG study 
and IMRT lowers the maximum from 58 Gy to 56 Gy. The dose to prescribed for this enrollee is relatively 
high, and the IMRT plan results in reduction in bowel exposure, such that it is plausible that IMRT could be of 
benefit in this patient in lowering the toxicity risk to the bowel, particularly given that concurrent 
chemotherapy is to be given. In summary, while the 3D plan is suitable to treat the enrollee, the IMRT plan is 
better and expected to result in lower toxicity risks. IMRT would therefore be furnished in accordance with 
accepted standards of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation therapy for bladder cancer have been met. Therefore, we decided that 
the Plan has to pre-approve radiation therapy for bladder cancer.   
 
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.