Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve fifteen (15) additional intensity-modulated radiation therapy 
(IMRT) fractions (77014, G6015). 
 
You asked the Plan to pre-approve additional IMRT fractions. You say that you disagree with the denial. The 
Plan denied your request. The Plan says that the additional fractions are not reasonable and necessary, as the 
enrollee's condition does not meet the Plan's policy. 
 
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 IMRT fractions. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found moderately hypofractionated image guided IMRT regimens (2.4-4 gray (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. The issue is the 
appropriateness of 48 fractions vs. 45 fractions (neither of which are preferred over moderate 
hypofractionation) Treatment with more fractions is costlier, which is the root of the dispute. 43 (requested in 
this case) - 45 fractions in considered acceptable (albeit not preferable) by National Comprehensive Cancer 
Network (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. The decision is favorable as 43 fractions fall 
within the standard 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 additional IMRT fractions have been met. Therefore, we decided that the Plan 
has to pre-approve fifteen (15) additional intensity-modulated radiation therapy (IMRT) fractions (77014, 
G6015).  
 
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.