Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve Heelex radiation treatment (77290, 77300 - 2 units, 77307, 77334 
- 2 units, 77263, 77280 - 1 unit, 77331 - 2 units, G6003 - 8 units, 77336 - 2 units, 77427 - 2 units). We also 
decided that the Plan does not have to pre-approve therapeutic radiology stimulation (77280- 2 units).  
 
You asked the Plan to pre-approve Heelex radiation treatment. You say that regular Medicare coverage of low-
dose radiotherapy is universal for all Medicare beneficiaries. The Plan denied your request. The Plan says that 
the procedure is investigational.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We decided that the Plan has to pre-approve Heelex radiation treatment (77290, 77300 - 2 units, 77307, 
77334 - 2 units, 77263, 77280 - 1 unit, 77331 - 2 units, G6003 - 8 units, 77336 - 2 units, 77427 - 2 units).  
 
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 Heelex radiation treatment. Our 
reviewer says that these services are medically necessary. Our physician reviewer found that radiation for 
treatment-resistant plantar fasciitis, based upon published literature and guideline statements would be 
considered to be furnished with accordance of 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 Heelex radiation treatment have been met. Therefore, we decided the Plan has 
to pre-approve Heelex radiation treatment (77290, 77300 - 2 units, 77307, 77334 - 2 units, 77263, 77280 - 1 
unit, 77331 - 2 units, G6003 - 8 units, 77336 - 2 units, 77427 - 2 units). 
 
We also decided that the Plan does not have to pre-approve therapeutic radiology stimulation (77280- 2 
units). 
 
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 Heelex radiation treatment. Our 
reviewer says that two units of therapeutic radiology stimulation is not medically necessary. Our physician 
reviewer found that two unites of therapeutic radiology stimulation are not justifiable as the standard of care for 
treatment of plantar fascial fibromatosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of therapeutic radiology stimulation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve therapeutic radiology stimulation (77280- 2 units). 
 
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.