Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 

The rules say that IMRT is clinically indicated (i.e., medical necessity criteria will be met) when highly 
conformal dose planning is required. IMRT planning may be clinically indicated when one or more of the 
following conditions are present: 
1. An immediately adjacent area has been previously irradiated and abutting portals must be established 
with high precision. 
2. Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar 
tumors with conventional treatment. 
3. The target volume is concave or convex, and the critical normal tissues are within or around that 
convexity or concavity. 
4. The target volume is in close proximity to critical structures that must be protected. 
5. The volume of interest must be covered with narrow margins to adequately protect immediately 
adjacent structures. 
On the basis of the above conditions demonstrating medical necessity, disease sites that may support the use of 
IMRT include the following: 
&#61623; Primary, metastatic or benign tumors of the central nervous system including the brain, the brain stem, 
and spinal cord. 
&#61623; Primary or metastatic tumors of the spine where the spinal cord tolerance may be exceeded with 
conventional treatment or where the spinal cord has previously been irradiated. 
&#61623; Primary, metastatic, benign or recurrent head and neck malignancies, including: orbits, sinuses, skull 
base, aero-digestive tract, and salivary glands. 
&#61623; Thoracic malignancies. 
&#61623; Abdominal malignancies when dose constraints to small bowel or other normal abdominal tissue are 
exceeded and present administration of a therapeutic dose. 
&#61623; Pelvic malignancies including: prostatic, gynecological and anal carcinoma. 
&#61623; Other pelvic or retroperitoneal malignancies. 
Other malignancies not delineated in the above can be supported with submission of documentation for medical 
necessity should a denial occur. The determination of appropriateness and medical necessity for IMRT for any 
site shall be found in the documentation from the radiation oncologist and must be available when requested or 
submitted in the appeals process. There must be documented rationale of the advantage of IMRT versus the use 
of other radiation therapy methods in the medical record of each patient for whom IMRT is provided. You can 
find this rule in the Local Coverage Determination for Intensity Modulated Radiation Therapy (IMRT), L36711 
(eff 11/14/19). 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.