Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 1 unit of simulation-aided field setting. We decided that the Plan 
does not have to pre-approve additional units of simulation-aided field setting.  
 
You asked the Plan to pre-approve therapeutic radiology simulation-aided field setting for electronic 
brachytherapy. You say that this is the best option for the enrollee. The Plan says that the enrollee does not 
meet requirements for approval.  We decided that the Plan has to pre-approve 1 unit of simulation-aided field setting.  
 
The Plan follows 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 simulation-aided field setting. Our 
reviewer says that the enrollee meets criteria for 1 unit of simulation-aided field setting. Our physician reviewer 
found for a course of superficial treatment, a single simulation code may be used for the initial setup of the 
fields and a single basic dosimetry calculation may be reported for the calculation of monitor units for each 
treatment field. 1 unit of code 77290 or 77280 prior to the first treatment is medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of simulation-aided field setting have been met. Therefore, we decided that the 
Plan has to pre-approve 1 unit of simulation-aided field setting.  
 
We also decided that the Plan does not have to pre-approve additional units of simulation-aided field 
setting. 
 
The Plan follows 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 simulation-aided field setting. Our 
reviewer says that the enrollee does not meet criteria for additional units of simulation-aided field setting 
beyond the first unit. Our physician reviewer found using ultrasound on a daily basis is not unreasonable to 
offer but is not necessary. Using daily simulations for a technology for which need has not been established by 
published data or supported by consensus guidelines is not necessary. Therefore, billing for daily simple 
simulations 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 simulation-aided field setting have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional units of simulation-aided field setting. 
 
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.