Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve IMRT Complex Treatment, 15 fractions (77386), an office visit 
(99213), treatment planning complex (77263), CT guidance CBCT (77014), treatment device IMRT (77338), 
calculation (77300), IMRT planning (77301), weekly physics (77336), respiratory management (77293) and 
image fusion (77399). 
 
You asked the Plan to pre-approve radiation therapy. You say that the requested therapy is medically 
necessary. The Plan denied your request. The Plan says that there is no current research showing that the 
enrollee's type of cancer responds better to the requested type of treatment than the type of treatment that can 
be approved. This type of treatment is called 3D-CRT (three-dimensional conformal radiation therapy). 
 
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. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has oligometastatic stage IV disease (and would have had Stage III NSCLC 
without the treated brain metastases). As the case file highlights, in the most recent NCCN guidelines 
(V8.2020), for enrollees with limited metastases, definitive radiotherapy or chemoradiotherapy is 
recommended after assessment of response to systemic therapy. This enrollee is being offered definitive 
radiotherapy prior to systemic therapy, which does not fully comply with the aforementioned randomized 
Phase II studies or NCCN guidelines which recommend upfront systemic therapy followed by assessment of 
response prior to offering consolidative thoracic radiotherapy. However, the approach is reasonable and would 
be considered in accordance with accepted standards. As the thoracic radiotherapy would be similar to that 
used for Stage III NSCLC, IMRT would be appropriate and furnished in accordance with accepted standards. 
The 15-fraction approach is what is being offered in the NRG LU002 protocol and would be an acceptable 
standard. The decision is favorable for 15 fractions of IMRT as the treatment would be in accordance with 
accepted standards. 
 
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 have been met. Therefore, we decided that the Plan has to pre-
approve IMRT Complex Treatment, 15 fractions (77386), an office visit (99213), treatment planning complex 
(77263), CT guidance CBCT (77014), treatment device IMRT (77338), calculation (77300), IMRT planning 
(77301), weekly physics (77336), respiratory management (77293) and image fusion (77399).  
 
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.