Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 15 fractions of IMRT, 1 treatment plan with IMRT, and 6 
fractions of 3D radiation therapy (3DRT). We decided that the Plan does not have to pre-approve the 
remainder of services at issue in this case.  
 
You asked the Plan to pre-approve intensity-modulated radiation therapy (IMRT) with non IMRT treatment 
(G6012, G6013, G6014, G6002 x16).. You say that this is medically necessary. The Plan says that the provider 
desires a hybrid treatment of hybrid IMRT with non IMRT, which is not covered.  
We decided that the Plan has to pre-approve 15 fractions of IMRT, 1 treatment plan with IMRT, and 6 
fractions of 3D radiation therapy (3DRT).  
 
The Plan follows Medicare rules. Medicare rules say that services are covered when they are 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 for these services. Our reviewer says that at issue in 
this case is the number of fractions prescribed to this patient to undergo whole breast radiotherapy after breast 
conserving surgery. Whether hypofractionated radiation in 15-16 vs 5 fractions would have more or less 
toxicity risks is  debatable though multiple studies show that 5-fractions of radiation is safe and effective for 
post-lumpectomy whole breast radiation. The appeal letter has emphasized that IMRT was not done, which is 
unclear why. Even before the Jagsi report and before the modified Choosing Wisely statement, high body mass 
index (BMI) and large chest wall separation were accepted indications to offer IMRT. IMRT would be a 
standard of care in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve 15 fractions of IMRT, 1 treatment plan with IMRT, and 6 fractions of 3D radiation therapy (3DRT).  
 
We also decided that the Plan does not have to pre-approve the remainder of services at issue in this 
case. 
 
The Plan follows Medicare rules. Medicare rules say that services are covered when they are 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 for the rest of the services. Our reviewer says that any 
other services would not be considered a standard of care for the enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the remainder of services at issue in this case have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the remainder of services at issue in this case. 
 
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.