Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT) 
 
You asked the Plan to pre-approve IMRT. You say that IMRT is medically necessary for this patient. The Plan 
denied your request. The Plan says IMRT is not medically necessary for this enrollee, IMRT is unproven in this 
context, and other forms of radiation are more appropriate. 
 
The Plan must follow 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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found Intensity modulated radiation therapy (IMRT) is a technique used to improve the dose 
conformality. In general, IMRT is not an experimental technique, but rather a radiation planning and delivery 
tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. Another advantage of IMRT is that is allows dose painting- i.e. certain regions 
can receive a higher dose per fraction than others. IMRT for rectal cancer is used to reduce dose to the small 
bowel, bladder, pelvic bone marrow and femoral heads.  Rectal cancer can readily be treated definitively 
(curatively) with conventional radiation, while maintaining acceptable dose constraints to the bladder, femurs 
and bowel. IMRT can be considered for exceptional circumstances.  This patient is being offered palliative 
radiotherapy for which IMRT is not an accepted standard.  The prescribed 15 fractions is not typical for 
palliation but even with 15 fractions x 2 Gy the dose is low.  
 
The older versions of the National Comprehensive Cancer Network (NCCN) guidelines (2021 and prior) had 
stated that IMRT should only be used in the setting of a clinical trial, in unique clinical situations such as 
reirradiation ... or unique anatomical situations .... The 2022-2023 guidelines now state that IMRT is 
preferred for reirradiation of previously treated patients with recurrent disease, patients treated postoperatively 
due to increased acute or later toxicity, or in unique anatomical situations (e.g., coverage of external iliac 
lymph nodes for T4 tumors invading anterior pelvic organs or inguinal lymph nodes or avoidance of small 
bowel). 
 
The NCCN guidelines apply to definitive/curative treatments and would not apply to this patient with widely 
metastatic disease to undergo palliative radiation. The case records do not adequately demonstrate the need for 
IMRT using plausible dosimetric evidence (i.e., to what extent IMRT reduced the dose-volume exposure of 
critical normal tissues) nor is it plausible that such a benefit could be demonstrated.  Simply asserting that 
IMRT is necessary does not constitute sufficient documentation for medical necessity of IMRT. IMRT for 
palliation of rectal cancer is not an accepted standard 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 IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity modulated radiation therapy (IMRT)