Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve seventeen (17) additional image-guided, intensity-modulated 
radiation therapy (IG-IMRT) fractions (77014, G6015). 
 
You asked the Plan to pre-approve additional IG-IMRT fractions. You say that the additional fractions are 
medically necessary. The Plan denied your request. The Plan says that the enrollee has localized prostate 
cancer. The extra treatments beyond 28 treatments are not reasonable and necessary. 
 
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 additional IG-IMRT fractions. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found conventional fractionation remains an acceptable alternative 1.8-2 gray (Gy) for 
37-45 fractions. moderately hypofractionated image guided IMRT regimens (2.4-4 Gy per fraction over 4-6 
weeks) have been tested in randomized trials, and their efficacy has been similar or non-inferior to 
conventionally fractionated IMRT, with on trial showing fewer treatment failures with a moderately 
hypofractionated regimen. Toxicity was similar between moderately hypofractionated and conventional 
regimens in some but not all of the trials. In addition, efficacy results varied among the trials, with some 
showing noninferiority or similar efficacy and others showing that hypofractionation may be less effective than 
conventional fractionation schemes. These safety and efficacy differences are likely a result of differences in 
fractionation schedules. In addition, results of a large cohort study showed no differences in quality of life of 
urinary or bowel function between those that received hypofractionated versus conventional regimens. Overall, 
the panel believes that hypofractionated IMRT techniques, which are more convenient for enrollees, can be 
considered as an alternative to conventionally fractionated regimens when clinically indicated. For this case, 
the issue is the appropriateness of 45 fractions vs. moderate hypofractionation. Treatment with more fractions 
is costlier, which is the root of the dispute. The reviewer believes that 45 fractions of IMRT would be within 
accepted standards of medical practice, therefore, the decision is favorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional IG-IMRT fractions have been met. Therefore, we decided that the 
Plan has to pre-approve seventeen (17) additional image-guided, intensity-modulated radiation therapy (IG-
IMRT) fractions (77014, G6015).  
 
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.