Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 15 fractions of IMRT. We decided that the Plan does not have to 
pre-approve 22 additional fractions of IMRT.  
 
You asked the Plan to pre-approve 37 fractions of intensity modulated radiation treatment (IMRT). You say 
that it is medically necessary to use IMRT as your mean lung dose should be less than 20 gray (Gy). The Plan 
says that the requested treatment is non-standard and not generally accepted as an aggressive approach is not 
being tried on the other known sites of disease. 
 We decided that the Plan has to pre-approve 15 fractions of IMRT.  
 
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 37 fractions of IMRT. Our reviewer 
says that the criteria for coverage of 15 fractions of IMRT have been met. Our physician reviewer found that 
because the thoracic radiotherapy would be similar to that used for Stage III non-small cell lung carcinoma 
(NSCLC), IMRT would be appropriate and furnished in accordance with accepted standards. 15 fractions of 
IMRT is more accepted as a standard with the caveat that for this enrollee, with more extensive metastatic 
disease that is not being treated, any consolidative thoracic treatment would not be based on strong data.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 37 fractions of IMRT have been met. Therefore, we decided that the Plan has to 
pre-approve 15 fractions of IMRT.  
 
We also decided that the Plan does not have to pre-approve 22 additional fractions of IMRT. 
 
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 37 fractions of IMRT. Our reviewer 
says that the criteria for coverage of 22 of the requested fractions have not been met. Our physician reviewer 
found there is no rationale provided for the need of more than 15 fractions, and in fact 33 fractions would be 
outside the standard of care. With no benefit in Stage III patients to treating with more than 30 fractions, doing 
so in Stage IV patients is even less likely to be of benefit and possibly could cause harm. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 22 additional fractions of IMRT have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 22 additional fractions of IMRT. 
 
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.