Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve sixteen (16) additional fractions of intensity-modulated radiation 
therapy (IMRT) (77014, 77385, 77387). 
 
You asked the Plan to pre-approve additional fractions of IMRT. You say that the additional fractions are 
medically necessary. The Plan denied your request. The Plan says that there is no good evidence in the records 
that the extra radiations are good for the enrollee's cancer. 
 
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 fractions of IMRT. 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.  for this case, the issue is the appropriateness of 44 fractions vs. moderate 
hypofractionation. Treatment with more fractions is costlier, which is the root of the dispute. 44 fractions in 
considered acceptable (albeit not preferable) by National Comprehensive Cancer Network (NCCN) guidelines 
and American Society for Radiation Oncology (ASTRO), American Society of Clinical Oncology (ASCO), and 
American Urological Association (AUA) Evidence-Based Guideline, with the expert guidelines acknowledging 
some limitations in the data. As such, the reviewer believes that 44 fractions of IMRT would be within 
accepted standards of medical practice. The decision is therefore favorable for 16 additional fractions. 
 
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 fractions of IMRT have been met. Therefore, we decided that the 
Plan has to pre-approve sixteen (16) additional fractions of intensity-modulated radiation therapy (IMRT) 
(77014, 77385, 77387).  
 
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.