Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve image-guided, intensity-modulated radiation therapy (IG-IMRT) 
(77385x8, 77387x8). 
 
You asked the Plan to pre-approve IG-IMRT. You say that the treatment is medically necessary for the 
enrollee. The Plan denied your request. The Plan says that Medicare guidance says use of more than 20 IMRTs 
is not considered necessary or reasonable for the enrollee's condition. 
 
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 IG-IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found prostate-specific membrane antigen-positron emission tomography (PSMA-PET) scan on June 
20, 2023, showed diffuse hypermetabolism to the right prostate, suspicious uptake within the right seminal 
vesicle, hypermetabolic bone lesions right acetabulum and sacrum, at least one possibly two pelvic nodes 
(rectal and left internal iliac). The enrollee received 6 cycles of docetaxel + darolutamide + androgen 
deprivation therapy (ADT). PSMA-PET on November 22, 2023, showed a single focus of increased radiotracer 
activity within the sacrum, other sites of disease either decreased or resolved. The enrollee had a 
consultation on December 14, 2023, and a course of radiotherapy to a total dose of 70 Gray (Gy) in 28 fractions 
to prostate and seminal vesicles and pelvis (to include nodal basins and the adjacent sites of osseous disease) 
was recommended using IMRT/volumetric modulated arc therapy (VMAT) technique with palliative intent. 
External beam radiotherapy to prostate/sievert (SVs) and pelvic lymph nodes including PSMA-PET+ bone 
disease (based on PSMA-PETs) +/- boosting PSMA-PET+ disease using 28 fractions of IMRT/VMAT is 
reasonable in this case, when more consolidative radiotherapy is considered outside of the STAMPEDE 
paradigm and covering PSMA-PET+ disease in the same radiation plan. Therefore, the requested coverage for 
28 fractions of radiotherapy using IMRT/VMAT is clinically reasonable and medically necessary and should 
be exceptionally approved in this enrollee given the special clinical scenario and radiologic findings. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IG-IMRT have been met. Therefore, we decided that the Plan has to pre-
approve image-guided, intensity-modulated radiation therapy (IG-IMRT) (77385x8, 77387x8).  
 
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.