Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve thoracic radiotherapy, IMRT, and cone beam CT for total 
dose of 6600 cGy in 30 fractions. We decided that the Plan does not have to pre-approve IMRT for total dose 
of 6600 cGy in 33 fractions.  
 
You asked the Plan to pre-approve thoracic radiotherapy, intensity-modulated radiation therapy (IMRT), and 
cone beam computed tomography (CT) for total dose of 6600 cGy in 33 fractions. You say that thoracic 
radiotherapy, IMRT, and cone beam CT for total dose of 6600 cGy in 33 fractions is medically necessary. The 
Plan says that thoracic radiotherapy, IMRT, and cone beam CT for total dose of 6600 cGy in 33 fractions is not 
medically necessary. 
 We decided that the Plan has to pre-approve thoracic radiotherapy, IMRT, and cone beam CT for total 
dose of 6600 cGy in 30 fractions.  
 
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 thoracic radiotherapy, IMRT, and cone 
beam CT for total dose of 6600 cGy in 33 fractions. Our reviewer says that thoracic radiotherapy, IMRT, and 
cone beam CT for total dose of 6600 cGy in 30 fractions is medically necessary. Our physician reviewer found 
IMRT is 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. For locally advanced Non-small cell 
lung cancer (NSCLC), there is a role of IMRT in reducing normal lung, cord, and esophageal dose as described 
below. 
 
This enrollee is being offered definitive radiotherapy PRIOR to systemic therapy, which does not fully comply 
with the aforementioned randomized Phase II studies or National Comprehensive Cancer Network (NCCN) 
guidelines which recommend upfront systemic therapy followed by assessment of response prior to offering 
consolidative thoracic radiotherapy. However, the approach is reasonable given the concern about impending 
symptoms.  
 
As the thoracic radiotherapy would be similar to that used for Stage III NSCLC, IMRT would be appropriate 
and furnished in accordance with accepted standards.  
 
For patients a Radiation Therapy Oncology Group (RTOG)/NRG Oncology (NRG) cooperative group study 
showed that with Stage III NSCLC, there was no advantage to escalating the dose beyond 60 Gy in 30 fractions 
with respect to survival outcomes, and patients treated to higher doses fared worse. For this enrollee, there is no 
rationale provided for the need of greater than 30 fractions, and in fact 33 fractions would be outside the 
standard of care. With no benefit in Stage III patients to treating with greater than 30 fractions, doing so in 
Stage IV patients is even less likely to be of benefit and possibly could cause harm.  Also, prolonging the 
thoracic radiotherapy in this enrollee would delay systemic therapy which is the standard treatment. With no 
rationale for why 33 fractions were requested, my decision ultimately would be partially favorable for 30 
fractions, as treating with more fractions without a plausible rationale for why is not standard.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of thoracic radiotherapy, IMRT, and cone beam CT for total dose of 6600 cGy in 
30 fractions have been met. Therefore, we decided that the Plan has to pre-approve thoracic radiotherapy, 
IMRT, and cone beam CT for total dose of 6600 cGy in 30 fractions.  
 
We also decided that the Plan does not have to pre-approve IMRT for total dose of 6600 cGy in 33 
fractions. 
 
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 for total dose of 6600 cGy in 33 
fractions. Our reviewer says that for patients a Radiation Therapy Oncology Group (RTOG)/NRG Oncology 
(NRG) cooperative group study showed that with Stage III NSCLC, there was no advantage to escalating the 
dose beyond 60 Gy in 30 fractions with respect to survival outcomes, and patients treated to higher doses fared 
worse. For this enrollee, there is no rationale provided for the need of greater than 30 fractions, and in fact 33 
fractions would be outside the standard of care. With no benefit in Stage III patients to treating with greater than 30 fractions, doing so in Stage IV patients is even less likely to be of benefit and possibly could cause 
harm.  Also, prolonging the thoracic radiotherapy in this enrollee would delay systemic therapy which is the 
standard treatment. With no rationale for why 33 fractions were requested, my decision ultimately would be 
partially favorable for 30 fractions, as treating with more fractions without a plausible rationale for why is not 
standard.  
 
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 for total dose of 6600 cGy in 33 fractions have not been met. Therefore, 
we decided that the Plan does not have to pre-approve IMRT for total dose of 6600 cGy in 33 fractions. 
 
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.