Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that the enrollee has adenocarcinoma of right lung. The 
provider feels the member would benefit from IMRT to maximize dose coverage of the target and limit dose to 
the normal surrounding tissues, including uninvolved lung, spinal cord, heart, and esophagus. The Plan denied 
your request. The Plan says that IMRT is not reasonable and necessary under Medicare guidelines. 
 
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 IMRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. 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. There is a role of 
IMRT in reducing normal lung, cord, and esophageal dose, although generally is considered necessary on a 
case-to-case basis for advanced lung cancer. IMRT is a tool that clinicians can use when there is concern about 
sparing normal tissues from high dose exposure. With IMRT, often full dose can be delivered to the target, 
while minimizing dose to the normal organs. IMRT can be considered necessary when a 3D plan is 
unacceptable and the IMRT plan results in a clinically meaningful reduction in normal tissue dose-volume 
delivery and/or improved target coverage. There are specific studies (or mostly specific) for Stage III non-small 
cell lung cancer (NSCLC) treated with concurrent chemoradiation while this enrollee has Stage II disease to be 
treated with chemoradiation and is to be prescribed high dose (60 gray (Gy)) as used with Stage III NSCLC. 
From the most recent 2023 National Comprehensive Cancer Network (NCCN) guidelines, To minimize 
potential lung and heart toxicities IMRT is preferred over 3D conformal radiation for locally advanced for 
non-small cell lung cancer. This enrollee is being treated as a locally advanced NSCLC. The decision is 
favorable as the reviewer believes that IMRT would be furnished in accordance with accepted standards of 
medical practice. 
 
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 have been met. Therefore, we decided that the Plan has to pre-approve 
Intensity Modulated Radiation Therapy (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.