Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve 55 Gy in 20 fractions of IMRT. We decided that the Plan does not 
have to pre-approve the additional Gy and fractions of IMRT.  
 You asked the Plan to pre-approve intensity-modulated radiotherapy (IMRT) of 70 Gy to the prostate and 
seminal vesicles in 28 fractions and 50.4 Gy in 28 fractions to the regional lymph nodes. You say that this 
should be approved as requested. The Plan says that the requested treatment is not medically necessary. 
 
We decided that the Plan has to pre-approve 55 Gy in 20 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 the item/service at issue. Our reviewer 
says that the enrollee meets criteria for the requested treatment, but at a lower dose and number of fractions 
than planned. Our physician reviewer found the enrollee has oligometastatic prostate cancer with involvement 
of the bilateral seminal vesicles. He has had chemotherapy but no prior radiation. The enrollee was seen and a 
course of radiotherapy to a total dose of 70 Gy in 28 fractions to prostate and seminal vesicles and 50.4 Gy in 
28 fractions to regional nodes was recommended using IMRT/volumetric arc therapy (VMAT) technique. This 
treatment is based on the STAMPEDE paradigm. 
 
Based on pathology and radiology findings, the patient is a candidate for external-beam radiotherapy to the 
prostate to a total dose of 55 Gy in 20 fractions over 4 weeks under the STAMPEDE paradigm. Prostate 
radiotherapy using 20 fractions of IMRT/VMAT is considered the standard of care for this patient and should 
be approved. The additional dose/fractions are not supported as medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item/service at issue have been met. Therefore, we decided that the Plan has 
to pre-approve 55 Gy in 20 fractions of IMRT.  
 
We also decided that the Plan does not have to pre-approve the additional Gy and 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. 
 
As noted above, the additional dose/fractions are not supported. We looked at this physician's review, the file, 
and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the item/service 
at issue have not been met. Therefore, we decided that the Plan does not have to pre-approve the additional Gy 
and 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.