Appeal type: Practitioner Services
Decision: Partially Favorable

 
You asked the Plan to pre-approve electronic brachytherapy with daily simple simulations. You say that this is 
medically necessary. The Plan says that there are insufficient long-term studies to support the safety and 
efficacy of this treatment. 
 
We decided that the Plan has to pre-approve electronic brachytherapy and one simulation.  
 
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 electronic brachytherapy and one initial simulation. Our physician 
reviewer found there are some societies/groups without conflicts of interest that consider this treatment 
acceptable and therefore electronic brachytherapy and superficial radiation are within accepted standards of 
medical practice, conceding that the National Comprehensive Cancer Network (NCCN) and two American 
Brachytherapy Society (ABS) guidelines recommend against routine use. Practice parameters consider it 
acceptable treatment for select patients. One unit of therapeutic radiation simulation (defined by code 77280) 
would be within accepted standards of care since initial simulation would be simple in this case. If performed 
on the first day of treatment this code would supersede the billing for treatment on that day. 
 
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 electronic brachytherapy and one simulation.  
 
We also decided that the Plan does not have to pre-approve additional daily simulations. 
 
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 the item/service at issue. Our reviewer 
says that the enrollee does not meet criteria for daily simply simulations beyond one unit prior to the first 
treatment. Our physician reviewer found use of code 77290 is not supported by the records as a simple 
ultrasound to determine depth and size or target would be more appropriately be billed as a simple versus 
complex simulation. Daily simple simulations would not 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 the item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional daily simulations. 
 
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.