Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Intensity Modulated Radiation Therapy (IMRT), 25 fractions 
(77014, G6002, G6015). 
 
You asked the Plan to pre-approve IMRT. You say that the requested treatment is medically necessary. The 
Plan denied your request. The Plan says that the request does not meet the Medicare or health plan coverage 
criteria. 
 
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 technique used to improve the dose conformality. The use of IMRT for the treatment 
of breast cancer is becoming more widely used. In general, IMRT is not an experimental technique, but rather 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 enrollees with an intact breast after 
resection, IMRT has been shown to improve skin and breast toxicity.  For post-mastectomy radiation, IMRT 
has been shown to significantly reduce the dose-volume exposure of the ipsilateral lung and (for left sided 
breast cancer) the heart. For these women (who have undergone a mastectomy), the chest wall, and skin are 
treated, and often bolus is placed on the chest wall to increase dose delivery to the superficial 
skin/subcutaneous tissues. Therefore, there is no need to spare the skin from radiation, although a more 
homogeneous plan with IMRT could reduce skin toxicity. IMRT can be considered necessary to spare the heart 
and lungs, which is generally an issue when treating a concave/convex target of the chest wall. While this 
enrollee has already undergone a mastectomy, the principles of IMRT for chest wall radiation still apply. While 
the enrollee has a right sided breast cancer, for which cardiac sparing is less of a concern (though still 
potentially an issue when treating internal mammary nodes), the complex target volume of treating the chest 
wall, and regional lymphatics make IMRT an accepted standard of care. 25 fractions are standard (as 
prescribed to this enrollee). The decision is favorable for 25 fractions of IMRT. 
 
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), 25 fractions (77014, G6002, G6015).  
 
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.