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 requested IMRT is medically necessary. The Plan 
denied your request. The Plan says that the requested IMRT is not medically necessary. 
 
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 IMRT is medically necessary. 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. 
 
IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose 
exposure.  IMRT generally implies inverse planning algorithms, i.e. the physician determines radiation 
treatment parameters to maximize dose to the target and minimize dose to normal tissues, and the planning 
algorithm maximizes the adherence to these parameters by modifying the beam spatially and/or temporally.  
 
3D conformal radiation for breast cancer generally implies the use of tangential chest wall fields that are 
forward planned. i.e. the fields are designed and optimized (i.e. beam weighting, beam shaping, beam modifiers 
such as wedges) by the dosimetrist and clinician (as opposed to IMRT in which the optimization is performed 
by a computer algorithm), plus additional fields to include the supraclavicular nodes or axilla. Often, 
segmented fields (i.e, field within fields) are used to improve dose homogeneity and organ sparing. Both 3D 
RT and IMRT deliver radiation to the breast or chest wall. 
 
Advantages of IMRT are to reduce the dose to the heart, lungs, skin and contralateral chest. IMRT can also 
improve the dose homogeneity of the treatment volume, and therefore reduce the hot spots that are often seen 
in the lateral chest wall.   
 
For patients 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 (which does not apply to this enrollee).  
 
From the National Comprehensive Cancer Network (NCCN) practice guidelines, for the section on optimizing 
delivery of individual therapy: Greater target dose homogeneity and sparing of normal tissues can be 
accomplished using compensators such as tissue wedges, forward planning using segments and intensity 
modulated radiation therapy (IMRT). 
 
A 2022 prospective multi-institutional report from 2204 patients treated at 23 institutions within the Michigan 
Radiation Oncology Quality Consortium, showed acute toxicity after inverse-planned IMRT versus 3D 
conformal radiation was significantly less with an odds ratio of 0.64 with conventional fractionation and 0.41 
with hypofractionation (Jagsi et al). 
 
Notably, in 2013 the American Society for Radiation Oncology (ASTRO) Choosing Wisely list included: 
Dont routinely use intensity modulated radiotherapy (IMRT) to deliver whole breast radiotherapy as part of 
breast conservation therapy. On July 28, 2022,  ASTRO removed/rescinded this recommendation, stating: 
Due to recently published evidence related to IMRT for breast cancer, ASTRO has withdrawn this 
recommendation. 
 
It is plausible that with this enrollees obesity (BMI ~40) IMRT would be necessary for dose homogeneity. 
 
One might dispute the number of fractions (25 whole breast + boost) given the NCCN guideline 
recommendations "The whole breast should receive a hypofractionated dose of 4042.5 Gy in 1516 fractions; 
in selected cases 4550.4 Gy in 2528 fractions may be considered.... Typical boost doses are 1016 Gy in 48 
fractions." In this enrollee, targeting the lower axilla in the setting of N1 disease could be considered a 
selected case 
 In summary, it is safe to say that IMRT is not experimental, but rather a useful tool available to radiation 
oncologists to potentially reduce toxicity and improve the lung, heart, and skin dose distributions. In light of 
the dosimetric improvement with IMRT in this enrollee, as well as ASTROs most recent update of its 
Choosing Wisely list, IMRT would be furnished in accordance with accepted standards of medical practice in 
this enrollee's case. 
 
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.