Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT). 
 
You asked the Plan to pre-approve IMRT. You say that due to the enrollee's current condition, you are making 
this expedited request. The Plan denied your request. The Plan says IMRT is not considered reasonable and 
necessary for the enrollee's condition. 
 
The Plan follows Medicare rules. Medicare rules say that IMRT is only coverable when medically necessary. It 
is not covered when IMRT does not offer an advantage over conventional or three-dimensional conformal 
radiation therapy techniques that deliver good clinical outcomes and low toxicity. 
 
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 IMRT is 
not considered reasonable and necessary in this case. Our physician reviewer found in general, radiation is used 
in the setting of bladder preservation after gross disease has been surgically removed. 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.   
 
Clinically meaningful reduction in the bowel volume receiving greater than 40-45 Gy can warrant 
consideration of IMRT as can limiting hot spots in the bowel in excess of 50-60 Gy. However, the prescribed 
dose in this patient is apparently only 50 Gy in 25 fractions, albeit with concurrent chemotherapy. The most 
recent National Comprehensive Cancer Network (NCCN) guidelines do not address IMRT as they do for other 
cancers. The American Society for Radiation Oncology (ASTRO) model policy states that conditions that 
frequently support the need for IMRT include pelvic malignancies. The policy does require justification for the 
need for IMRT. The medical records do not offer an explanation as to why, or offer a quantifiable rationale, for 
why IMRT is needed in this patient. No specific information about a 3D conformal plan being unacceptable 
was provided. 
 
In summary, IMRT is not experimental, but rather a useful tool available to radiation oncologists to potentially 
reduce toxicity and improve the dose distribution in patients when the dose-volume exposure of normal tissues 
warrant its use.  ASTROs position is that IMRT is necessary when the need is sufficiently supported. For this 
patient with metastatic disease, aggressive treatment could be considered, though 38 fractions is perhaps 
excessive without justification.  There is no justification for the need 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 not been met. Therefore, we decided that the Plan does not have to 
pre-approve intensity-modulated radiation therapy (IMRT).