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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that intensity-modulated radiation therapy (IMRT) is clinically indicated (i.e., medical necessity
criteria will be met) when highly conformal dose planning is required. IMRT planning may be clinically
indicated when one or more of the following conditions are present:
- An immediately adjacent area has been previously irradiated and abutting portals must be established
with high precision.
- Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar
tumors with conventional treatment.
- The target volume is concave or convex, and the critical normal tissues are within or around that
convexity or concavity.
- The target volume is in close proximity to critical structures that must be protected.
- The volume of interest must be covered with narrow margins to adequately protect immediately
adjacent structures.
On the basis of the above conditions demonstrating medical necessity, disease sites that may support the use of
IMRT include the following:
- Primary, metastatic or benign tumors of the central nervous system including the brain, the brain
stem, and spinal cord.
- Primary or metastatic tumors of the spine where the spinal cord tolerance may be exceeded with
conventional treatment or where the spinal cord has previously been irradiated.
- Primary, metastatic, benign or recurrent head and neck malignancies, including orbits, sinuses, skull
base, aero-digestive tract, and salivary glands.
- Thoracic malignancies.
- Abdominal malignancies when dose constraints to small bowel or other normal abdominal tissue are
exceeded and present administration of a therapeutic dose.
- Pelvic malignancies including prostatic, gynecological and anal carcinoma.
- Other pelvic or retroperitoneal malignancies.
Other malignancies not delineated in the above can be supported with submission of documentation for medical
necessity should a denial occur. The determination of appropriateness and medical necessity for IMRT for any
site shall be found in the documentation from the radiation oncologist and must be available when requested or
submitted in the appeals process.
IMRT is not considered reasonable and necessary when at least one of the criteria listed above and one of the
applicable diagnosis codes are not present. ASTRO IMRT Model Policy outlines clinical scenarios that would
not typically support the use of IMRT. These include:
- Where IMRT does not offer an advantage over conventional or three-dimensional conformal
radiation therapy techniques that deliver good clinical outcomes and low toxicity.
- Clinical urgency, such as spinal cord compression, superior vena cava syndrome or airway
obstruction. - Palliative treatment of metastatic disease where the prescribed dose does not approach normal
tissue tolerances.
- Inability to accommodate for organ motion, such as for a mobile lung tumor.
- Inability of the patient to cooperate and tolerate immobilization to permit accurate and
reproducible dose delivery.
There must be documented rationale of the advantage of IMRT versus the use of other radiation therapy
methods in the medical record of each patient for whom IMRT is provided. You can find these rules in Local
Coverage Determination (LCD) Intensity Modulated Radiation Therapy (IMRT) (L36711). If you want to read
these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.