Appeal type: unknown
Decision: unknown

 
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 say that for many cancers, surgical resection is an established method to either achieve a prolongation 
of life or a cure. Radiation delivered in conjunction with surgery improves outcomes for some types of cancer 
presumably through its ability to reduce tumor volume, kill grossly visible neoplastic tissue that was not 
resected due to technical infeasibility, and destroy microscopic foci of cancer surrounding the known tumor 
site. However, radiation is toxic not only to the neoplastic but also to healthy tissues, and in some cases, 
mortality benefits due to cancer related deaths appear to be attenuated by non-cancer related mortality from 
complications of radiation to healthy tissue. Intraoperative radiation has been posed as a radiation delivery 
method that allows providers to deliver a large dose of radiation focally to the tumor bed, thereby aggressively 
treating the tumor but sparing healthy tissues. 
 
 Surgical resection of the tumor must be reasonable and necessary for the treatment of the patients 
malignancy based on all available information at the time that the decision to put the patient through surgery is 
made. As such, the medical record should reflect that surgical resection was indicated. Palmetto GBA 
recognizes that intraoperative findings may change the course of treatment, and resection may not be carried 
out or completed in such cases. 
 Surgery strictly for the sake of delivery of intraoperative radiation is not supported by the evidence and is not 
considered reasonable and necessary. 
 This LCD is not intended to provide recommendations regarding treatment. Radiation treatment should be 
reasonable and necessary for a patients individual case, in light of that patients cancer diagnosis and cancer 
stage or grade, as well as the patients comorbid clinical conditions. 
 The choice of radiation dose and areas to irradiate should be derived from evidence-based treatment 
protocols. The relevant evidence should be on hand for review if requested. 
 Radiation treatment planning and delivery should be handled by an experienced and qualified team with the 
necessary knowledge and skills to ensure that appropriate precautions are taken to protect the patient, 
healthcare providers, and the public from the hazards of radiation in the OR environment. The relevant 
professionals with such skills and knowledge who are involved in the case must be documented. All federal, 
state, and local laws governing the use and handling of radiation must be followed. 
 
 Pre-procedural documentation must include a complete initial evaluation, including history and an 
appropriately focused physical examination with review of relevant pathology and imaging results. Treatment 
plans formulated in conjunction with other providers (e.g., medical oncologist, surgeon, tumor board, etc.) 
should be included if these discussions support that the procedure is reasonable and necessary. 
  A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. 
Required elements of the note include a description of the mode of radiation delivered, anatomic sites to which 
it is delivered, dose of radiation (in Gray), as well as any necessary pre- and post-procedural assessments. This 
note must have a legible signature, time, and date. 
 
You can find this rule in the Local Coverage Determination (LCD) Intraoperative Radiation Therapy L37779. 
 
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.