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 state that intensity modulated radiation therapy (IMRT) is clinically indicated when highly conformal 
dose planning is required to spare normal surrounding tissue as a specific clinical benefit to that individual 
beneficiary. Based on medical necessity, disease sites that may support the use of IMRT include the following: 
- Primary, metastatic or benign tumors of the central nervous system (CNS) 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, with treatment directly impacting 
the orbits, paranasal sinuses, skull base, aero-digestive tract-nasopharynx, oropharynx, hypopharynx, 
and larynx/glottic areas, salivary glands, oral cavity, nasal cavity 
- Thoracic malignancies 
- Abdominal malignancies when dose constraints to small bowel or other normal abdominal tissue are 
exceeded 
- Pelvic malignancies including: prostatic, gynecologic and anal carcinomas 
- Other pelvic or retroperitoneal malignancies 
- Reirradiation that meets the requirements for medical necessity and which is duly documented 
 
Documentation of the medical necessity for each unique, individual beneficiary is crucial for allowing coverage 
and must include the following: 
- The specific diagnosis and target volume requiring IMRT; the total dose and dose per fraction 
- The type of treatment planning used must be specified (i.e., forward or inverse) 
- The specific prior history of any RT related to site and total dose 
- A narrative statement documenting the special need for IMRT rather than conventional or 3D RT 
relating to the individual specific beneficiary 
- Medical necessity documentation for IMRT should include 1 or more of the following clinical 
scenarios: 
~ An immediately adjacent area has been previously irradiated and highly precise planning is 
needed for the current therapy with abutting portals 
~ Dose escalation is planned to deliver radiation doses exceeding those commonly used 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 very close to critical structures that must be protected 
~ The volume of interest must be covered with narrow margins to adequately protect immediately 
adjacent structures 
- With claimed delivery of prescribed IMRT, an easily identified, authenticated dose prescription must be 
present along with clearly labeled, color comparative treatment plans which include the dose volume 
histograms. Toward this requirement, collaboration with ones electronic medical record vendor is 
strongly recommended. 
 
Other malignancies not delineated above as potentially covered could be considered for coverage 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. You can find 
these rules in Local Coverage Determination (LCD) Radiation Therapies (L39553). 
 
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.