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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 Intensity Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, 
and delivery of generally narrow, patient specific, spatially and often temporally modulated beams of radiation 
to solid tumors within a patient. IMRT planning and delivery uses an approach for obtaining the highly 
conformal dose distributions needed to irradiate complex targets positioned near, or invaginated by, sensitive 
normal tissues, thus improving the therapeutic ratios. IMRT delivers a more precise radiation dose to the tumor 
while sparing the surrounding normal tissues by using non-uniform radiation beam intensities that are 
determined by various computer-based optimization techniques. 
 
The computer-based optimization process is referred to as inverse planning. Inverse planning develops a dose 
distribution based on the input of specific dose constraints for the planned treatment volume (PTV) and nearby 
clinical structures and is the beginning of the IMRT treatment planning process. The gross tumor volume 
(GTV), the PTV, and surrounding normal tissues must be identified by a contouring procedure and the 
optimization must sample the dose with a grid spacing of one centimeter or less. 
 
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 ICD-10-CM diagnosis codes are not present. Refer to Billing and Coding: Intensity Modulated 
Radiation Therapy (IMRT), A56725, for applicable CPT/HCPCS codes and diagnosis codes. 
    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 the 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.