The requirements for IMRT have been consistent for quite some time but there is still much confusion in the field as to what exactly is necessary in order to use this form of treatment. The two main requirements, as stated in most LCD’s, are: 1) the need for a statement of medical necessity by the physician for the use of IMRT, and 2) dose constraints and goals for critical structures.
This medical necessity statement would not only indicate why IMRT is needed but also why it is necessary over conventional forms of treatment like 3D. This should be provided up front prior to any planning being performed and in many cases is needed for any pre-authorizations required by the payer. Many physicians do not include this statement of medical necessity in each medical record until they are requested by a payer after the treatment has been concluded. There is another misconception that this information doesn’t need to be included for prostate IMRT planning and treatment since the efficacy of IMRT is widely published.
The dose constraints, or organ goals, are another item commonly not found in the medical records reviewed. Most centers believe that the information contained within the treatment plan is sufficient, but technically the plan cannot be generated without these constraints and goals being established. This information is typically relayed to the dosimetrists but not always documented in the medical record. Due to the IMRT requirements in most LCD’s it is necessary for the physician to provide this information prior to planning and is recommended at the time the plan is ordered.
Below is a quote from Highmark Medicare Services, Inc., and Trailblazer Health Enterprises, LLC. The verbiage from both LCD’s is identical and these 2 MAC’s cover multiple states throughout the country.
- The prescription must define the goals and requirements of the treatment plan, including the specific dose constraints for the target(s) and nearby critical structures.
- A statement by the treating physician documenting the special need for performing IMRT on the patient in question, rather than performing conventional or 3-dimensional treatment planning and delivery.
- A signed IMRT inverse plan that meets prescribed dose constraints for the planning target volume (PTV) and surrounding normal tissue using either dynamic multi-leaf collimator (DMLC), segmented multi-leaf collimator (SMLC) (average number of "steps" required to meet IMRT delivery is 5), or inverse planned IMRT solid compensators to achieve intensity modulation radiation delivery.
Review your specific MAC’s documentation and medical necessity requirements and ensure that this information can be clearly identified in your medical record for each patient undergoing IMRT planning and IMRT treatment delivery.