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Intensity-Modulated Radiation Therapy (IMRT) (Independence Administrators)
09.00.17r

Policy

This policy only applies to members for whom Independence Administrators serves as the claims administrator and whose group has not enrolled in the UM vendor program.  For those groups who have been given the option to enroll in the UM vendor program, this policy is no longer applicable upon their renewal effective date. Individual member benefits must be verified before/prior to providing services.

MEDICALLY NECESSARY
​
Intensity-modulated radiation therapy (IMRT) is considered medically necessary and, therefore, covered if at least one of the following criteria is met for the indications listed, and when IMRT is not used as a replacement for conventional or three-dimensional conformal radiation therapy, and sparing surrounding normal tissue is of added benefit:
  • 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.
  • An immediately adjacent area has been previously irradiated and abutting portals have been established with high precision.
  • The target volume is concave or convex, and critical normal tissues are within or around that convexity or concavity.
  • Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors with conventional treatment.
  • The use of IMRT techniques would decrease the probability of Grade 2 or Grade 3 radiation toxicity, compared with conventional radiation in greater than 15 percent of similar cases.
ABDOMEN AND PELVIS
  • Cancer of the anus/anal canal
  • Cancer of the abdomen and pelvis, including but not limited to the following list when dosimetric planning with standard three-dimensional (3-D) conformal radiation predicts that the radiation dose to an adjacent organ would result in unacceptable normal tissue toxicity:
    • Stomach (gastric)
    • Hepatobiliary tract
    • Pancreas
    • Esophageal
    • Rectal locations
    • Gynecological tumors (e.g., cervical, endometrial, and vulvar)
    • Abdominal malignancies when dose constraints to the small bowel or other normal abdominal tissue are exceeded and present administration of a therapeutic dose
BREAST AND LUNG
  • Left-sided breast cancer when used for w​hole-breast irradiation following breast-conserving surgery when all the following criteria are met:
    • Significant cardiac radiation exposure cannot be avoided using alternative radiation techniques.
    • IMRT dosimetry demonstrates significantly reduced cardiac target volume radiation exposure.
  • Whole-breast irradiation following breast-conserving surgery when any the following criteria are met:
    • Treatment in the curative setting that overlaps with a previously irradiated area
    • An optimized 3D conformal plan exceeds the tolerances for organs at risk (OARs) as outlined by either Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) or National Comprehensive Cancer Network (NCCN) guidelines
  • Breast cancer in individuals with large breasts when treatment with 3-D conformal radiation results in hot spots (i.e., focal regions with dose variation >10% of target) and the hot spots can be avoided with IMRT
  • Partial-breast irradiation following breast-conserving surgery
  • Lung cancer when all the following criteria are met:
    • Radiation therapy is being given with curative intent
    • 3-D conformal radiation will expose greater than 35% of normal lung tissue to more than 20 Gy dose-volume (V20)
    • IMRT dosimetry demonstrates reduction in the V20 to at least 10% below the V20 that is achieved with the 3-D plan
CENTRAL NERVOUS SYSTEM
  • Tumors of the central nervous system (primary, metastatic, or benign) when the tumor is in close proximity to organs at risk (e.g., brain stem, spinal cord, cochlea, eye structures including optic nerve and chiasm, lens and retina) and 3-D conformal radiation planning is not able to meet dose volume constraints for normal tissue tolerance
  • 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
HEAD AND NECK
  • Primary, metastatic, benign, or recurrent lesions to the head and neck area including any of the following:
    • Orbits
    • Sinuses
    • Skull base
    • Aerodigestive tract
    • Salivary glands
  • Thyroid (e.g., thymoma and thymic) cancers in close proximity to organs at risk (e.g., esophagus, salivary glands, and spinal cord) and 3-D conformal radiation planning is not able to meet dose volume constraints for normal tissue tolerance ​as outlined by either QUANTEC or NCCN guidelines ​ or is used for treatment in the curative setting that overlaps with a previously irradiated area
PROSTATE
  • Localized prostate cancer
  • As adjuvant therapy after radical prostatectomy when there are adverse pathological findings at prostatectomy or with a persistently detectable prostate-specific antigen (PSA) level post-prostatectomy
    • Adverse pathological findings at prostatectomy include positive surgical margins, seminal vesicle invasion, extraprostatic extension, and Gleason scores of 8 to 10
  • As salvage therapy after radical prostatectomy when there is evidence of biochemical or local recurrence when there is no evidence of distant metastatic disease
    • Biochemical recurrence is a detectable or rising PSA value after surgery that is 0.2 ng/mL or greater with a second confirmatory level of 0.2 ng/mL or greater
SMALL CELL LUNG


Small cell lung cancer may be considered medically necessary for individuals with stage I or node-negative stage IIA limited stage small-cell lunger cancer (LS-SCLC) status postlobectomy with positive margins, gross residual disease, or N2 disease​, stage IIB LS-SCLC or s​tage III disease when any of the following are met:
  • An optimized 3D conformal plan exceeds the tolerances for OARs as outlined by either QUANTEC or NCCN guidelines ​​​
NON-SMALL CELL LUNG

Non-small cell lung cancer may be considered medically necessary when any of the following are met:
  • ​​Treatment in the curative setting that overlaps with a previously irradiated area
  • An optimized 3D conformal plan exceeds the tolerances for OARs as outlined by either QUANTEC or NCCN guidelines ​
OTHER INDICATIONS
  • Thoracic malignancies
  • Pediatric tumors (benign or malignant)
  • Re-irradiation that meets the requirements for medical necessity listed above​
HIPPOCAMPAL-AVOIDING INTENSITY-MODULATED RADIOTHERAPY​

Hippocampal-avoiding intensity-modulated radiotherapy may be considered medically necessary for individuals with brain tumor metastases outside a 5-mm margin around either hippocampus and expected survival greater than or equal to 4 months.


EXPERIMENTAL/INVESTIGATIONAL

IMRT is considered experimental/investigational and, therefore, not covered for the following indication:
  • Postmastectomy irradiation of the chest wall
NOT MEDICALLY NECESSARY

IMRT is considered not medically necessary and, therefore, not covered for the following indications:
  • As a palliative treatment option for lung cancer
  • All uses for IMRT that do not meet the above criteria are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.
IMAGE-GUIDED RADIATION THERAPY (IGRT)

When required, image-guided radiation therapy (IGRT) is considered medically necessary and, therefore, covered and eligible for separate reimbursement when used and documented with medically necessary IMRT treatment delivery.

BILLING REQUIREMENTS: IMRT

The following Current Procedural Terminology (CPT) codes are part of the development of the IMRT treatment planning (CPT code 77301) and, therefore, considered integral and are not eligible for separate reimbursement when billed prior to or part of the development of the IMRT treatment plan code 77301:

CPT CodeCPT Code Description
77014Computerized axial tomography guidance for placement of radiation therapy fields
77280Therapeutic radiology simulation-aided field setting, simple
77285Therapeutic radiology simulation-aided field setting, intermediate
77290Therapeutic radiology simulation-aided field setting, complex
77293Respiratory motion management simulation (List separately in addition to code for primary procedure)
772953-dimensional radiotherapy plan, including dose-volume histograms
​77321
​Special teletherapy port plan, particles, hemibody, total body
77331Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician
​77370
​Special medical radiation physics consultation​

IMRT TREATMENT PLANNING
IMRT planning (77301) should typically reported only once per course of IMRT.

IMRT DOSIMETRY
Basic radiation dosimetry calculations (77300) arrive at the relationship between monitor units (or time) and doses, and encompass the physician's verification, review, and approval. The documentation should contain the independent check of each field, separate from the computer-generated IMRT plan. This code can be typically billed once for each IMRT beam or arc, up to a limit of 10.

IMRT TREATMENT DEVICES
Multi-leaf collimator devices for IMRT (77338), should be reported once per IMRT plan.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the following:

  • The medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
  • A prescription that defines the dose to the target and the dose constraints to the nearby critical structures.
  • A signed IMRT inverse plan that meets prescribed dose constraints for the planning target volume (PTV) and surrounding normal tissue.
  • Target verification methodology, which must include the following:
    • ​Documentation of the clinical treatment volume (CTV) and the PTV
    • Documentation of immobilization and patient positioning
  • Independent basic dose calculations of monitor units for each beam before the individual's first treatment.
  • Documentation of fluence distributions (recomputed and measured in a phantom or dosimetry measuring device).
  • Identification of structures that traverse high- and low-dose regions created by respiration (voluntary breath-holding alone is not a satisfactory solution for accounting for organ motion).
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

Intensity-modulated radiation therapy (IMRT) is excluded from the capitated radiology program and is, therefore, eligible for separate reimbursement consideration.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, IMRT is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Description

The goal of radiation therapy is to attain the highest possible tumor control or cure with the least amount of morbidity and toxicity to adjacent tissues. The achievement of optimal patient care outcomes (e.g., homogeneous radiation delivery to reduce secondary malignancies and tissue toxicity among others) requires the delivery of the desired dose distribution of ionizing radiation to target tissue while limiting the radiation dose to the surrounding tissue to an acceptable level. By taking into account axial anatomy and complex tissue contours, intensity-modulated radiation therapy (IMRT) allots for refined dose calculations and dose delivery. IMRT differs from conventional, and other conformal external beam radiation techniques, in that through the application of a multileaf collimator (MLC), the number and intensity of fields projected into the target volume are modulated. Beam modulation results in increased conformality and may permit escalated tumor doses without increasing normal tissue toxicity and thus may improve local tumor control, with decreased exposure to surrounding normal tissues.

IMRT TREATMENT PLANNING

IMRT treatment plans are geometrically more accurate and tailored to target volumes than conventional or three-dimensional radiation plans. The IMRT planning computer algorithm describes the necessary field sizes, gantry angles, and other beam characteristics needed to achieve the desired dose distribution. The essential feature of an IMRT plan is that it describes the means to deliver treatment utilizing non-uniform beam intensities.

Three-dimensional image acquisition by simulation (e.g., computed tomography [CT], magnetic resonance imaging [MRI], positron emission tomography [PET], or similar image fusion technology) is a prerequisite to IMRT treatment planning. The physician then outlines (contours) the visible abnormality seen on each slice of the image set. The three-dimensional summation of these contours defines the gross tumor volume (GTV). The physician draws a margin around the GTV to generate a clinical target volume (CTV), which encompasses the volume of tissue at risk for microscopic disease (not visible on imaging studies). To account for potential individual set-up variation or organ and individual motion, a final margin is then added to create the planning target volume (PTV). The physician also contours nearby normal structures that potentially could be damaged by radiation (“organs at risk”).

The physician assigns specific dose requirements for the PTV (i.e., minimum dose and dose homogeneity) and dose constraints for the organs at risk (i.e., maximum allowable doses). A treatment plan that satisfies these requirements and constraints should maximize the potential for disease control and minimize the risk of radiation injury to normal tissue.

The radiation physicist or a supervised dosimetrist calculates a complex multibeam treatment plan to deliver the dose to the PTV and satisfy the normal tissue dose constraints. The radiation beam is, in effect, a collection of “beamlets,” each with a different level of radiation intensity. The summation of these “beamlets” distributes the characteristic, highly conformal IMRT dose. The PTV, therefore, receives a high dose of radiation while nearby organs receive significantly lower doses.

Prior to treatment delivery, the physicist performs basic dose calculations on each of the modulated beams. These specific monitor unit computations verify through a second dose calculation method (independent of treatment planning) that the computer has correctly performed the treatment planning calculations. The calculated beams are then delivered to either a phantom or a dosimetry measuring device to confirm that the point dose and dose distribution are physically verifiable and that the intensity-modulated beams are technically feasible.

IMRT TREATMENT DELIVERY

IMRT treatment delivery can be accomplished through a variety of technologies. The most common approach utilizes a MLC to modulate the intensity of the beam. The basic requirement for all forms of IMRT treatment delivery is that the technology must accurately produce the calculated dose distribution described by the IMRT plan. IMRT techniques utilize either fixed gantry or moving gantry technology, and include the following:
  • Static MLC (step and shoot), where the leaves do not move when the beam is on
  • Dynamic MLC (sliding window), where the leaves move during treatment
  • Fan-beam therapy, which uses a binary collimator to deliver slice-by-slice treatment
  • Intensity-modulated arc therapy, in which the gantry rotates while moving MLCs to create a nonuniform dose to the PTV during individual arc segments
A different technical solution for IMRT is to use a solid compensator with varying thickness filters to modulate the beam.

The highly conformal dose distribution produced by IMRT results in much sharper spatial dose gradients than conventional or three-dimensional conformal radiation therapy. Consequently, small changes in individual or target position within the body can cause large changes in the dose delivered to the PTV and to the organs at risk. Thus, individual immobilization is required for precision IMRT. Changes in the location of the target within the body during a single fraction can arise from respiratory motion or other physiologic variances. To accommodate such changes, the PTV may be drawn based on published studies of organ motion or on dynamic imaging studies; treatment delivery may also be actively modulated by direct measures of motion during treatment.

Following the treatment planning, simulation directs the treatment beams to the specific volume of interest. Simulation may be carried out using a conventional simulator, CT scanner, radiation therapy treatment unit (e.g., linear accelerator), or diagnostic imaging equipment (e.g., fluoroscopy, CT, MR). The typical course of radiation therapy requires between one and three simulations performed on various days. Simulations are described as simple, intermediate, complex, and three-dimensional.

Basic radiation dosimetry is a separate service from IMRT planning. The radiation dose delivered by each IMRT beam must be calculated and verified before the course of radiation treatment begins.

Treatment devices are used in conjunction with the delivery of IMRT radiotherapy. The devices ensure that the beam is accurately on target.

Medical radiation physics consultation includes assessment of the treatment parameters, quality assurance of dose delivery, and review of the treatment documentation in support of the radiation oncologist.

IMAGE-GUIDED RADIATION THERAPY (IGRT)

IGRT utilizes imaging technology (e.g., ultrasound, kilovoltage or megavoltage cone beam CT scan, stereoscopic X-ray) to modify treatment delivery to account for changes in the position of the intended target and to guide the delivery of radiation to the PTV. IGRT is used in conjunction with IMRT in individuals whose tumors are located near or within critical structures and/or in tissue with inherent setup variation.

HIPPOCAMPAL-AVOIDING WHOLE BRAIN RADIATION THERAPY (HA-WBRT)

HA-WBRT is utilized with IMRT in an effort to avoid memory-specific hippocampal neural stem cells during treatment of brain metastases to better preserve cognitive function.

References

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Cahlon O, Zelefsky MJ, Shippy A, et al. Ultra-high dose (86.4 Gy) IMRT for localized prostate cancer: toxicity and biochemical outcomes. Int J Radiat Oncol Biol Phys. 2008;71(2):330-337.

Chang JY, Liu HH, Komaki R. Intensity modulated radiation therapy and proton radiotherapy for non-small cell lung cancer. Curr Oncol Rep. 2005;7(4):255-259.

Chen CC, Wang L, Lu CH, et al. Comparison of clinical outcomes and toxicity in endometrial cancer patients treated with adjuvant intensity-modulated radiation therapy or conventional radiotherapy. J Formos Med Assoc. 2014;113(12):949-955.

Chen MF, Tseng CJ, Tseng CC, et al. Adjuvant concurrent chemoradiotherapy with intensity-modulated pelvic radiotherapy after surgery for high-risk, early stage cervical cancer patients. Cancer J. 2008;14(3):200-206.

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Eade TN, Hanlon AL, Horwitz EM, et al. What dose of external-beam radiation is high enough for prostate cancer? Int J Radiat Oncol Biol Phys. 2007;68(3):682-689.

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Frazier RC, Vicini FA, Sharpe MB, et al. Impact of breathing motion on whole breast radiotherapy: a dosimetric analysis using active breathing control. Int J Radiat Oncol Biol Phys. 2004;58(4):1041-1047.

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Freedman GM, Li T, Nicolaou N, et al. Breast intensity-modulated radiation therapy reduces time spent with acute dermatitis for women of all breast sizes during radiation. Int J Radiat Oncol Biol Phys. 2009;74(3):689-694.

Fuller CD, Choi M, Forthuber B, et al. Standard fractionation intensity modulated radiation therapy (IMRT) of primary and recurrent glioblastoma multiforme. Radiat Oncol. 2007;2:26.

Fuller CD, Dang ND, Wang SJ, et al. Image-guided intensity-modulated radiotherapy (IG-IMRT) for biliary adenocarcinomas: Initial clinical results. Radiother Oncol. 2009;92(2):249-254.

Fuss M, Wong A, Fuller CD, et al. Image-guided intensity-modulated radiotherapy for pancreatic carcinoma. Gastrointest Cancer Res. 2007;1(1): 2-11.

Gandhi AK, Sharma DN, Rath GK, et al. Early clinical outcomes and toxicity of intensity modulated versus conventional pelvic radiation therapy for locally advanced cervix carcinoma: a prospective randomized study. Int J Radiat Oncol Biol Phys. 2013;87(3):542-548.

Ghosh-Laskar S, Yathiraj PH, Dutta D, et al. Prospective randomized controlled trial to compare 3-dimensional conformal radiotherapy to intensity-modulated radiotherapy in head and neck squamous cell carcinoma: long-term results. Head Neck. 2016;38 Suppl 1:E1481-1487.

Gold DG, Neglia JP, Potish RA, et al. Second neoplasms following megavoltage radiation for pediatric tumors. Cancer. 2004;100:212-213.

Gondi V, Pugh SL, Tome WA, et al. Preservation of memory with conformal avoidance of the hippocampal neural stem-cell compartment during whole-brain radiotherapy for brain metastases (RTOG 0933): a phase II multi-institutional trial. J Clin Oncol. 2014;32(34):3810-3816.

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Gupta T, Wadasadawala T, Master Z, et al. Encouraging early clinical outcomes with helical tomotherapy-based image-guided intensity-modulated radiation therapy for residual, recurrent, and/or progressive benign/low-grade intracranial tumors: a comprehensive evaluation. Int J Radiat Oncol Biol Phys. 2012;82(2):756-764.

Guttmann DM, Gabriel P, Kennedy C, et al. Comparison of acute toxicities between contemporary forward- planned 3D conformal radiotherapy and inverse-planned intensity-modulated radiotherapy for whole breast radiation. Breast J. Mar 2018;24(2):128-132.

Han D, Qin Q, Hao S, et al. Feasibility and efficacy of simultaneous integrated boost intensity-modulated radiation therapy in patients with limited-disease small cell lung cancer. Radiat Oncol. 2014;9(1):280.

Hardee ME, Raza S, Becker SJ, et al. Prone hypofractionated whole-breast radiotherapy without a boost to the tumor bed: comparable toxicity of IMRT versus a 3D conformal technique. Int J Radiat Oncol Biol Phys. 2012;82(3):e415-423.

Harris JP, Murphy JD, Hanlon AL, et al. A population-based comparative effectiveness study of radiation therapy techniques in stage III non-small cell lung cancer. Int J Radiat Oncol Biol Phys. 2014;88(4):872-884.

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Treutwein M, Hipp M, Kölbl O, Bogner L. IMRT of prostate cancer. Strahlentherapie und Onkologie. 2009;185(6):379-383.

Tribius S, Bergelt C. Intensity-modulated radiotherapy versus conventional and 3D conformal radiotherapy in patients with head and neck cancer: Is there a worthwhile quality of life gain? Cancer Treat Rev. 2011;37(7):511-519.

Tunceroglu A, Park JH, Balasubramanian S, et al. Dose-painted intensity modulated radiation therapy improves local control for locally advanced pancreas cancer. ISRN Oncol. 2012;2012:572342.

Ursino S, D'Angelo E, Mazzola R, et al. A comparison of swallowing dysfunction after three-dimensional conformal and intensity-modulated radiotherapy: A systematic review by the Italian Head and Neck Radiotherapy Study Group. Strahlenther Onkol. Nov 2017;193(11):877-889.

Uy NW, Woo SY, Teh BS, et al. Intensity-modulated radiation therapy (IMRT) for meningioma. Int J Radiat Oncol Biol Phys. 2002;53(5):1265-1270.

Veldeman L, Madani I, Hulstaert F, et al. Evidence behind use of intensity-modulated radiotherapy: a systematic review of comparative clinical studies. Lancet Oncol. 2008;9(4):367-375.

Vergeer MR, Doornaert PA, Rietveld DH, et al. Intensity-modulated radiotherapy reduces radiation-induced morbidity and improves health-related quality of life: results of a nonrandomized prospective study using a standardized follow-up program. Int J Radiat Oncol Biol Phys. 2009;74(1):1-8.

Viani GA, Viana BS, Martin JE, et al. Intensity-modulated radiotherapy reduces toxicity with similar biochemical control compared with 3-dimensional conformal radiotherapy for prostate cancer: A randomized clinical trial. Cancer. 2016;122(13):2004-2011.

Vicini FA, Sharpe M, Kestin L, et al. Optimizing breast cancer treatment efficacy with intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys. 2002;54(5):1336-1344.

Violet JA, Harmer C. Breast cancer: improving outcome following adjuvant radiotherapy. Br J Radiol. 2004;77(922):811-820.

Vora SA, Wong WW, Schild SE, et al. Analysis of biochemical control and prognostic factors in patients treated with either low-dose three-dimensional conformal radiation therapy or high-dose intensity-modulated radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys. 2007;68(4):1053-1058.

Vora SA, Wong WW, Schild SE, et al. Outcome and toxicity for patients treated with intensity modulated radiation therapy for localized prostate cancer. J Urol. 2013;190(2):521-526.

Weber DC, Trofimov AV, Delaney TF, et al. A treatment planning comparison of intensity modulated photon and proton therapy for paraspinal sarcomas. Int J Radiat Oncol Biol Phys. 2004;58:1596-1606.

Wiegel T, Bottke D, Steiner U, et al. Phase III postoperative adjuvant radiotherapy after radical prostatectomy compared with radical prostatectomy alone in pT3 prostate cancer with postoperative undetectable prostate-specific antigen: ARO 96-02/AUO AP 09/95. J Clin Oncol. 2009;27(18):2924-2930.

Wong WW, Vora S, Schild SE, et al. Radiation dose escalation for localized prostate cancer: intensity-modulated radiotherapy versus permanent transperineal brachytherapy. Cancer. 2009;115(23):5596-5606.

Xu N, Rossi PJ, Jani AB. Toxicity analysis of dose escalation from 75.6 gy to 81.0 gy in prostate cancer. Am J Clin Oncol. 2011;34(1):11-15.

Yong JH, Beca J, McGowan T, et al. Cost-effectiveness of intensity-modulated radiotherapy in prostate cancer. Clin Oncol (R Coll Radiol). 2012;24(7):521-531.

Yu T, Zhang Q, Zheng T, et al. The effectiveness of intensity modulated radiation therapy versus three-dimensional radiation therapy in prostate cancer: a meta-analysis of the literatures. PLoS One. 2016;11(5):e0154499.

Zelefsky MJ, Fuks Z, Hunt M, et al. High-dose intensity modulated radiation therapy for prostate cancer: early toxicity and biochemical outcome in 772 patients. Int J Radiat Oncol Biol Phys. 2002;53(5):1111-1116.

Zelefsky MJ, Kollmeier M, Cox B, et al. Improved clinical outcomes with high-dose image guided radiotherapy compared with non-IGRT for the treatment of clinically localized prostate cancer. Int J Radiat Oncol Biol Phys.2012;84(1):125-129.

Zelefsky MJ, Levin EJ, Hunt M, et al. Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys. 2008;70(4):1124-1129.

Zhao Y, Qi G, Yin G, et al. A clinical study of lung cancer dose calculation accuracy with Monte Carlo simulation. Radiat Oncol. 2014;9(1):287.

Zhou L, Liu J, Xue J, et al. Whole brain radiotherapy plus simultaneous in-field boost with image guided intensity-modulated radiotherapy for brain metastases of non-small cell lung cancer. Radiat Oncol. 2014;9:117.

Zhu J, Gu W, Lian P, et al. A phase II trial of neoadjuvant IMRT-based chemoradiotherapy followed by one cycle of capecitabine for stage II/III rectal adenocarcinoma. Radiat Oncol. 2013;8:130.

Zhu J, Lian P, Liu F, et al. Phase II trial of first-line chemoradiotherapy with intensity-modulated radiation therapy followed by chemotherapy for synchronous unresectable distant metastases rectal adenocarcinoma. Radiat Oncol. 2013;8:10.

Zietman AL, DeSilvio ML, Slater JD, et al. Comparison of conventional-dose vs high-dose conformal radiation therapy in clinically localized adenocarcinoma of the prostate. JAMA. 2005;294(10):1233-1239.​

Coding

CPT Procedure Code Number(s)
77280, 77285, 77290, 77293, 77295, 77300, 77301, 77321, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77385, 77386, 77387
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
Report the most appropriate diagnosis code in support of medical necessity as listed in the policy.
HCPCS Level II Code Number(s)

N/A​

Revenue Code Number(s)
0333 Radiology-Therapeutic and/or Chemotherapy Administration-Radiation Therapy


Coding and Billing Requirements

Policy History

Revisions From 09.00.17r: 
​03/04/2026
​This policy has been reissued in accordance with the Company's annual review process​.​
01/01/2026Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

This policy version has been identified for the CPT/HCPCS code update, effective  01/01/2026.

The following CPT/HCPCS codes have been terminated (no longer valid codes) and removed from this policy:

77014
G6001
G6002
G6015
G6016

Revisions From 09.00.17q:
​06/11/2025
​The policy has been reissued in accordance with the Company's annual review process.
04/03/2024The policy has been reissued in accordance with the Company's annual review process.
11/06/2023This version of the policy will become effective 11/06/2023.

The coverage positions for esophageal, small cell and non-small cell lung cancers​have been updated to be considered medically necessary.

The criteria for use of intensity-modulated radiation therapy (IMRT) in treatment of breast, lung, and thymoma an thymic cancers have been clarified. 

Revisions From 09.00.17p:
​07/01/2022

​The policy has been reviewed and reissued to communicate the Company's continuing position on Intensity-Modulated Radiation Therapy (IMRT)​.


Effective July 1, 2022, the policy disclaimer was revised to communicate:

This policy only applies to members for whom Independence Administrators serves as the claims administrator and whose group has not enrolled in the UM vendor program.  For those groups who have been given the option to enroll in the UM vendor program, this policy is no longer applicable upon their renewal effective date. Individual member benefits must be verified before/prior to providing services.

04/12/2021The following changes were made to the Policy Section:

CENTRAL NERVOUS SYSTEM

The following treatment and indication was added as Medically Necessary under cancer of the central  nervous system: 

  • Hippocampal-avoiding intensity-modulated radiotherapy may be considered medically necessary for individuals with brain tumor metastases outside a 5-mm margin around either hippocampus and expected survival ≥4 months​.​​

Revisions From 09.00.17o:
11/06/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on Intensity-Modulated Radiation Therapy (IMRT).
01/01/2019This policy has been identified for the CPT code update, effective 01/01/2019.

The following CPT narrative has been revised in this policy:

77387:

FROM: Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed

TO: Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed

Revisions From 09.00.17n:
11/21/2018This policy has been reissued in accordance with the Company's annual review process.
11/17/2017The following changes were made to the Policy Section:

ABDOMEN AND PELVIS

The following indication was added as Medically Necessary under cancer of the abdomen and pelvis:
  • Abdominal malignancies when dose constraints to the small bowel or other normal abdominal tissue are exceeded and present administration of a therapeutic dose
CENTRAL NERVOUS SYSTEM

The following coverage statement was revised:
    FROM:
    Tumors of the central nervous system (primary or metastatic) when the tumor is in close proximity to organs at risk (e.g., brain stem, spinal cord, cochlea, eye structures).
    TO:
    Tumors of the central nervous system (primary, metastatic, or benign) when the tumor is in close proximity to organs at risk (e.g., brain stem, spinal cord, cochlea, eye structures including optic nerve and chiasm, lens and retina) and 3-D conformal radiation planning is not able to meet dose volume constraints for normal tissue tolerance.
The following indication was added as Medically Necessary:
    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.
HEAD AND NECK

The following coverage statements were revised:
    FROM:
    • Primary, metastatic, or benign lesions to the head and neck area including any of the following:
        • Orbits
        • Sinuses
        • Skull base
        • Aero-digestive tract
        • Salivary glands
    • Thyroid cancers in close proximity to organs at risk (e.g., esophagus, salivary glands, and spinal cord)
    TO:
    • Primary, metastatic, benign or recurrent lesions to the head and neck area including any of the following:
        • Orbits
        • Sinuses
        • Skull base
        • Aero-digestive tract
        • Salivary glands
    • Thyroid cancers in close proximity to organs at risk (e.g., esophagus, salivary glands, and spinal cord) and 3-D conformal radiation planning is not able to meet dose volume constraints for normal tissue tolerance.
PROSTATE

The following coverage statement was revised:
    FROM:
    • As salvage therapy when there is evidence of biochemical or local recurrence when there is no evidence of distant metastatic disease
    TO:
    • As salvage therapy after radical prostatectomy when there is evidence of biochemical or local recurrence when there is no evidence of distant metastatic disease
OTHER INDICATIONS

The following indication was added as Medically Necessary under Other Indications:
  • Thoracic malignancies
The following CPT Codes were removed from the table located under Billing Requirements: 76376, 76377, 77306, 77307

CODING

The following CPT Codes were removed from the Coding Table: 76376, 76377, 77306, 77307

Effective 10/05/2017 this policy has been updated to the new policy template format.
1/1/2026
1/2/2026
3/4/2026
09.00.17
Medical Policy Bulletin
Commercial
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