IMRT treatment planning (code 77301) and delivery (code 77418) are considered investigational/experimental. The safety and efficacy of IMRT in improved tumor control and decreased morbidity have not yet been proven in long-term clinical studies. A participating, preferred, or network provider can bill the member for the denied service.

Intensity modulated radiation therapy (IMRT) is an advanced form of conformal radiotherapy. IMRT uses 3-dimensional inverse treatment planning and a sophisticated computer-controlled radiation delivery system to achieve a more precise degree of target conformity and radiation dose distribution to the tumor volume than traditional radiation therapy treatment planning and delivery systems.

Not all tumors are cleanly separated from surrounding organs or tissue that require a lesser dose of radiation or no radiation treatment at all. An example of this is where tumor volume margins are extremely concave. Conformal radiation therapy is a treatment modality that can be used when the target tumor volume is irregularly shaped and/or in close proximity to critical structures or tissues that must be protected. This method of radiation treatment geometrically shapes the treatment beam so that it is contoured or “conformed” to the shape of the tumor.

In IMRT, the clinical objectives are defined through mathematical algorithms. Using previously acquired imaging data (typically, CT scans), sophisticated physics and dosimetry, a higher dose of radiation can be delivered to the target tumor volume. A computer geometrically modulates the dose of radiation delivered to a specific treatment area by conforming it precisely to the tumor. Sensitive and/or critical structures, organs or tissues are spared through the use of decreasing radiation dosages, special shields and multiple variations in blocking within the treatment field.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

PRN References

02/2002, Intensity modulated radiation therapy not covered

Intensity Modulation Using Multileaf Collimators: Current Status, Medical Dosimetry, Volume 26, No. 2, Summer 2001

Treatment Planning and Delivery of Intensity-Modulated Radiation Therapy for Primary Nasopharynx Cancer, International Journal of Radiation Oncology, Biology, Physics, Volume 49, No. 3, March 2001

Intensity-Modulated Radiation Therapy (IMRT) for Prostate Cancer with the Use of a Rectal Balloon for Prostate Immobilization: Acute Toxicity and Dose-Volume Analysis, International Journal of Radiation Oncology, Biology, Physics, (Clinical Investigation), Volume 49, No. 3, March 2001

Intensity-Modulated Radiation Therapy in Head and Neck Cancers: The Mallinckrodt Experience, International Journal of Cancer, Volume 20, No. 2, April 2000

Intensity Modulated Radiation Therapy (IMRT): A New Promising Technology in Radiation Oncology, The Oncologist, Volume 4, No. 6, December 1999

The Theory & Practice of Intensity Modulated Radiation Therapy, A Monograph by Edward S. Sternick, Ph.D., Editor, Advanced Medical Publishing, Madison, WI.