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| Medical Policy: | R-11-024 |
| Topic: | Intensity Modulated Radiation Therapy (IMRT) |
| Section: | Radiation Therapy & Nuclear Medicine |
| Effective Date: | October 1, 2016 |
| Issue Date: | October 3, 2016 |
| Last Reviewed: | February 2016 |
Intensity Modulated Radiation Therapy (IMRT) is an advanced form of three-dimensional conformal radiation therapy (3D CRT) that uses varying intensities of radiation to produce dose distributions that are more conformal than those possible with standard 3D CRT. The beam intensity is varied across the treatment field. The patient is treated with many very small beams of varying intensities. This method of irradiation delivers a more uniform dose of radiation to the tumor, while protecting surrounding tissue from unnecessarily high doses of radiation. |
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.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
IMRT may be considered medically necessary when ALL the following criteria are met:
- IMRT should not be used as a substitute for conventional radiation therapy methods; and
- Sparing surrounding normal tissue is of added benefit; and
- One or more of the following conditions are met:
- The target volume is in close proximity to critical structures that must be protected; or
- The volume of interest must be covered with narrow margins to adequately protect immediately adjacent structures; or
- An immediately adjacent area has been previously irradiated and abutting portals must be established with high precision; or
- Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors with conventional treatment.
IMRT is considered not medically necessary for all other indications not listed in this medical policy.
Intensity modulated radiation therapy (IMRT) may be considered medically necessary in some clinical situations for the following conditions:
- Primary bone and articular cartilage cancer of the skull and face, vertebral column, sacrum and coccyx as related to dose needed to be delivered; or
- Primary, metastatic, or benign tumors of the central nervous system including the brain, brain stem, and spinal cord; or
- Primary, metastatic, or benign tumors of the spine where the spinal cord tolerance may be exceeded with conventional treatment; or
- Primary, metastatic, or benign lesions to the head and neck area including any of the following sites: lip; eye; thyroid; salivary glands; hypopharynx; oropharynx; nasopharynx; other parts of the pharynx not explicitly identified here; oral cavity; tongue; nasal cavities; middle ear; accessory sinuses; larynx; lymph nodes of the head, face and neck; pituitary gland, pineal gland, carotid body; and skin of lip, eyelid, ear and external auditory canal; or
- Primary small cell and non-small cell lung cancer; or
- Carcinoma of the prostate; or
- Pelvic and retroperitoneal malignancies; or
- Squamous cell cancer of the anus/anal canal; or
- Locally advanced rectal adenocarcinoma when dosimetric planning predicts the risk of small intestine injury with standard 3D conformal treatment would be unacceptable; or
- Gynecological cancer may be given consideration when one or more of the following conditions are met:
- When the planned dose will be higher than the standard 45-50.4 Gy; or
- A positive margin will be treated concomitantly; or
- An extended field will be treated; or
- There has been a history of adhesions or small bowel complications; or
- Imaging confirms an excessive amount of small bowel in the treatment field; or
- The use of IMRT for breast cancer will be reviewed on a case-by-case basis (e.g., IMRT may be indicated if the breast cancer cannot be adequately covered using 3D conformal therapy).
The list of approved anatomic sites for IMRT is not all-inclusive. Therefore, requests for conditions other than those listed will be reviewed on a case-by-case basis as to medical necessity.
The rationale for using IMRT over other forms of radiation therapy should be documented in the patient’s medical record.
IMRT is considered not medically necessary for all other indications not listed in this policy.
The medical necessity criteria only apply to the 3D rendering procedures when reported in conjunction with IMRT services.
IMRT should be reported once for each treatment volume during a course of therapy. If reported more than once for the same tumor, the patient’s medical record must document the medical necessity for the additional service and be available for review upon request.
Simultaneous or planned sequential treatment of multiple targets within a region is considered a single treatment plan.
If the following services are reported on the same day as IMRT treatment planning, they are not eligible for separate payment.
- Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction
- Simulation-aided field setting
- Teletherapy, isodose planning
Report the design and construction of multi-leaf collimator (MLC) device(s) according to the IMRT treatment plan.
IMRT treatment delivery when performed in a hospital setting.
IMRT treatment delivery when performed in a freestanding facility setting.
For additional information on other radiation therapy services, refer to Medical Policy Bulletin R-4
| Place of Service: Outpatient |
Intensity Modulated Radiation Therapy (IMRT) is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| FEP Guidelines |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
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The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
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If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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