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| Medical Policy: | R-60-009 |
| Topic: | Image-Guided Radiation Therapy (IGRT) |
| Section: | Radiation Therapy & Nuclear Medicine |
| Effective Date: | August 1, 2018 |
| Issue Date: | July 30, 2018 |
| Last Reviewed: | May 2018 |
Image-Guided Radiation Therapy (IGRT) is a method by which image guidance is applied to place the isocenter for the upcoming treatment appropriately. This technology typically is applied for an individual undergoing Intensity-Modulated Radiation Therapy (IMRT). However, in some cases in which the isocenter is the main concern, IGRT occasionally can be used with three-dimensional (3D) conformal radiation therapy (3DCRT). |
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. |
IGRT during IMRT
IGRT may be considered medically necessary when IMRT has been approved and is being utilized.
IGRT during 3DCRT
IGRT in conjunction with 3DCRT may be considered medically necessary in the following circumstances:
- When the planning target volume (PTV) is in close proximity to a previously irradiated area
- Treatment of the hepatobiliary tract
- Treatment of head and neck cancer
- Treatment of Hodgkin’s and Non-Hodgkin’s Lymphoma
- Treatment of lung cancer
- Treatment of prostate cancer
- Treatment of esophageal cancer
- Treatment of gastric cancer
- Treatment of pancreatic cancer
- Treatment of pelvic cancers (i.e. rectal cancer) when the individual is in the prone position on a belly board
- During breast boost when using photons
- During external beam-based accelerated partial breast irradiation (APBI)
- During treatment of breast cancer when a DIBH technique is being used
- Treatment of breast cancer when the individual is in the prone position
- During the boost to the bladder
- Preoperative or postoperative treatment of sarcomas
IGRT and brachytherapy
In brachytherapy cases, imaging may be considered medically necessary to verify source position in all but the simplest of cases. The images may also be used to perform dosimetry calculations.
| Place of Service: Inpatient/Outpatient |
IGRT 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 |
| 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.
| Links |
- Link to Provider Resource Center for the Medical Policy Update
05/2018, REMINDER: Radiation Therapy
01/2018, REMINDER: Radiation Therapy
 |
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.
Discrimination is Against the Law
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:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
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.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
