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.

Radiation therapy techniques  

• Three-dimensional conformal radiation therapy (3DCRT) and Intensity- Modulated Radiation Therapy (IMRT) techniques may be considered medically necessary.
• The use of neutron beam therapy may be considered medically necessary in select cases of salivary gland tumors;
• Preoperative radiation therapy is medically necessary in select cases:
  • May be given in up to 35 fractions in three (3) phases;
  • May use Complex, 3DCRT, or IMRT techniques.

Radiation therapy treatment intent/timing

• Definitive radiation therapy:
  • May be considered medically necessary for selected T1-2, N0 cases as monotherapy;
  • May employ up to 42 fractions in a maximum of two (2) phases;
  • Depending on the simplicity or complexity of the case, Complex, 3DCRT, or IMRT techniques may be considered medically necessary;
• Definitive radiation therapy as monotherapy:
  • May be considered medically necessary for selected T1N1 and T2N0-1 cases;
  • Radiation may be given utilizing any of several schedules including conventional daily fractionation, concomitant boost accelerated fractionation, and hyperfractionation (twice-daily radiation);
  • Up to 68 fractions may be considered medically necessary, in two (2) phases;
• Definitive concurrent chemoradiation:
  • May be considered medically necessary in unresected T2-4a, N0-3 cases utilizing up to 42 fractions with conventional schedule;
  • 3DCRT or IMRT techniques may be considered medically necessary, in up to four (4) phases;
  • Concurrent chemotherapy carries a high toxicity burden and requires substantial supportive care and the expertise of an experienced multidisciplinary team;
• Postoperative radiation therapy
  • May be considered medically necessary for cases that have ANY of the following high risk factors:
    • PT3 or pT4 primary tumors
    • N2 or N3 nodal disease
    • Positive nodes in levels IV or V
    • Perineural invasion
    • Vascular tumor embolism
    • Positive surgical margins or residual gross disease
  • 35 fractions may be considered medically necessary;
  • 3DCRT or IMRT techniques may be considered medically necessary, in up to three (3) phases;
  • Chemotherapy may be added concurrently with postoperative radiation and may be considered medically necessary in cases with positive margins or extracapsular nodal extension;
  • Concurrent chemotherapy also may be considered in cases with the other high risk factors mentioned above, in which up to 40 fractions in two (2) phases may be considered medically necessary;
  • Concurrent chemotherapy carries a high toxicity burden and requires substantial supportive care and the expertise of an experienced multidisciplinary team.

Radiation therapy, brachytherapy

• Low Dose Rate (LDR) or High Dose Rate (HDR) brachytherapy may be considered medically necessary in select cases of epithelial tumors of the head and neck region:
  • In appropriate early cases, it may be considered medically necessary as monotherapy;
  • In more advanced cases, it may be substituted for one phase of 3DCRT or IMRT;
• Brachytherapy for head and neck malignancies should be performed only by those radiation oncologists specifically trained in its use.

Radiation therapy, palliative

• In a previously un-irradiated individual with symptomatic local disease, Complex, 3DCRT or IMRT techniques may be considered medically necessary for symptom control;
• Up to 20fractions are medically necessary, in one (1) phase.

Re-treatment for salvage after prior radiation

• Re-irradiation may be considered medically necessary in cases of recurrent or persistent disease, or for in-field new primary tumors, in cases in which there are no known distant metastases;
• Reirradiation carries increased risk;
• Stereotactic Body Radiation Therapy (SBRT) may be considered medically necessary for retreatment in patients who have no evidence of metastatic disease.

Radiation therapy for head and neck cancer 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.

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.

• Link to Provider Resource Center for the Medical Policy Update

05/2018, REMINDER: Radiation Therapy
01/2018, REMINDER: Radiation Therapy

• Link to References