| Highmark Commercial Medical Policy - Pennsylvania |
| 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 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:
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.
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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