77295
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
4.18
Facility
$485.32
Non-Facility
$485.32
Documentation Required
- With IMRT planning and delivery, the physician must document consideration of other organs at risk (OAR) and adjacent critical structures.
- All documentation must be maintained in the patient's medical record, be legible, include appropriate patient identification (e.g., full name, dates of service), and be made available to the contractor upon request.
- The medical record must include legible signatures and credentials of the physician, non-physician practitioner, dosimetrist, physicist, or radiation therapist responsible for care.
- Submitted records must support the selected ICD-10-CM diagnosis code(s) and the submitted CPT/HCPCS code(s) must accurately describe the service rendered at the level of specificity appropriate for the claim year.
Key Coverage Criteria
- Radiation therapy is covered when the patient's medical record documents medical necessity consistent with LCD L39553.
- Stereotactic Radiosurgery (SRS) or Stereotactic Body Radiation Therapy (SBRT) is covered for oligometastatic disease when documentation justifies aggressive local therapy to one or more metastatic deposits for total disease clearance or to reduce systemic disease burden with a specifically defined clinical benefit.
- SRS or SBRT is covered for palliation or recurrent disease when tumor cannot be treated as effectively or safely by other radiotherapy methods due to proximity to previously irradiated volumes and beneficiary-unique facts are documented.
- Radiation therapy for non-cancer diagnoses (e.g., epilepsy, trigeminal/facial nerve conditions, movement disorders, Parkinson's disease, tremor) may be covered only when prior therapies tried and failed are clearly documented with names, durations, and response.
- SRS and SBRT require documentation of the patient's overall performance status (e.g., Karnofsky Performance Status or ECOG) and a radiation oncologist's evaluation of clinical and technical aspects with the resulting management decision to support coverage.
- IMRT is indicated when highly conformal dose planning is required to spare adjacent normal tissues as a specific clinical benefit for the individual patient.
12 Active Policies
AMBETTER-CP.MP.251 — Radiation Therapy for Skin Cancer
AETNA-CPB-0682 — Microwave Thermotherapy
A59350 — Billing and Coding: Radiation Therapies
L39553 — Radiation Therapies
CARELON-proton-beam-therapy-2022-03-13 — Proton Beam Therapy
Related Codes
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