77387
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.68
Facility
$36.41
Non-Facility
$36.41
Documentation Required
- "Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews."
- For exception/coverage consideration when non-listed condition is requested: comparison of treatment plans for the IMRT and non-IMRT technique (e.g., three-dimensional conformal treatment plan) demonstrating that non-IMRT would increase the probability of clinically meaningful normal tissue toxicity
- When the same or an adjacent area has been previously irradiated: prior radiation records and cumulative dose assessment demonstrating that the IMRT dose distribution is sculpted to avoid exceeding cumulative tolerance dose of nearby normal tissue
Key Coverage Criteria
- Applies to individuals 19 years of age and older. (Note: IMRT is covered without further review for individuals younger than 19 years of age.)
- IMRT for Definitive Therapy for the primary site of the following conditions: Anus/anal canal cancer
- IMRT for Definitive Therapy for the primary site of the following conditions: Breast cancer when either: (a) the left-sided internal mammary nodes are being treated; or (b) accelerated partial breast irradiation of up to 5 fractions
- IMRT for Definitive Therapy for the primary site of the following conditions: Central nervous system (CNS) tumors (primary or benign) including the brain, brainstem, and spinal cord
- IMRT for Definitive Therapy for the primary site of the following conditions: Cervical cancer
- IMRT for Definitive Therapy for the primary site of the following conditions: Endometrial cancer
8 Active Policies
UHC-POL-intensity-modulated-radiation-therapy — Intensity-Modulated Radiation Therapy
UHC-POL-proton-beam-radiation-therapy — Proton Beam Radiation Therapy
UMR-POL-UMR-intensity-modulated-radiation-therapy — Intensity-Modulated Radiation Therapy
UMR-POL-UMR-proton-beam-radiation-therapy — Proton Beam Radiation Therapy
Related Codes
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