77399
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage (refer to the protocol titled Medical Records Documentation Used for Reviews).
- For IGRT used with 3D-CRT for conditions not specifically listed, documentation must show one or more of the following: 'Clinically significant difference in normal tissue sparing between DIBH and free breathing as documented by comparison plans and dose-volume histogram (DVH)'; 'Member unable to tolerate immobilization during computed tomography (CT) simulation'; 'Significant target motion as documented by imaging'; 'Smaller clinical target volume (CTV) margins are required than what is traditionally used for 3D-CRT.'
- For breast EBRT exceptions to fractionation limits, documentation of one of the listed criteria is required (e.g., treatment of supraclavicular/internal mammary lymph nodes; post-mastectomy radiation therapy; prior thoracic radiation therapy; diagnosis of connective tissue disorder such as lupus or scleroderma).
Key Coverage Criteria
- IGRT is medically necessary during boost treatment of rectal and bladder cancer.
- Palliative external beam radiation therapy (EBRT) for the treatment of a bone metastasis: Delivery of up to 10 fractions of radiation therapy.
- Palliative EBRT for a bone metastasis: Delivery of greater than 10 fractions for the treatment of a site that has previously received radiation therapy.
- EBRT for breast adenocarcinoma: Delivery of up to 5 fractions for accelerated partial breast irradiation (APBI).
- EBRT for breast adenocarcinoma: Delivery of up to 21 fractions (inclusive of a boost to the tumor bed).
- EBRT for breast adenocarcinoma: Delivery of up to 33 fractions (inclusive of a boost to the tumor bed) when any of the following criteria are met: Treatment of supraclavicular and/or internal mammary lymph nodes; or Post-mastectomy radiation therapy; or Individual has received previous thoracic radiation therapy; or Individual has a connective tissue disorder such as lupus or scleroderma.
4 Active Policies
UHC-POL-radiation-therapy-fractionation-image-special-services — Radiation Therapy: Fractionation, Image-Guidance, and Special Services
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL — EviCore Radiation Oncology Coding Manual
ANTHEM-RAD.00012 — THER-RAD.00012 Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
REGENCE-MED167 — Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk
Related Codes
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