77401
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- Medical records must support medical necessity for simulation, fractionation regimen, dosing, dosimetry, medical physics evaluation, and any changes in ongoing treatment regimens.
- The medical record must include the patient’s primary diagnosis, history of present illness, active comorbidities, performance status (when applicable), relevant imaging reports, proposed treatment plan, number/location/size of tumors, disease stage, and the anatomic site of radiation delivery.
- Every page of the medical record must be legible, include appropriate patient identification (e.g., full name, dates of service), and contain the legible signature and credentials of the responsible treating clinician, dosimetrist, physicist or radiation therapist.
- The treatment plan/prescription must be present and define treatment goals and requirements, including specific dose constraints for targets and nearby critical structures (organs at risk).
Key Coverage Criteria
- Superficial radiation therapy (SRT) for nonmelanoma skin cancers (NMSC) is payable only when delivered in a non-facility setting (freestanding radiation therapy centers or physician offices that meet freestanding RT center requirements).
- Coverage requires documentation that SRT is medically necessary over other conventional treatments, including a provider statement that the patient is a nonsurgical candidate and documentation of the informed discussion with the patient about present and future RT risks and why SRT is preferred.
- SRT for nonmelanoma skin cancers (NMSC) is payable only when delivered in a non-facility setting (freestanding radiation therapy centers or physician offices that meet state requirements).
- SRT may be covered when the provider documents that the patient is a nonsurgical candidate for treatment of NMSC (provider statement required).
- SRT may be covered when documentation supports medical necessity of SRT over other conventional treatment modalities for the patient’s NMSC(s).
- SRT is covered for the treatment of diagnosed nonmelanoma skin cancer (NMSC) when medical necessity is supported according to the applicable LCD (DL40189).
20 Active Policies
A60212 — Billing and Coding: Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)
J05
L40192 — Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)
J05
L40167 — Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)
J06
A60177 — Billing and Coding: Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC)
J06
Related Codes
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