Radiation Therapy: Fractionation, Image-Guidance, and Special Services – Commercial and Individual Exchange Medical Policyopen_in_new

UnitedHealthcare covers EBRT within specified fractionation limits by indication (e.g., bone mets ≤10 fractions unless re‑irradiation, breast APBI ≤5 or whole breast ≤21–33 fractions with specified exceptions, NSCLC ≤35, prostate 20/28/45 depending on disease/setting) and considers IGRT medically necessary only in defined situations (e.g., with IMRT/PBRT, prior RT, fiducials, listed tumor sites and certain 3D‑CRT breast/boost settings) while excluding IGRT when criteria aren’t met, prohibiting separate IGRT reporting with SBRT/SRS or for brachytherapy, and limiting concurrent code use with superficial RT. Medical records must document that the patient meets the stated clinical criteria or exceptions (including the prostate “Limited Metastatic Disease” definition), and must justify use of special dosimetry (77331), physics consults (77370) or special procedures (77470) as single, prescribed services and provide specified evidence when IGRT is used with 3D‑CRT (e.g., DVH comparisons for DIBH, immobilization intolerance, significant target motion, or need for reduced CTV margins).