Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27515

Radiation Therapy Services

L27515

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section allows coverage and payment for only those services considered medically reasonable and necessary.

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Manual System, Pub 100-4, Medicare Claims Processing Manual, Chapter 12, Section 70 and Chapter 13, Sections 20 and 90. These sections discuss payment conditions for radiology/radiation therapy services.

Transmittal 132, Change Request 3154, March 30, 2004-07-08. Allows compensator-based IMRT technology (Effective 04/01//2004)

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Radiation oncology is the specialty of medicine that utilizes high-energy ionizing radiation in the treatment of malignant neoplasms and certain non-malignant conditions. It uses several distinct therapeutic modalities; teletherapy, brachytherapy, hyperthermia, and stereotactic radiation. These may be directed at either malignant or benign lesions.

The Role of the Radiation Oncologist

The Radiation Oncologist is responsible for initially evaluating the patient, determining the need for radiation treatments, identifying the site(s) and calculating the dosage of radiation therapy. He/she assesses the goal(s) of therapy, the fractionation to be utilized, the indication for, and the sequencing of, combined modality therapy with other oncology specialists. The radiation oncologist then orders and coordinates the technical planning and execution of the treatment with ancillary staff, including radiation therapists, dosimetrists and physicists. The treatment is supervised by the radiation oncologist, and the response to treatment and tolerance of the therapy is monitored. The radiation oncologist manages the entire process of treatment from the initial decision to treat, to the planning preparation, execution and effectiveness of treatment.

Because some words; e.g., port and field, have been used interchangeably, and because some payments are allowed based on these words, this policy will stipulate the following definitions.

Port, Portal:

These words are synonymous and refer to the site, on the skin, where the radiation beam enters the body. Field, often used as a synonym for port, will not be used in this policy.

Volume of Interest:

This phrase refers to that volume within the body to which the radiation therapy is directed. In this policy, volume of interest is never synonymous with port and is preferred to other terms with (presumably) the same meaning because it is the phrase most commonly used by radiation oncologists. Treatment volume is accurate but seldom used. Area of interest, used in the AMA’s CPT manual, suggests a two-dimensional configuration and is, in this geometric sense, inaccurate. Target site seems to point to just the tumor itself and excludes the surrounding volume of tissue that might be of interest. Field is used sometimes to mean volume of interest, and other times to mean port. It should be discarded.

While this policy recognizes the legitimate use of these terms in other documents and cannot obviously proscribe them, it will use volume of interest in place of these terms.

Intensity Modulated Radiation Therapy (IMRT):

Description:

Intensity Modulated Radiation Therapy (IMRT) is a technology for delivering highly conformal external beam radiation to solid tumors. The radiation beams are customized for each patient; the treatment volume is well-defined and the beam intensity is modulated. The delivery of treatment with radiation beams whose intensity varies across the beam surface makes IMRT particularly useful for obtaining the highly conformal dose distributions needed to irradiate complex targets positioned near, or immediately adjacent to, sensitive normal tissues.

IMRT Treatment Planning:

IMRT treatment plans are geometrically more accurate and tailored to the target volumes than are conventional or three-dimensional radiation plans. The IMRT planning computer algorithm describes the necessary field sizes, gantry angles, and other beam characteristics needed to achieve the desired dose distribution. The essential feature of an IMRT plan is that it describes the means to deliver treatment utilizing non-uniform beam intensities.

Three-dimensional image acquisition by simulation (e.g., CT, MRI, PET or similar image fusion technology) is a prerequisite to IMRT treatment planning. The physician then outlines (contours) the visible abnormality seen on each slice of the image set. The three-dimensional summation of these contours defines the Gross Tumor Volume (GTV). The physician draws a margin around the GTV to generate a Clinical Target Volume (CTV) which encompasses the volume of tissue at risk for microscopic disease (not visible on imaging studies). To account for potential patient set-up variation or organ and patient motion, a final margin is then added to create what is termed the Planning Target Volume (PTV). The physician also contours nearby normal structures that potentially could be damaged by radiation ("organs at risk").

The physician must assign specific dose requirements for the PTV (minimum dose and dose homogeneity) and dose constraints for the organs at risk (maximum allowable doses). A treatment plan that satisfies these requirements and constraints should maximize the potential for disease control and minimize the risk of radiation injury to normal tissue.

Finally, the radiation physicist or a supervised dosimetrist calculates a complex multi-beam treatment plan that will deliver the prescription dose to the PTV and satisfy the normal tissue dose constraints. The radiation beam is, in effect, a collection of "beamlets," each with a different level of radiation intensity. The summation of these "beamlets" delivers the characteristic, highly conformal IMRT dose distribution. The PTV, therefore, receives a high dose of radiation while nearby organs receive significantly lower doses.

Prior to treatment delivery the physicist performs basic dose calculations on each of the modulated beams. These patient specific monitor unit computations verify through a second (independent of treatment planning) dose calculation method that the computer has correctly performed the treatment planning calculations. The calculated beams are then delivered either to a phantom or a dosimetry measuring device to confirm that the point dose and dose distribution are physically verifiable and that the intensity modulated beams are technically feasible.

Documentation of all aspect of the planning process is essential.

IMRT Treatment Delivery:

IMRT treatment delivery can be accomplished through a variety of technologies. The most common approach utilizes a multileaf collimator (MLC) to modulate the intensity of the beam. Various forms of MLC technology include fixed gantry types such as static MLC (step and shoot) where the leaves do not move when the beam is on and dynamic MLC (sliding window) where they move during treatment. There are also moving gantry technologies including fan-beam therapy that uses a binary collimator to deliver slice-by-slice treatment and intensity modulated arc therapy, in which the gantry rotates while moving MLCs create non-uniform dose to the planning target volume during individual arc segments. A different technical solution for IMRT is to use a solid compensator with varying thickness filters to modulate the beam. The basic requirement for all forms of IMRT treatment delivery is that the technology must accurately produce the calculated dose distribution described by the IMRT plan.

The highly conformal dose distribution produced by IMRT results in much sharper spatial dose gradients than conventional or three-dimensional conformal radiation therapy. Consequently, small changes in patient or target position within the body can cause large changes in the dose delivered to the PTV and to the organs at risk. Thus patient immobilization is required for precision IMRT. A number of imaging techniques (e.g., ultrasound, kilovoltage or megavoltage cone beam CT scan, stereoscopic X-ray) may also be utilized to account for the daily motion of the PTV and more accurately deliver the treatment (Image Guided Radiation Therapy or IGRT). Changes in the location of the target within the body during a single fraction can arise from respiratory motion or other physiologic variances. To accommodate such changes the PTV may be drawn based upon published studies of organ motion or on dynamic imaging studies, or treatment delivery may be actively modulated by direct measures of motion during treatment.

Indications

Radiation oncology services are considered medically reasonable and necessary when the following conditions are indicated and documented in the patient’s medical records.

Tumor Mapping and Clinical Treatment Planning (77261-77263)

77261 Therapeutic radiology treatment planning; simple

77262 Therapeutic radiology treatment planning; intermediate

77263 Therapeutic radiology treatment planning; complex

Simple planning requires a single volume of interest encompassed in a single port or simple parallel-opposed ports with simple or no blocking.

Intermediate planning requires three or more converging ports, two separate volumes of interest, multiple blocks, or special time dose constraints.

Complex planning requires highly complex blocking, custom shielding blocks, tangential ports, compensators, three or more separate volumes of interest, rotational or special beam considerations, multi-leaf collimation, intensity modulated radiotherapy, three or more separate volumes, or a combination of therapeutic modalities.

Clinical treatment planning and tumor mapping is crucial to identifying the location, extent, and volume of tumor(s) to be treated and all critical structures surrounding them. The physician plans the appropriate course of radiation therapy that will allow for maximum benefit while protecting surrounding tissues and structures. Clinical treatment planning may involve ordering and interpreting special tests such as lymphangiography, CT scan, MR scan, radionuclide scan, and/or surgical exploration with biopsy and markers placed for the purpose of treatment planning and tumor localization.

Treatment planning is a one-time charge per course of therapy. Billing for multiple treatment plans for a single course of treatment is not allowed.

This is a professional service only and the physician is responsible for all of the technical aspects of the treatment planning process.

Report CPT code 77261 when the volume of interest to be treated is clearly defined and easily encompasses the tumor while excluding normal tissue and structures. Simple planning requires no interpretation of special tests and involves no more than one critical structure.

Report CPT code 77262 when there is a moderate level of planning difficulty involved. Two separate volumes of interest (non-contiguous) are involved. Critical or sensitive organs that need protection usually are involved. Interpretation of special tests, localization of tumor volume, and not more than two critical structures are involved when planning the optimum course of treatment.

Report CPT code 77263 when complex treatment planning is involved. Three or more volumes of interest may require treatment. Planning includes interpreting complex tests such as MR and/or CT localization tumor(s). The cancer is generally complex in its distribution regardless of whether the patient is in early or advanced stages of cancer. Multiple critical areas generally require planning of special protection. Combined therapy may be required for optimum benefit such as brachytherapy, surgery, and chemotherapy.

Therapeutic Radiology Simulation – Aided Field Setting (77280-77295)

77280 Therapeutic radiology simulation-aided field setting; simple

77285 Therapeutic radiology simulation-aided field setting; intermediate

77290 Therapeutic radiology simulation-aided field setting; complex

77295 Therapeutic radiology simulation-aided field setting; 3-dimensional

Following treatment planning, simulation is used to actually direct the treatment beams to the specific volume of interest. Simulation may be carried out on a dedicated conventional simulator or CT scanner, radiation therapy treatment unit (e.g., linear accelerator), or using diagnostic imaging equipment (e.g., fluoroscopy, CT, MR).

The complexity of simulation is based on the number of ports, volumes of interest, and the inclusion and type of treatment devices. However, the number of films taken per treatment, the modality from which images for simulation are obtained, and the use of fluoroscopy are not determinants of complexity. Portal changes based on unsatisfactory initial simulation(s) are not reported as additional simulations. Additional simulations may be necessary during treatment in order to account for changes in port size, boost dose, or tumor volume. However, minor changes in port size without changes in beam or without clinical justification do not warrant an additional charge or a higher level of complexity.

The inclusion of treatment devices in the simulation process typically increases the complexity. Simulation without the inclusion of devices or with any pre-made devices (e.g., blocks, immobilization) is considered simple. The addition of custom immobilization devices or tangential ports is an indicator of complex level of simulation.

Documentation of simulation requires a written record of the procedure, hard copy of electronic images, and evidence of image review by physicians, including signature or initials and data review.

The typical course of radiation therapy will require between one and three simulations. However, no more than one simulation should be reported on any given day.

77280 Therapeutic radiology simulation-aided field setting; simple

If any of the following factors are present, the simulation is simple.

• Single volume of interest with either a simple port or parallel opposed ports
• Simple or no blocking
• Block verification simulation
• Custom immobilization devices

77285 Therapeutic radiation simulation-aided field setting; intermediate

If any of the following factors are present, the simulation will be considered intermediate.

• Simulation of three or more converging ports, or two separate volumes of interest
• Multiple blocks when clinically necessary
• Tangential ports without devices or with a single pair of pre-manufactured wedges

77290 Therapeutic radiation simulation-aided field setting; complex

If any of the following factors are present, the simulation will be considered complex.

• Three or more volumes of interest
• Rotation or arc therapy
• Complex blocking or custom made shielding blocks or compensators, when clinically necessary
• Any use of contrast media (e.g., body cavity, GI tract, or intravascular) when clinically necessary to define anatomic structures and the volume of interest
• Tangential ports with multiple devices

77295 Therapeutic radiology simulation-aided field setting; 3-dimensional

This procedure involves three dimensional computer-generated reconstruction of tumor volume and surrounding critical normal tissue structures from direct CT scan and/or MRI data in preparation for non-coplanar or coplanar therapy. The simulation uses documented 3-D beam’s eye view volume-dose displays of multiple or moving beams. Documentation with 3-D volume reconstruction and dose distribution is required.

This descriptive paragraph expands the definition of CPT code 77295 to include those procedures done in preparation for use of coplanar therapy beams. CPT code 77295 also includes the work done for a teletherapy isodose plan (codes 77305-77315) and accordingly, codes 77305-77315 should not be billed separately.

Procedure code 77295 should be used only when true 3-D treatment planning computers are used. When this equipment is used, it is appropriate to bundle CPT code 77295 with CPT code 77315 because the entire procedure is performed on one computer. The radiation oncologist and physicist do the procedure together. It would not be appropriate to bill for CPT code 77315 because there is not a separately billable procedure. The entire process is appropriately billed as one code, namely CPT code 77295.

Three dimensional simulation and treatment is clinically warranted when one or more of the following conditions exist:

• The volume of interest is irregular and in close apposition to normal structures that must be protected;
• The volume of interest is in such a location that its’ parameters can only be defined by MR or CT;
• The final boost volume of interest must be constructed to the exact tumor volume with its irregular configuration;
• Multiple conformed portals are necessary to cover the volume of interest with close margins and protect immediately adjacent normal structures;
• “Beams eye view” of multiple portals must be established for conformal treatment delivery; or
• An immediately adjacent region has been irradiated and abutting portals must be established with high precision.

Basic Radiation Dosimetry Calculation (77300)

77300 Basic radiation dosimetry, calculation, central axis depth dose, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, as required during course of treatment, only when prescribed by the treating physician.

This service is considered to be medically necessary for each treatment port and if a patient has off-axis calculations, calculations for different depth doses, different volumes of interest, secondary film dosimetry, abutting volumes of interest, or any other situation requiring individual point calculations of radiation dosage. Changes in a patient’s weight or girth during the course of radiation treatment may necessitate dosimetry recalculation.

This procedure need not be routinely performed each time the patient is treated. Basic dosimetry calculations may be reported as many times as the calculations are performed.

Medicare would expect to see ongoing documentation that would include any changes in dosimetry calculations and change in radiation treatment and frequency. Supporting documentation will be requested for dosimetry calculations of greater than ten (10).

Teletherapy Isodose Plan (77305-77315)

77305 Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel opposed unmodified ports directed to a single area of interest)

77310 Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more treatment ports directed to a single area of interest)

77315 Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations)

This service is considered medically necessary for a given course of radiation therapy to a specific volume of interest.

The typical course of radiation therapy will require from one to three isodose plans.

Usually only one plan per volume of interest will be sufficient, though some patients may require multiple teletherapy plans during the course of therapy. Situations that may require an extra teletherapy plan include the need to change the machine or the volume of interest. Toward the end of treatment, due to clinical variations of the patient, another plan may be required.

CPT code 77305 is used when there are one or two ports directed at one volume of interest.

CPT code 77310 is used when there are three or more ports converging on a single volume of interest. Blocking may be utilized to eliminate the beam from certain portions of the isodose plan and must be verified.

CPT code 77315 is used when five or more ports converge on a single volume of interest or when complex blocking and/or wedges are used with any port arrangement. Three-dimensional stereotactic isodose planning can be classified as a complex level isodose plan and may be billed with CPT code 77315 or as part of CPT code 77295 but not with both. The physician’s documentation must be specific to the number of volumes of interest. The specific location of tumor(s) to be treated must be documented as well as the specific number of ports involved with each volume of interest treated. All isodose plans must be checked and signed by the medical radiological physicist and the radiation oncologist.

Special Teletherapy Port Plan (77321)

77321 Special teletherapy port plan, particles, hemi-body, total body

Only one plan should be billed per treatment course.

Special Dosimetry (77331)

77331 Special dosimetry (e.g., TLD, micro-dosimetry) (specify), only when prescribed by the treating physician

This service is considered medically necessary once per port when the physician determines that it is necessary to have a measurement of the amount of radiation that a patient has actually received at a given point, with the final results being utilized to accept or modify the current treatment plan.

This procedure will generally be reimbursed one time per port per course of treatment when prescribed by the treating physician. Additional payments may be made if documentation supports the extra service requested in the patients’ record.

The monitoring devices utilized for measuring and monitoring can include thermoluminescent dosimeters (TLD), solid state diode probes, special dosimetry probes, or film dosimetry. The physician must specify the type of special dosimetry.

When special dosimetry is employed, the usual frequency will vary from one to four.

Treatment Devices, Designs, and Construction (77332-77334) 

77332 Treatment devices, design and construction; simple (simple block, simple bolus)

77333 Treatment devices, design and construction; intermediate (multiple blocks, stents, premade wedges, bite blocks, special bolus)

77334 Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, molds or casts)

Multiple treatment devices may be charged during a course of therapy if documentation substantiates multiple volumes of interest/ports, the use of custom-made devices, and/or the necessity of replacement devices.

Simple treatment devices (CPT code 77332) include any of the following:

• Simple port blocks that include one or two hand-positioned pre-made blocks;
• Simple prefabricated bolus that is capable of being shaped for an individual patient; or
• Independent jaw motion or asymmetrical collimation;
• Application devices used in Brachytherapy such as tandem and ovoids, cylinders used in prostate seed implants.

Intermediate treatment devices (CPT code 77333) include any of the following:

• Multiple port blocks which include three or more pre-made blocks such as comer pelvis blocks, beam splitter blocks, or midline spinal cord blocks;
• Stents;
• Bite blocks; or
• Special multi-use bolus.

Complex treatment devices (CPT code 77334) include any of the following:

• Customized, single-use bolus such as wax molds conformed to a particular patient body part;
• Customized blocks (low temperature alloy);
• Customized compensators;
• Wedges;
• Molds or casts;
• Multi-leaf collimation; or
• Intensity modulated therapy
• Custom made immobilization devices
• Eye shields.

Providers should bill for devices at the beginning of the treatment course and then may bill again later in the course of treatment when additional or new devices are required. Payment for one set of treatment devices may be allowed per separate port when radiation therapy is started. A pair of devices for opposing ports, constructed from drawings made by a physician on a single film, is considered for physician professional billing purposes to be one port. Each individual device constructed may be billed separately by the facility. This is true regardless of the level of complexity of the devices used to create these ports. It is the responsibility of the provider to determine complexity, the physician must be directly involved in the design, selection, and placement of any of the devices.

Custom-made immobilization devices should be billed at a complex level (CPT code 77334). These would include restraining devices such as aquaplast and alpha cradle. The use of passive restraints such as straps, pillows, sandbags, etc. are not billable.

When the patient has a combination of a wedge compensator (complex beam modification device) and a bolus (simple beam modification device), covering the same treatment port, this would be billed as a single complex treatment device charge rather than as a separate charge for each of the additional items of lower complexity. If beam modification devices of two separate levels of complexity are utilized for the same treatment port, only the one of highest complexity will be billable. Restraining devices and beam modification devices may be billed separately for the same port, but only one restraining device may be billed for each volume of interest treated.

The typical course of radiation therapy will justify from one to five charges for devices. Billing more than eight units for treatment device services (CPT 77332, 77333, and 77334) may require supporting documentation.

Medical Radiation Physics Consultation (77336-77370)

77336 Continuing medical radiation physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy

77370 Special medical radiation physics consultation

CPT code 77336 is specific to the review of the weekly radiation treatment plan. This service ensures that the treatment administered conforms to the specifications of the prescribing physician. This service includes a documented review of the patient’s treatment chart and record to verify that the patient received the prescribed radiation dosage, appropriate positioning and beam orientation and radiation safety. This procedure is reported weekly (once every consecutive five treatments delivered), a frequency that would match the weekly radiation treatments billed.

CPT code 77370 should be used for consultative purposes when a problem or special situation arises during radiation therapy. This code requires a detailed written report describing the problem to be given to the requesting physician.

CPT codes 77336 and 77370 are technical services only, and are payable by Medicare only in a setting in which the technical component is payable, i.e., in the freestanding radiation oncology center that employs its own radiation physicist (11).

Proton Beam Delivery (77380-77381)

See codes 77520-77523 for this treatment.

77380 Proton beam delivery to a single treatment area, single port, custom block, with or without compensation, with treatment set-up and verification images

77381 Proton beam treatment to one or two treatment areas, two or more ports, two or more custom blocks, and two or more compensators, with treatment set-up and verification images

Because proton beam therapy is available in only a few locations, the contractor assigned to the locale in which proton beam therapy is provided is responsible for all applicable coverage and pricing.

Radiation Treatment Delivery (77401-77416)

77401 Radiation treatment delivery, superficial and/or ortho voltage

77402 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV

77403 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 6-10 MeV

77404 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 11-19 MeV

77406 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 20 MeV or greater

77407 Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; up to 5 MeV

77408 Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 6-10 MeV

77409 Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 11-19 MeV

77411 Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 20 MeV or greater

77412 Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV

77413 Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV

77414 Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 MeV

77416 Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater

These codes recognize the technical component and the various energy levels administered.

If the dates of service are not consecutive or the energy or level of service is not the same, each date of service must be billed in a separate detail line.

When more than one treatment is performed on the same day, e.g., hyperfractionization, each treatment should be billed on a separate detail line.

Multiple treatment sessions on the same day are payable as long as there has been a distinct break in therapy services and the individual sessions are of the character usually furnished on different days.

The physician’s documentation within the patient’s medical record must support the specific energy levels reported to Medicare.

The number of treatment delivery codes billed will depend upon the number of fractions delivered.

Portal Verification Film(s) (77417)

77417 Therapeutic radiology port film(s)

Use CPT code 77417 to report port verification films or electronic portal imaging for verification. Centers with electronic portal imaging technology may bill port film verification (77417) when this technique is substituted for x-ray film. The above text in relation to port verification films applies to electronic portal imaging also. These films should agree with the original simulation films and dosimetry. This procedure may not be quantity billed to Medicare.

Port film verification (CPT code 77417) is a technical component only procedure and does not carry a professional physician component. No modifier is required for these services. The review and interpretation of port films are considered part of the weekly clinical treatment management by the physician. Portal verification films should be reported as one charge per five fraction of therapy, regardless of the number of films required during this time interval.

Radiation treatment management is reported using the following code:

77427 Radiation treatment management, five treatments

Radiation treatment management is reported using the following guidelines:

For CPT code 77427, radiation treatment management is reported once for every five fractions or treatment sessions regardless of the actual time period in which the services are furnished. The services need not be furnished on consecutive days. Multiple fraction representing two or more treatment sessions furnished on the same day may be counted separately as long as there has been a distinct break in therapy and the fractions are of the character usually furnished on different days.

If there are three (3) or four (4) fractions beyond a multiple of five at the end of a course of treatment, then one unit of radiation therapy management may be billed. If one or two fractions beyond a multiple of five at the end of a course of treatment are delivered, no separate reporting should be made.

The professional services furnished during treatment management typically consist of:

• Review of port films;
• Review of dosimetry, dose delivery and treatment parameters;
• Review of patient treatment set-up; and
• Examination of patient for medical evaluation and management (e.g., assessment of the patient’s response to treatment, coordination of care and treatment, review of imaging and/or lab test results.)

Providers should report radiation treatment management as follows:

• Each radiation therapy management service should be billed on a separate detail line.
• The date of service should be the beginning date for each service of 5 treatments.
• Payment should only be made after the fifth treatment has been delivered, not before. However, payment will be made for one radiation therapy management service if the entire treatment course consists of only three or four fractions.
• One (1) unit will be reimbursed for each “set” of five (5) fractions.
• Claims should be clearly documented when a new course of therapy begins. Claims not containing this information will be processed as a continuation of therapy. This omission will result in an incorrect payment.

77431 Radiation therapy management with complete course of therapy consisting of one or two fractions only

If a patient's entire treatment course consists of only one or two fractions, the physician should bill CPT code 77431 (radiation therapy management with complete course of therapy consisting of one or two fractions only) and report the number of fractions in the units/days field/block. This code should not be used for reimbursement of the remaining treatments at the end of a long course of therapy.

Neutron Beam Treatment Delivery (77422 and 77423)

High energy neutron beam treatment delivery has been demonstrated to be reasonable and necessary in the management of advanced salivary gland tumors. However, it's usefulness in the treatment of other malignancies is investigational.

Special Treatment Procedures (77470)

77470 Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation)

CPT code 77470 covers the additional physician effort and work required for the special procedures of hyper-fractionation, total body irradiation, per oral, endocavitary, or intraoperative cone use, or when other modalities are being managed in combination with external beam therapy, such as, brachytherapy, stereotactic radiosurgery, intraoperative radiation therapy and any other special time consuming treatment plan.

This code is not intended to be used because a patient has another ongoing medical diagnosis such as diabetes, COPD, or hypertension.

It is considered an acceptable standard of practice for this code to be reported only once during a treatment course, and may be billed with the radiation therapy management codes. For the remaining treatment course, a physician should use the appropriate radiation therapy management codes (77427 or 77431) for the management of the patient. If the treatment course is modified for any reason, the physician should use the appropriate CPT code for the simulation field-setting and dosimetry. CPT code 77470 should not be used for this reason.

Proton Treatment Delivery (77520-77525)

77520 Proton treatment delivery; simple, without compensation

77522 Proton treatment delivery; simple, with compensation

77523 Proton treatment delivery; intermediate

77525 Proton treatment delivery; complex

Because proton beam therapy is available in only a few locations, the contractor assigned to the locale in which proton beam therapy is provided is responsible for all applicable coverage and pricing.

IMRT

The decision process for using IMRT requires an understanding of accepted practices that take into account the risks and benefits of such therapy compared to conventional treatment techniques. While IMRT technology may empirically offer advances over conventional or 3-Dimensional conformal radiation, a comprehensive understanding of all consequences is required before applying this technology.

IMRT is not a replacement therapy for conventional and 3D conformal radiation therapy methods in every situation. IMRT is considered reasonable and necessary in instances where sparing the surrounding normal tissue is essential and the patient has at least one of the following conditions met:

• Important dose limiting structures adjacent to, but outside the PTV are sufficiently close and require IMRT to assure for safety and morbidity reduction.
• An immediately adjacent volume has been irradiated and abutting portals must be established with high precision.
• Gross Tumor Volume (GTV) margins are concave or convex and in close proximity to critical structures that must be protected to avoid unacceptable morbidity.
• Only IMRT techniques would decrease the probability of grade 2 or grade 3 radiation toxicity as compared to conventional radiation in greater than 15 percent of radiated similar cases.

It is expected that the Dose Volume Histogram (DVH) would illustrate at least three (3) critical structures protected by the use of IMRT.

IGRT

Image Guided Radiation Therapy (IGRT) utilizes various imaging technologies to account for changes in the position of the intended target before or during treatment deliver. IGRT is used where patients have tumors located near or within critical structures and/or in tissue with inherent setup variation. Thus, although IGRT is a distinct service, it may be used and documented along with conformal treatment delivery (CPT 77402-77416), or IMRT treatment delivery (77418). Several different imaging modalities are utilized for image guided radiation therapy. These include the use of kV and MV imaging via stereoscopic X-ray guidance, 2D or 3D ultrasound guidance, 3D cone beam CT guidance, tracking of respiratory motion via infrared cameras or video monitoring, and 4D localization and tracking of electromagnetic transponders. Some image guidance modalities require the implantation of fiducial markers; other image guidance modalities use external markers, the organ itself, or adjacent anatomic structures to reference location of the target.

Limitations

In addition to services that are bundled based on Correct Coding Initiative (CCI), the following services are also bundled into the radiation treatment management codes; therefore, no separate payment will be made for any of the following services rendered by radiation oncologists or in conjunction with radiation therapy:

• Anesthesia (whatever code billed)
• Care of infected skin (whatever code billed)
• Checking of treatment charts, verification of dosage, as needed (whatever code billed)
• Continued patient evaluation, examination, written progress notes, as needed (whatever code billed)
• Final physical examination (whatever code billed)
• Medical prescription writing (whatever code billed)
• Nutritional counseling (whatever code billed)
• Pain management (whatever code billed)
• Review and revision of treatment plan (whatever code billed)
• Routine medical management of unrelated problem (whatever code billed)
• Special care of ostomy (whatever code billed)
• Written reports, progress note (whatever code billed)
• Follow-up examination and care for 90 days after last treatment (whatever code billed)

IMRT

IMRT is not considered reasonable and necessary unless at least one of the criteria listed in the indications of coverage section of this LCD is present.

Radiation Therapy (Inpatient). Radiation Therapy (Outpatient)

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.

Each claim must be submitted with ICD-9-CM codes that reflect the condition of the patient, and indicate the reason(s) for which the service was performed. Claims submitted without ICD-9-CM codes will be returned.

Documentation in the patient’s medical records must support:

• The reasonable and necessary requirements as outlined under the coverage and limitations sections of this LCD and must be available to the Contractor for review upon request.
  
• Documentation must include the planned course of therapy, type and delivery of treatment, level of clinical management involved and ongoing documentation of any changes in course of treatment.

Additional Documentation for IMRT must include:

• The prescription must define the goals and requirements of the treatment plan, including the specific dose constraints for the target(s) and nearby critical structures.
  
• A statement by the treating physician documenting the special need for performing IMRT on the patient in question, rather than performing conventional or 3-dimensional treatment planning and delivery.
  
• A signed IMRT inverse plan that meets prescribed dose constraints for the planning target volume (PTV) and surrounding normal tissue using either dynamic multi-leaf collimator (DMLC), segmented multi-leaf collimator (SMLC) (average number of "steps" required to meet IMRT delivery is 5), or inverse planned IMRT solid compensators to achieve intensity modulation radiation delivery.
  
• The target verification methodology must include the following:

Documentation of the clinical treatment volume (CTV) and the planning target volume (PTV). This may include the services described by CPT code 77421 which provides for stereoscopic X-ray images prior to treatment delivery in order to visualize the internal anatomy or implanted markers. Comparison with the digitally reconstructed radiographs (DRRs) enables real-time analysis of the targeted area.

Documentation of immobilization and patient positioning.

Means of dose verification and secondary means of verification.

The monitor units (MU’s) generated by the IMRT treatment plan must be independently checked before the patients’ first treatment.

• Documentation of fluence distributions re-computed in a phantom is required.
  
• Documentation is required to account for structures moving in and out of high and low dose regions created by respiration. Voluntary breath holding is not considered appropriate and the solution for movement can best be accomplished with gating technology.

Documentation must be available to the contractor upon request.

A GLOSSARY OF TERMS FOR RADIATION THERAPY

BOLUS - A material of density nearly equivalent to tissue which may be utilized on the surface of the patient within the treatment beam to compensate for uneven body contours or to enhance the build up of electrons on the surface of the skin.

CENTRAL AXIS DEPTH DOSE - The dosage as derived along the central axis of an isodose curve. This is the most common method of expression of tumor dose as related to maximum dose.

COMPLEX TREATMENT - Treatment of malignant disease requiring complex field localization, the use of beam shaping devices, three or more treatment volumes being irradiated per day, massive single dose treatment, mantle field, inverted "y" field, the use of wedges or compensators, electron or other special beam considerations.

CONFORMAL TREATMENT - Treatment of malignant disease utilizing multiple custom megavoltage treatment beams that are focused on a large three-dimensional reconstructed target.

CONTOUR PREPARATION - The utilization of some means of transferring a cross-sectional shape of the patient's body onto a suitable surface for the purpose of dosimetry calculations. Normally followed by locations of consequential internal structures and the suspected tumor volume.

DOSIMETRY –

(1) The means of calculating the amount of radiation dosage delivered, or to be delivered to a specific area under study.

(2) Strictly, the measurement of dose. By application, all activities relating to the specification for determination of radiation dose delivered.

(3) Consideration includes the beam orientations and exposures, tissue inhomogeneities, volume under treatment, isodose distributions, etc.

ELECTRON BEAM THERAPY - The delivery of external beam radiation therapy by means of an electron beam of specific energy.

HYPERFRACTIONATION - The delivery of radiation in smaller than usual doses, more than once per day.

ISODOSE DISTRIBUTION - A geometric plan usually representing one or more intersection treatment beams giving a summation of similar dosages within the volume of interest. A time consuming process which is now usually computer derived.

ISODOSE DISTRIBUTION - BRACHYTHERAPY - The dosage distribution plot around an application or implant of radioactive substance.

ISODOSE DISTRIBUTION - SIMPLE - Composite of one or two therapy beams directed into a specific area.

ISODOSE DISTRIBUTION - INTERMEDIATE - Composite of three or more therapy beams directed into a specific area, or a situation where special factors must be considered.

ISODOSE DISTRIBUTION - COMPLEX - One or more treatment beams directed into a specific area but with the addition of wedge filters, moving fields, compensation for tissue or geometric inhomogeneities, bolus, special blocking procedures, mantle fields, tangential fields, etc.

LINEAR ACCELERATOR - A megavoltage treatment machine capable of delivering high energy x-ray, and in some instances an electron beam.

PORT FILM - A radiograph taken with the patient interposed between the treatment machine portal and an x-ray film. The purpose of this film is to radiographically demonstrate that the treatment port as externally set on the patient adequately encompasses the treatment volume and at the same time avoids adjacent critical structures.

RADIATION THERAPIST- A radiation therapist is the personnel responsible for the actual treatment delivery on the linear accelerator or treatment unit.  The radiation therapist works directly with and under the supervision of the radiation oncologist or therapeutic radiologist.  The radiation oncologist is a physician with specific training in the therapeutic radiology; however the radiation therapist is a staff member with specific training on the use of the linear accelerator, simulator, CT scanner, treatment planning computer, etc.  They are responsible for providing and documenting daily treatments as prescribed by the physician, as well as other necessary functions for patient positioning, simulation, and imaging.

REMOTE AFTERLOADING - A method or technique of brachytherapy whereby the application of a low or high dose radioisotope is accomplished through equipment or a device which provides more precision delivery of the isotope due to the predictable position of the applicators, patient convenience, and enhanced protection for the technician.

SIMPLE TREATMENT - An individual application of radiations for benign or malignant disease. May be the utilization of a single external beam, surface or intracavitary therapy applied without general anesthesia.

SIMULATION - The use of a simulator to determine the various treatment field outlines and orientations to be used in the course of radiation therapy.

SIMULATOR - A radiation generator operating in the diagnostic x-ray range with the mechanical capability to orient a radiation beam toward a patient with parameters imitating that proposed for therapy, and affording direct x-ray fluoroscopic visualization and roentgenographic images of the area. Machine not capable of delivering radiation therapy.

SPECIAL TESTING - The ordering and interpretation of results of special diagnostic procedures for further delineation of the patient's general condition or extent of tumor. (i.e. ultrasound, nuclear medicine, special procedure x-rays, special laboratory work, etc.)

STRONTIUM-90 APPLICATION - A low energy beta ray source used for contact therapy. Usually used for eye lesions.

SUPERFICIAL X-RAY - X-rays produced by a machine with an energy of usually less than 140 KVP.

SUPERVOLTAGE - 600 KVP to 2 MeV including cobalt-60 and cesium-137.

TELETHERAPY - The delivery of radiation treatments to a patient from a machine located remotely from the body.

TREATMENT COURSE - The amount of time necessary to administer therapy based on the results of treatment planning. Typically, a 2 month period of time.

TREATMENT DAY - A summation of the daily treatments delivered in one calendar day.

TREATMENT FIELD - A single surface area as defined by the collimated radiation beam of the treatment machine. Term often used synonymously with treatment port. A single treatment region which may have one or more treatment ports converging upon it.

TREATMENT PLAN - An ensemble of radiation exposure beams or sources designed to produce a prescribed dosage pattern in and for the patient; includes spatial and temporal distributions.

TREATMENT PLANNING - A complex service including interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment modality, determination of number and size of treatment, ports, selection of appropriate treatment devices, and other procedures.

Simple - Planning requiring single treatment area of interest encompassed in a single port or simple parallel opposed ports with minimal blocking.

Intermediate - Planning requiring three or more converging ports, two separate treatment areas, special blocking, standard wedges, or special time dose constraints.

Complex - Planning requiring highly complex blocking, tangential ports, special wedges or compensators, three or more separate areas, special beam considerations.

TREATMENT PORT - See treatment field. The machine opening through which the radiation beam is delivered.

TUMOR LOCALIZATION - The various studies and procedures to circumscribe the volume of tumor involvement.

WEDGE FILTER - A tapered block of attenuating material designed to produce a differential distribution of radiation exposures over the area of a radiation beam. 

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Specific utilization guidelines can be found under individual code sections in the policy. 

ACR Practice Guideline for Radiation Oncology (10/01/2004)

American College of Radiology, ACR Standards 2000-2001

ASTRO/ACR Guide to Radiation Oncology Coding 2007

American Medical Association’s “Physician's Current Procedural Terminology CPT “

Burstein H, Polyak K, Wong J, et al.  Ductal Carcinoma In Situ of the Breast.  N Engl J Med.  2004; 350: 1430-41.

Carlos A. Perez, MD and Luther W. Brady, MD, eds., Principles and Practice of Radiation Oncology, 3rd ed. (Philadelphia, Lippincott - Raven, 1998)

CANCER, Principles & Practice of Oncology; by DeVita, Hellman, Rosenberg, Fifth Edition, Volume 2 Chapter 66, pp3090-3106; published by Pippincott-Raven

Chang SX, Deschesne KM , Cullip TJ, Parker SA, Earnhart J. A comparison of different intensity modulation treatment techniques for tangential breast irradiation. Int. J. Radiation Oncology Biol. Phys. 1999; 45(5): 1305-1314.

Chang, Sha X; Cullip, Timothy J; Deschesne, Katharin M; Intensity modulation delivery techniques: “Step & shoot” MLC auto-sequence versus the use of a modulator. Med. Phys 27 (5), May 2000, 948-959.

Chang SX, Cullip TJ, Deschesne KM, Miller EP, Rosenman JG. Compensators: An alternative IMRT delivery technique. Journal of Applied Clinical Medical Physics. 2004 Summer; 5(3): 15-36.

Chao, Clifford, M.D., Deasy, Joseph, PhD., Markman Jerry, D.Sc., Haynie Joyce, R.N., Perez, Carlos, M.D., Purdy, James, Ph.D., Low, Daniel, PhD.: A Prospective Study of Salivary Function Sparing in Patients with Head-and-Neck Cancers Receiving Intensity-Modulated or Three-Dimendional Radiation therapy: Initial Results; Radiation Oncology Biol. Phys. Vol 49, No 4, pp. 907-916, 2001.

Chao KS, Majhail N, Huang CJ, Simpson JR, Perez CA, Haughey B, Spector G. Intensity-modulated radiation therapy reduces late salivary toxicity without compromising tumor control in patients with oropharyngeal carcinoma: a comparison with conventional techniques. Radiother Oncol. 2001 Dec; 61(3): 275-80.

Cozzi, Luca, Ph.D., Fogliata, Antonella, Dr., Bolsi, Alessandra, Dr., Nicolini, Giorgia, Dr., Bernier, Jacques, Ph.D, M.D. :Three-Dimensional Conformal vs. Intensity-Modulated Radiotherapy in Head-and-Neck Cancer patients: Comparative Analysis of Dosimetric and Technical Parameters; Int. J. Radiation Oncology Biol. Phys. Vol 58, No 2, pp. 617-624, 2004.

DeVita, V., Hellman, S., Rosenberg, S., Cancer Principles and Practice of Oncology, 4th Edition, 1993

Dogan N, Leybovich LB, King S, Sethi A, Emami B. Improvement of treatment plans developed with intensity-modulated radiation therapy for concave-shaped head and neck tumors. Radiology. 2002 Apr; 223(1): 57-64.

Ernster VL, Barclay J, Kerlikowske K, et al.  Incidence and Treatment for Ductal Carcinoma In Situ of the Breast.  JAMA 1996; 275: 913-8.

Esthappan Jacqueline, Mutic Sasa, Malyapa Robert, Grigsby Perry, Zogeri Imran, Dehdashti Farroukh, Miller Tom, Bosch Walter and Low Daniel: Treatment planning guidelines regarding the use of CT/PET-guided IMRT for cervical Carcinoma with positive paraaortic lymph nodes; Int. J. Radiation Oncology Biol. Phys. Vol 58, Issue 4, Pages 1289-1297, (15 March 2004).

Federal Register 2004, Volume 69, Number 219, p. 66370.

Fisher B, Digman J, Wolmark N, et al.  Lumpectomy and Radiation Therapy for the Treatment of Intraductal Breast Cancer:  Findings from National Surgical Adjuvant Breast and Bowel Project B-17.  J Clin Oncol 1998; 16: 441-52.

Fraass BA; Kessler ML; McShan DL; Marsh LH; Watson BA; Dusseau WJ; Eisbruch A; Sandler HM; Lichter AS: Optimization and clinical use of multisegment intensity-modulated radiation therapy for high-dose conformal therapy. Seminars Radiation Oncology 1999 Jan;9(1):60-7

Gallagher, Michael, M.D., Brereton, Harmar, M.D., Rostock, Robert, M.D., Zero, Jeffrey, Zekoski, Debbie, R.T.T., Poyss, Leo, MRP, Richter, Melvyn, M.D. Kligerman, Morton, M.D.: A Prospective Study of Treatment Techniques to Minimize the Volume of Pelvic Small Bowel with Reduction of Acute and Late Effects Associated with Pelvic Irradiation; Radiation Oncology Biol. Phys. Vol 12, pp. 1565-1573.

Gunderson, Leonard, Martenson, James, Jr.: Gastrointestinal Tract Radiation Tolerance; Front Radiat Ther Oncol. Besel Karger, 1989, Vol 23, pp 277-298.

Heron, D.E., Gerszten, K., R.N., Selvaraj, G.C.., King, D. Sonnik, Gallion, J. Comerci, R.P. Edwards, A. Wu, R.S.,Andrade, and S. Kalniki: Conventional 3D conformal versus intensity-modulated radiotherapy for the adjuvant treatment of gynecologic malignancies: a comparative dosimetric study of dose-volume histograms; Gynecologic Oncology 91 (2003)39-45.

Hurkmans C, John Cho BC, Damen E, et al.  Reduction of Cardiac and Lung Complication Probabilities after Breast Irradiation Using Conformal Radiotherapy with or without Intensity Modulation.  Radiotherapy and Oncology 2002; 62: 163-171.

Intensity-Modulated Radiotherapy Collaborative Working Group. Intensity-Modulated Radiotherapy: Current Status and Issues of Interest. Int J Radiat Oncol Biol Phys 2001; 54(4): 880-914

Jabban S, Feng A, Lin A, Kim H.M., Tsien C, Murdoch-Kinch C.A., Eisbruch A,: Xerostomia and quality of life (QOL) after parotid sparing IMRT for head and neck (HN) cancer: A matched case-control comparison with standard radiotherapy (RT); Int. J. Radiation Oncology Biol. Phys. Vol 60, Issue (Supplement), Page S321 (September 2004).

Jiang, Steve B; Ayyangar, Komanduri M: On compensator design for photon beam intensity-modulated conformal therapy. Med. Phys 25 (5), May 1998, 668-675.

John Cho BC, Hurkmans CW, Zijp LJ, et al.  Intensity Modulated Versus Non-Intensity Modulated Radiotherapy in the Treatment of the Left Breast and Upper Internal Mammary Lymph Node Chain: A Comparative Study.  Radiotherapy and Oncology 2002; 62:127-136.

Knab BR, Roeske JC,  Metha N, Sutton H, Mundt AJ: Outcome of Endometrial Cancer aptients Treated with Adjuvant Intensity Modulated Pelvic Radiation Therapy; Radiation of Cellular Oncology, University of Chicago, Proceddings of the 46th annual ASTRO Meeting.

Kruger E, Frass B, McShan DL, et al.  Clinical Aspects of Intensity-Modulated Radiotherapy in the Treatment of Breast Cancer.  Seminars in Radiation Oncology 2002; 12: 250-259.

Kuppersmith RB; GrecoSC; Teh BS et al: Intensity modulated radiotherapy: first results with this new technology on neoplasms of the head and neck. Ear Nose Throat J 1999 April;78(4):238-248

Lee N, Xia P, Quivey JM, Sultanem K, Poon I, Akazawa C, Akazawa P, Weinberg V, Fu KK. Intensity-modulated radiotherapy in the treatment of nasopharyngeal carcinoma: an update of the UCSF experience. Int J Radiat Oncol Biol Phys. 2002 May 1; 53(1): 12-22.

Lee, Nancy, Xia, Ping, Fischbein, Nancy, Akazwa, Pam, Akazawa, Clayton, Quivey, Jeanne: Intensity-Modulated Radiation Therapy for Head-and-Neck Cancer: The UCSF Experience Focusing on Target Volume Delineation; Int. J. Radiation Oncology Biol. Phys. Vol 57, Issue, Pages 49-60 (1 September 2003).

Mundt, Arno, M.D., Roeske, John C. Ph.D., Lujan, Anthony Ph.D., Yamada, Diane M.D. Rotmensch, Jacob M.D., Waggoner, Steve E., M.D., and Fleming, Gini, M.D.: Initial Clinical Experience with Intensity-Modulated whole-Pelvis Rdiation Therapy in Women with Gynecologic Malignancies; Gynecologic Oncology 81, 456-463 (2001).

Mundt, Arno, M.D., Mell Loren, M.D. and Roeske John, PhD.: Preliminary Analysis of chronic Gastorintestinal Toxicity in Gynecology Patient treated with Intensity-Modulated whole Pelvic Radiation Therapy; Int. J. Radiation Oncology Biol. Phys. Vol 56, No 5, pp. 1354-1360, 2003.

Muttic Sasa, M.S., Malyapa, Robert, M.D., Ph.D., Grigsby, Perry, M.D., Dehdashti, Farroukh, M.D., Miller, Tom, M.D., PhD., Zoberi, Imran, M.D., Bosch, Walter, D.Sc., Esthappan, Jacueline, PhD., Low, Daniel, PhD.,: PET Guided IMRT for Cervical Carcinoma with Positive Para-Aortic Lymph Nodes-A Dose-Escalation Treatment Planning Study; Int. J. Radiation Oncology Biol. Phys. Vol 55, No 1, pp. 28-35, 2003

Nutting, Christopher, M.R.C.P., F.R.C.R., Convey, David, PhD., Cosgrove, Vivian, Ph.D., Rowbottom, Carl, PhD., Padhani, Anwar, M.R.C.P., F.R.C.R., Webb, Steve, D.Sc., and Dernalley, David, M.D., F.R.C.R.: Reduction of Small and Large Bowel Irradiation Using an Optimized Intensity-Modulated Pelvic Raiotherpy Technique in Patients with Prostate Cancer; Int. J. Radiation Oncology Biol. Phys. Vol 48, No 3, pp. 649-656, 2000.

Nutting CM, Convery DJ, Cosgrove VP, Rowbottom C, Vini L, Harmer C, Dearnaley DP, Webb S. Improvements in target coverage and reduced spinal cord irradiation using intensity-modulated radiotherapy (IMRT) in patients with carcinoma of the thyroid gland. Radiother Oncol. 2001 Aug; 60(2): 173-80.

Patel S, Vuong T, Ballivy O, Portelance W, Parker W, Patrocinio H: Phase II Trial of Pelvic Intensity-Modulated Raiotherapy (IMRT) with Concurrent chemotherapy for patients with Rectal Cancer; I.J. Radiation Oncology, Volume 60, Number 1, Supplement 2004.

Pirzkall A, Carol M, Lohr F, et al. Comparison of Intensity Modulated Radiotherapy with Conventional Conformal Radiotherapy for Complex-Shaped Tumors. Int J Radiat Oncol Biol Phys 2000; 48(5): 1371-1380

Portelance, Lorraine, M.D., Chao, Clifford, M.D., Grigsby, Perry, M.D., Bennet, Harold, M.D. Low, Daniel, PhD.,: Intensity-Modulated Radiation Therapy (IMRT) Reduces Small Bowel, Rectum, and Bladder Doses in Patients with Cervical Cancer Receiving Pelvic and Para-Aortic Irradiation; Int. J. Radiation Oncology Biol. Phys. Vol 51, No 1, pp. 261-266, 2001.

Roeske, John C. Ph.D., Lujan, Anthony Ph.D., Rotmensch, Jacob M.D., Waggoner, Steve E., M.D., Yamada, Diane M.D. and Mundt, Arno, M.D.: Intensity-Modulated Whole Pelvic Radiation Therapy in Patients with Gynecologic Malignancies; Int. J. Radiation Oncology Biol. Phys. Vol 48, No 5, pp. 1613-1621, 2000.

Roeske, John C. Ph.D., Lujan, Anthony Ph.D., Rotmensch, Jacob M.D., Waggoner, Steve E., M.D., Yamada, Diane M.D. and Mundt, Arno, M.D.: Intensity-Modulated Whole Pelvic Radiotherapy in Women with Gynecologic Malignancies; Int. J. Radiation Oncology Biol. Phys. Vol 52, No 5, pp. 1330-1337, 2002.

Roeske John, Bonta Dacian, Mell Loren, Lujan Anthony, Mundt Arno: A dosimetric analysis of acute gastrointestinal toxicity in women receiving intensity-modulated whole-pelvic radiation therapy; Radiotherapy and oncology 69 (2003) 201-207.

Schwartz G, Solin L, Olivotto I, et al.  Consensus Conference Committee on the Classification of Ductal Carcinoma of the Breast, April 22-25, 1999.  Cancer 2000; 88: 946-954.

Selvaraj, K., R.N., Gerszten, G.C., Sonnik King, Heron, D.E.: Conventional 3-D Versus Intensith Modulated Radiotherapy for the Adjuvant Treatment of Gynecologic Malignancies: A Comparative Study of Dose-Volume Histograms and the Potential Impact on Toxicities; I.J. Radiaion Oncology, Volume 51, Number 3, Supplement 1, 2001.

Shu HG, Lee T, Vigneault E, et al. Toxicity Following High-Dose 3-Dimensional and Intensity-Modulated radiation Therapy for Clinically Localized Prostate Cancer. Urology 2001; 57(1) 102-107

Teh BS; Woo SY; Butler EB: Intensity modulated radiation therapy (IMRT): a new promising technology in radiation oncology. Oncologist 1999;4(6):433-42

Textbook of Radiation Oncology, by Leibel, Phillips, 1st Edition, Chapter 8 pp138-149, published by Saunders

Wieland Petra, Dobler Barbara, Mai Sabine, Hermann Brigitte, Tiefenbacher Uta, Steil Volker, wenz Frederik and Lohr Frank: IMRT for postoperative treatment of gastric cancer: covering large target volumes in the upper abdomen: A comparison of a step-and-shoot and an arc therapy approach; Int. J. Radiation Oncology Biol. Phys. Vol 59, Issue 4, Pages 1236-1244 (15 July 2004).

Xia P, Fu K, Wong G, et al. Comparison of Treatment Plans Involving Intensity Modulated radiotherapy for Nasopharyngeal Carcinoma. Int J Radiat Oncol Biol Phys 2000; 48(2): 329-337

Zelefsky MJ; Fuks Z; et al: Clinical experiences with intensity modulated radiation therapy (IMRT) in prostate cancer. Radiother Oncol 2000 Jun;55(3): 241-249.

Zelefsky MJ, Fuks Z, Hunt M, Lee HJ, Lombardi D, Ling CC, Reuter VE, Venkatraman ES, Leibel SA. High dose radiation delivered by intensity modulated conformal radiotherapy improves the outcome of localized prostate cancer. J Urol. 2001 Sep; 166(3): 876-81.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from radiology, radiation therapy and radiation oncology.

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27515

07/31/2008

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