Download Intensity Modulated Radiation Therapy (IMRT)

Intensity Modulated Radiation Therapy (IMRT)
Policy Number:
MM.05.006
Line(s) of Business:
HMO; PPO; QUEST
Section:
Radiology
Place(s) of Service:
Outpatient
Original Effective Date:
03/09/2004
Current Effective Date:
02/01/2013
I. Description
Intensity modulated radiation therapy (IMRT) is an advanced form of three-dimensional conformal
radiotherapy (3D CRT) that uses varying intensities of radiation to produce dose distributions that
are more conformal than those possible with standard 3D CRT. The beam intensity is varied across
the treatment field, delivering a more uniform dose of radiation to the tumor. This method of
radiation delivery targets the tumor while sparing the surrounding normal tissues and/or organs.
IMRT also allows for dose escalation which can potentially improve local tumor control resulting in
prolonged survival for patients who have already received the maximum amount of radiation
through conventional means.
II. Criteria/Guidelines
IMRT is covered (subject to Limitations/Exclusions and Administrative Guidelines) in the following
situations:
A. Tumors of the central nervous system, when the tumor is in close proximity to organs at risk
(brain stem, spinal cord, cochlea and eye structures, including optic nerve and chiasm, lens and
retina) and 3-D CRT planning is not able to meet dose volume constraints for normal tissue
tolerance
B. Head and neck cancers defined as cancers arising from the oral cavity and lip, larynx,
hypopharynx, oropharynx, nasopharynx, paranasal sinuses, nasal cavity, salivary glands and
occult primaries in the head and neck region
C. Prostate cancer
D. Thyroid cancers in close proximity to organs at risk (esophagus, salivary glands, and spinal
cord) and 3-D CRT planning is not able to meet dose volume constraints for normal tissue
tolerance
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E. Squamous cell cancer of the anus/anal canal
F. Lung cancer when all of the following criteria are met:
1. Radiation therapy is being given with curative intent
2. 3D conformal will expose >35% of normal lung tissue to more than 20Gy dose-volume
(V20)
3. IMRT dosimetry demonstrates reduction in the V20 to at least 10% below the V20 that is
achieved with the 3D plan (e.g., from 40% down to 30% or lower)
G. Breast cancer:
1. As a technique to deliver whole breast irradiation in patients receiving treatment for leftsided breast cancer after breast conserving surgery when all of the following conditions are
met:
a. Significant cardiac radiation exposure is expected to be greater than or equal to 25Gy to
10cc or more of the heart (V25 greater than or equal to 10cc) with 3D conformal RT
despite the use of a complex positioning device
b. With the use of IMRT, there is a reduction in the absolute heart volume receiving 25 Gy
or higher by at least 20% (e.g., volume predicted to receive 25Gy by 3D RT is 20 cc and
the volume predicted by IMRT is 16 cc or less)
2. In individuals with large breasts when the treatment planning with 3D conformal results in
hot spots (focal regions with dose variation greater than 10% of target) and the hot spots
are able to be avoided with IMRT
H. IMRT may be covered (Subject to Limitations/Exclusions and Administrative Guidelines) for
other indications not listed above if the treating physician has written documentation* that
the isodose curves substantiate the advantage of IMRT when compared to other radiation
treatment techniques (including conventional or 3-D conformal) AND the patient has at least
one of the following:
1. The target volume is in close proximity to critical structure(s) that must be protected
2. The volume of interest must be covered with narrow margins to adequately protect
immediately adjacent structures
3. An immediately adjacent area has been previously irradiated and abutting portals must be
established with high precision
4. The target volume is concave or convex and critical normal tissues are within or around
that convexity or concavity
5. Dose escalation is planned to deliver radiation doses in excess of those commonly utilized
for similar tumors with conventional radiation treatment
* Written documentation must include all of the following:
A written prescription that defines the goals and requirements of the treatment plan,
including specific dose constraints for the targets and nearby critical structures
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A statement by the treating physician that documents the medical necessity for IMRT
instead of conventional or 3D CRT treatment planning and delivery, including the need to
protect pertinent vital structures
III. Limitations/Exclusions
A. IMRT is not covered as a replacement therapy for conventional and 3-D conformal radiation
therapy methods
B. Real-time intra-fraction target tracking during radiation therapy to adjust radiation doses or
monitor target movement during individual radiation therapy treatment sessions does not
meet payment determination criteria (See HMSA’s Real-Time Intra-Fraction Target Tracking
During Radiation Therapy Policy for clarification)
IV. Administrative Guidelines
A. Precertification is required except for the conditions listed below. Complete HMSA's
Precertification request and mail or fax the form as indicated. The request must include the
following documentation:
1. A written prescription that defines the goals and requirements of the treatment plan,
including specific dose constraints for the target(s) and nearby critical structures
2. A statement. by the treating physician that documents the medical necessity for IMRT
instead of conventional or 3D CRT treatment planning and delivery, including the need to
protect pertinent vital structures
B. HMSA reserves the right to perform periodic reviews on this service for all indications. The
following documentation must be kept in the patient's medical records and be made available
upon request:
1. The reason IMRT was chosen over other radiation treatments
2. A prescription, defining the goals and requirements of the treatment plan, including the
specific dose constraints for the targets and nearby critical structures
3. A signed and dated IMRT inverse plan that meets prescribed dose constraints for the PTV
and surrounding normal tissue using either dynamic multi-leaf collimator or segmented
multi-leaf collimator to achieve intensity modulation radiation delivery
4. The target verification methodology including:
a. Documentation of the clinical treatment volume and the PTV
b. Documentation of immobilization and patient positioning
c. Means of dose verification and secondary means of verification
5. An independent check of the monitor units generated by the IMRT treatment plan, prior to
the patient's first treatment
6. Fluence distributions re-computed in a phantom
7. Plan 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
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C. HMSA has adopted Medicare’s Correct Coding Initiative (CCI) coding edits for payment of IMRT
services. A complete listing and explanation of the CCI edits may be found on the following web
site: http://www.cms.hhs.gov/NationalCorrectCodInitEd/
D. Applicable codes:
CPT Codes
Description
77301
Intensity modulated radiotherapy plan, including dose-volume histograms for
target and critical structure partial tolerance specification
77418
Intensity modulated treatment delivery, single or multiple fields/arcs, via
narrow spatially and temporally modulated beams, binary, dynamic MLC, per
treatment session
77338
Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy
(IMRT), design and construction per IMRT plan
*Report once per IMRT plan and cannot not be reported with 0073T
0073T
Compensator-based beam modulation treatment delivery of inverse planned
treatment using three or more high resolution (milled or cast) compensator
convergent beam modulated fields, per treatment session.
E. Code that does not meet payment determination criteria:
CPT Codes
0197T
Description
Intra-fraction localization and tracking of target or patient motion during
delivery of radiation therapy, each fraction of treatment
F. Codes that do not require precertification:
ICD-9 Codes
Description
140.0-149.9
Malignant neoplasm of lip, oral cavity, and pharynx, code range
160.0
nasal cavities
160.2-160.5
of the accessory sinuses, code range
161.0-161.9
Larynx , code range
185
Prostate
190.0-190.9
Malignant neoplasm of eye , code range
191.0-191.9
of brain, code range
194.3
pituitary gland and craniopharyngeal duct
198.3
Secondary malignant neoplasm of brain and spinal cord
225.1
Benign neoplasm of cranial nerves
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225.2
cerebral meninges
227.3
of other endocrine glands and related structures, pituitary gland and
craniopharyngeal duct (pouch)
227.4
pineal gland
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ICD-10 codes are provided for your information. These will not become effective until 10/1/2014:
ICD-10 Codes Description
C00.0-C00.9
Malignant neoplasm of lip, code range
C01
Malignant neoplasm of base of tongue
C02.0-C02.9
Malignant neoplasm of other and unspecified parts of tongue, code range
C03.0-C03.9
Malignant neoplasm of gum, code range
C04.0-C04.9
Malignant neoplasm of floor of mouth, code range
C05.0-C05.9
Malignant neoplasm of hard palate, code range
C06.0-C06.9
Malignant neoplasm of other and unspecified parts of mouth, code range
C07
Malignant neoplasm of parotid gland
C08.0-C08.9
Malignant neoplasm of other and unspecified major salivary glands
C09.0-C09.9
Malignant neoplasm of tonsil, code range
C10.0-C10.9
Malignant neoplasm of oropharynx, code range
C11.0-C11.9
Malignant neoplasm of nasopharynx, code range
C12
Malignant neoplasm of pyriform sinus
C13.0-C13.9
Malignant neoplasm of hypopharynx, code range
C14.0-C14.8
Malignant neoplasm of other and ill-defined sites in the lip, oral cavity, and
pharynx, code range
C30.0
Malignant neoplasm of nasal cavity
C31.0-C31.9
Malignant neoplasm of the accessory sinuses, code range
C32.0-C32.9
Malignant neoplasm of the larynx, code range
C61
Malignant neoplasm prostate
C69.00C69.92
Malignant neoplasm of eye and adnexa, code range
C71.0-C71.9
Malignant neoplasm of brain, code range
Intensity Modulated Radiation Therapy
C75.1
Malignant neoplasm of pituitary gland
C75.2
Malignant neoplasm of craniopharyngeal duct
C79.31
Secondary malignant neoplasm of brain
D32.0
Benign neoplasm of cerebral meninges
D32.9
Benign neoplasm of meninges, unspecified
D33.3
Benign neoplasm of cranial nerves
D35.2
Benign neoplasm of pituitary gland
D35.3
Benign neoplasm of craniopharyngeal duct
D35.4
Benign neoplasm of pineal gland
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VI. Important Reminder
The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not
intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is
intended to discourage or prohibit providing other medical advice or treatment deemed
appropriate by the treating physician.
Benefit determinations are subject to applicable member contract language. To the extent there
are any conflicts between these guidelines and the contract language, the contract language will
control.
This Medical Policy has been developed through consideration of the medical necessity criteria
under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4),
generally accepted standards of medical practice and review of medical literature and government
approval status. HMSA has determined that services not covered under this Medical Policy will not
be medically necessary under Hawaii law in most cases. If a treating physician disagrees with
HMSA’s determination as to medical necessity in a given case, the physician may request that
HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any
supporting documentation.
VI. References
1. ECRI institute. Custom Hotline Response. Intensity modulated radiation therapy for breast
cancer. Updated 04/01/08.
2. Gregoire V, De Neve W, et. al. Intensity-Modulated radiation therapy for head and neck
carcinoma. The Oncologist 2007; 12; 555-564.
3. International Radiosurgery Association (IRSA). Radiosurgery Practice Guidelines for IMRT.
Copyright IRSA 2008.
4. Kuppersmith RB, Greco SC, 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; 78(4):238248.
Intensity Modulated Radiation Therapy
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5. Lee N, Chuang C, Quivey JM, et al. Skin toxicity due to intensity-modulated radiotherapy for
head and neck carcinoma. Int J Radiat Oncol Biol Phys. 2003; 55(4):1150.
6. Lee N, Xia P, Quivey JM, et al. Intensity-modulated radiotherapy in the treatment of
nasopharyngeal carcinoma: An update of the UCSF experience. Int J Radiat Oncol Biol Phys.
2002; 53(1):12-22.
7. National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology.
Breast Cancer. Version 1.2012
8. NCCN. Clinical Practice Guidelines in Oncology. Prostate Cancer v. 3.2012
9. NCCN Clinical Practice Guidelines in Oncology. Non-Small Cell Lung Cancer V.3.2012
10. NCCN Clinical Practice Guidelines in Oncology. Small Cell Lung Cancer Version 1.2013
11. NCCN Clinical Practice Guidelines in Oncology. Anal Carcinoma. Version 2.2012
12. Palmetto GBA. LCD for Intensity Modulated Radiation Therapy (IMRT) L28272. Revision
effective date 10/01/2011
13. BCBSA Medical Policy Reference Manual. Intensity Modulated Radiation Therapy (IMRT) of the
Breast and Lung. #8.01.46. Reviewed March 2012
14. BCBSA Medical Policy Reference Manual. Intensity Modulated Radiation Therapy (IMRT) of the
Abdomen and Pelvis #8.01.43. Last reviewed 08/12
15. Sethi A, et al. Role of IMRT in reducing penile doses in dose escalation for prostate cancer. Int J
Radiation Oncology Biol Phys. 2003; 55(4):970-978.
16. Zelefsky MJ, Fuks Z, Hunt M, et al. High-dose intensity modulated radiation therapy for prostate
cancer: early toxicity and biochemical outcome in 722 patients. Int J Radiation Oncology Biol
Phys. 2003; 53(5):1111-1116.
17. Samson DM, Ratko TA, Rothenberg BM et al. Comparative effectiveness and safety of
radiotherapy treatments for head and neck cancer. Comparative Effectiveness Review No. 20.
(Prepared by Blue Cross and Blue Shield Association Technology Evaluation Center Evidencebased Practice Center under Contract from the Agency for Healthcare Research and Quality.
May 2010.