IV.72 INTENSITY MODULATED RADIATION THERAPY (IMRT) (REQUIRES PREAUTHORIZATION)
INTENSITY MODULATED RADIATION THERAPY (IMRT) (REQUIRES PREAUTHORIZATION)
IV.72
IV.72 INTENSITY MODULATED RADIATION THERAPY (IMRT) (REQUIRES PREAUTHORIZATION)
Description
Intensity-modulated radiotherapy (IMRT) is an established technique of radiation planning and delivery that uniquely sculpts the radiation to the target volume more precisely in order to: 1) decrease the exposure in the surrounding normal tissues, thus reducing acute toxicity; and 2) increase the dose to the tumor target, thus potentially reducing local recurrence rates. With IMRT, the target volume can be treated with different fraction sizes simultaneously. A variety of delivery techniques are available. For example, the beam can be shaped as it exits a linear accelerator (linac) using a multi-leaf collimator (MLC) that blocks or "collimates" the beam to create curved edges. A computer can vary the aperture size continuously and independently for each MLC leaf pair, dividing the beam into "beamlets." IMRT has been promoted over non-modulated external beam radiation, two-dimensional (2D) and three-dimensional (3D) conformal techniques on the basis of computer planning studies that have shown better planning target volume coverage and better sparing of organs at risk.
IMRT aims radiation at the tumor from many more directions, and thus subjects more normal tissue to low-dose radiation than occurs with conventional EBRT or 3 dimensional conformal radiation therapy (3D-CRT). This may increase late effects of radiation therapy. Treatment planning and delivery are more complex, time consuming and labor-intensive for IMRT than for 3D-CRT. Clinical studies must test whether IMRT improves tumor control or reduces acute and late toxicities, when compared with 3D-CRT.
Other advanced techniques may further improve radiotherapy (RT) treatment by improving dose distribution. These techniques are considered variations of IMRT. Volumetric modulated arc therapy (VMAT) delivers radiation from a continuous rotation of the radiation source. The principal advantage of volumetric modulated arc therapy is greater efficiency in treatment delivery time, reducing radiation exposure and improving target radiation delivery due to less patient motion. Image-guided RT involves the incorporation of imaging before and/or during treatment to more precisely deliver RT to the target volume.
Dates
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Original Effective
05-31-2006
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Last Review
08-07-2024
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Next Review
08-11-2025
Policy
Related Policies
IV.76 Accelerated Irradiation Therapy, Brachytherapy, and Intraoperative Radiation Therapy
III.83 Charged Particle Radiation, Helium Ion or Proton, and Stereotactic Radiosurgery, Stereotactic Body Radiotherapy
I. Intensity Modulated Radiation Therapy (IMRT) may be considered Scientifically Validated for the following:
A. Prostate Cancer
B. Head and Neck Cancer
1. orbits
2. sinuses
3. skull base
4. aero-digestive tract within the head, neck and salivary glands
5. supraglottic laryngeal
C. Central Nervous System lesion
D. Primary Malignant Gynecologic tumors
E. Anal Cancer
F. Patient who require repeat irradiation of a field which includes the spinal cord when the same region of the spinal cord was exposed to a cumulative dose of greater than 40 Gy during prior irradiation treatment
G. Lung cancer when the following criteria are met:
1. radiotherapy is being given with curative intent AND
2. three-dimensional conformal radiotherapy will expose greater than 35% of normal lung tissue to more than a 20-Gy dose volume (V20) AND
3. IMRT dosimetry demonstrates a reduction in the V20 to at least 10% below the V20 that is achieved with the three-dimensional plan (e.g. from 40% down to 30% or lower) OR
4. If necessary to get the heart dose below 20Gy and/or to get volume of the heart that gets more than 50Gy under 25%
H. Abdominal and pelvic cancer where IMRT planning and clinical rationale demonstrates superior treatment to 3D CRT
I. Whole breast irradiation in patients receiving treatment for left sided breast cancer after breast conserving surgery when all of the following are met:
1. significant cardiac radiation exposure cannot be avoided using alternative radiation technique AND
2. IMRT dosimetry demonstrates significantly reduced cardiac target volume radiation exposure (see guidelines)
J. Individuals with large breasts when 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 using IMRT.
K. Individuals with recurrent tumors or target tissue that includes the far medial chest wall, internal mammary nodal area, or sternum, with or without intact breast.
II. Intensity Modulated Radiation Therapy (IMRT) is investigational when the above criteria are not met.
III. Intensity Modulated Radiation Therapy (IMRT) is investigational for all other diagnoses, including but not limited to:
A. Palliative treatment for lung cancer
NOTE: Volumetric modulated arc therapy (VMAT) is a form of IMRT.
Guidelines
The followiing are an example of clinical guidelines that may be used with IMRT in left-sided breast lesions:
- The target volume coverage results in cardiac radiation exposure that is expected to be greater than or equal to 25 Gy to 10 cc or more of the heart (V25 greater than or equal to 10 cc) with 3D conformal RT despite the use of a complex positioning device (such as Vac-Lok™), and
- 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 25 Gy by 3D RT is 20 cc and the volume predicted by IMRT is 16 cc or less).
Quick Code Search
Procedure
Diagnosis
Codes
Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications
Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan
Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple
Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex
Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services
Beam Radiation of Brain using Photons <1 MeV
Beam Radiation of Brain using Photons 1 - 10 MeV
Beam Radiation of Brain using Photons >10 MeV
Beam Radiation of Brain Stem using Photons <1 MeV
Beam Radiation of Brain Stem using Photons 1 - 10 MeV
Beam Radiation of Brain Stem using Photons >10 MeV
Beam Radiation of Spinal Cord using Photons <1 MeV
Beam Radiation of Spinal Cord using Photons 1 - 10 MeV
Beam Radiation of Spinal Cord using Photons >10 MeV
Beam Radiation of Bone Marrow using Photons <1 MeV
Beam Radiation of Bone Marrow using Photons 1 - 10 MeV
Beam Radiation of Bone Marrow using Photons >10 MeV
Beam Radiation of Thymus using Photons <1 MeV
Beam Radiation of Thymus using Photons 1 - 10 MeV
Beam Radiation of Thymus using Photons >10 MeV
Beam Radiation of Spleen using Photons <1 MeV
Beam Radiation of Spleen using Photons 1 - 10 MeV
Beam Radiation of Spleen using Photons >10 MeV
Beam Radiation of Neck Lymphatics using Photons <1 MeV
Beam Radiation of Neck Lymphatics using Photons 1 - 10 MeV
Beam Radiation of Neck Lymphatics using Photons >10 MeV
Beam Radiation of Axillary Lymphatics using Photons <1 MeV
Beam Radiation of Axillary Lymphatics using Photons 1 - 10 MeV
Beam Radiation of Axillary Lymphatics using Photons >10 MeV
Beam Radiation of Thorax Lymphatics using Photons <1 MeV
Beam Radiation of Thorax Lymphatics using Photons 1 - 10 MeV
Beam Radiation of Thorax Lymphatics using Photons >10 MeV
Beam Radiation of Abdomen Lymphatics using Photons <1 MeV
Beam Radiation of Abdomen Lymphatics using Photons 1 - 10 MeV
Beam Radiation of Abdomen Lymphatics using Photons >10 MeV
Beam Radiation of Pelvis Lymphatics using Photons <1 MeV
Beam Radiation of Pelvis Lymphatics using Photons 1 - 10 MeV
Beam Radiation of Pelvis Lymphatics using Photons >10 MeV
Beam Radiation of Inguinal Lymphatics using Photons <1 MeV
Beam Radiation of Inguinal Lymphatics using Photons 1 - 10 MeV
Beam Radiation of Inguinal Lymphatics using Photons >10 MeV
Beam Radiation of Eye using Photons <1 MeV
Beam Radiation of Eye using Photons 1 - 10 MeV
Beam Radiation of Eye using Photons >10 MeV
Beam Radiation of Ear using Photons <1 MeV
Beam Radiation of Ear using Photons 1 - 10 MeV
Beam Radiation of Ear using Photons >10 MeV
Beam Radiation of Nose using Photons <1 MeV
Beam Radiation of Nose using Photons 1 - 10 MeV
Beam Radiation of Nose using Photons >10 MeV
Beam Radiation of Hypopharynx using Photons <1 MeV
Beam Radiation of Hypopharynx using Photons 1 - 10 MeV
Beam Radiation of Hypopharynx using Photons >10 MeV
Beam Radiation of Mouth using Photons <1 MeV
Beam Radiation of Mouth using Photons 1 - 10 MeV
Beam Radiation of Mouth using Photons >10 MeV
Beam Radiation of Tongue using Photons <1 MeV
Beam Radiation of Tongue using Photons 1 - 10 MeV
Beam Radiation of Tongue using Photons >10 MeV
Beam Radiation of Salivary Glands using Photons <1 MeV
Beam Radiation of Salivary Glands using Photons 1 - 10 MeV
Beam Radiation of Salivary Glands using Photons >10 MeV
Beam Radiation of Sinuses using Photons <1 MeV
Beam Radiation of Sinuses using Photons 1 - 10 MeV
Beam Radiation of Sinuses using Photons >10 MeV
Beam Radiation of Hard Palate using Photons <1 MeV
Beam Radiation of Hard Palate using Photons 1 - 10 MeV
Beam Radiation of Hard Palate using Photons >10 MeV
Beam Radiation of Soft Palate using Photons <1 MeV
Beam Radiation of Larynx using Photons <1 MeV
Beam Radiation of Larynx using Photons 1 - 10 MeV
Beam Radiation of Larynx using Photons >10 MeV
Beam Radiation of Nasopharynx using Photons <1 MeV
Beam Radiation of Nasopharynx using Photons 1 - 10 MeV
Beam Radiation of Nasopharynx using Photons >10 MeV
Beam Radiation of Oropharynx using Photons <1 MeV
Beam Radiation of Oropharynx using Photons 1 - 10 MeV
Beam Radiation of Oropharynx using Photons >10 MeV
Beam Radiation of Trachea using Photons <1 MeV
Beam Radiation of Trachea using Photons 1 - 10 MeV
Beam Radiation of Trachea using Photons >10 MeV
Beam Radiation of Bronchus using Photons <1 MeV
Beam Radiation of Bronchus using Photons 1 - 10 MeV
Beam Radiation of Bronchus using Photons >10 MeV
Beam Radiation of Lung using Photons <1 MeV
Beam Radiation of Lung using Photons 1 - 10 MeV
Beam Radiation of Lung using Photons >10 MeV
Beam Radiation of Pleura using Photons <1 MeV
Beam Radiation of Pleura using Photons 1 - 10 MeV
Beam Radiation of Pleura using Photons >10 MeV
Beam Radiation of Mediastinum using Photons <1 MeV
Beam Radiation of Mediastinum using Photons 1 - 10 MeV
Beam Radiation of Mediastinum using Photons >10 MeV
Beam Radiation of Chest Wall using Photons <1 MeV
Beam Radiation of Chest Wall using Photons 1 - 10 MeV
Beam Radiation of Chest Wall using Photons >10 MeV
Beam Radiation of Diaphragm using Photons <1 MeV
Beam Radiation of Diaphragm using Photons 1 - 10 MeV
Beam Radiation of Diaphragm using Photons >10 MeV
Beam Radiation of Esophagus using Photons <1 MeV
Beam Radiation of Esophagus using Photons 1 - 10 MeV
Beam Radiation of Esophagus using Photons >10 MeV
Beam Radiation of Stomach using Photons <1 MeV
Beam Radiation of Stomach using Photons 1 - 10 MeV
Beam Radiation of Stomach using Photons >10 MeV
Beam Radiation of Duodenum using Photons <1 MeV
Beam Radiation of Duodenum using Photons 1 - 10 MeV
Beam Radiation of Duodenum using Photons >10 MeV
Beam Radiation of Jejunum using Photons <1 MeV
Beam Radiation of Jejunum using Photons 1 - 10 MeV
Beam Radiation of Jejunum using Photons >10 MeV
Beam Radiation of Ileum using Photons <1 MeV
Beam Radiation of Ileum using Photons 1 - 10 MeV
Beam Radiation of Ileum using Photons >10 MeV
Beam Radiation of Colon using Photons <1 MeV
Beam Radiation of Colon using Photons 1 - 10 MeV
Beam Radiation of Colon using Photons >10 MeV
Beam Radiation of Rectum using Photons <1 MeV
Beam Radiation of Rectum using Photons 1 - 10 MeV
Beam Radiation of Rectum using Photons >10 MeV
Beam Radiation of Liver using Photons <1 MeV
Beam Radiation of Liver using Photons 1 - 10 MeV
Beam Radiation of Liver using Photons >10 MeV
Beam Radiation of Gallbladder using Photons <1 MeV
Beam Radiation of Gallbladder using Photons 1 - 10 MeV
Beam Radiation of Gallbladder using Photons >10 MeV
Beam Radiation of Bile Ducts using Photons <1 MeV
Beam Radiation of Bile Ducts using Photons 1 - 10 MeV
Beam Radiation of Bile Ducts using Photons >10 MeV
Beam Radiation of Pancreas using Photons <1 MeV
Beam Radiation of Pancreas using Photons 1 - 10 MeV
Beam Radiation of Pancreas using Photons >10 MeV
Beam Radiation of Pituitary Gland using Photons <1 MeV
Beam Radiation of Pituitary Gland using Photons 1 - 10 MeV
Beam Radiation of Pituitary Gland using Photons >10 MeV
Beam Radiation of Pineal Body using Photons <1 MeV
Beam Radiation of Pineal Body using Photons 1 - 10 MeV
Beam Radiation of Pineal Body using Photons >10 MeV
Beam Radiation of Adrenal Glands using Photons <1 MeV
Beam Radiation of Adrenal Glands using Photons 1 - 10 MeV
Beam Radiation of Adrenal Glands using Photons >10 MeV
Beam Radiation of Parathyroid Glands using Photons <1 MeV
Beam Radiation of Parathyroid Glands using Photons 1 - 10 MeV
Beam Radiation of Parathyroid Glands using Photons >10 MeV
Beam Radiation of Thyroid using Photons <1 MeV
Beam Radiation of Thyroid using Photons 1 - 10 MeV
Beam Radiation of Thyroid using Photons >10 MeV
Beam Radiation of Face Skin using Photons <1 MeV
Beam Radiation of Face Skin using Photons 1 - 10 MeV
Beam Radiation of Face Skin using Photons >10 MeV
Beam Radiation of Neck Skin using Photons <1 MeV
Beam Radiation of Neck Skin using Photons 1 - 10 MeV
Beam Radiation of Neck Skin using Photons >10 MeV
Beam Radiation of Arm Skin using Photons <1 MeV
Beam Radiation of Arm Skin using Photons 1 - 10 MeV
Beam Radiation of Arm Skin using Photons >10 MeV
Beam Radiation of Chest Skin using Photons <1 MeV
Beam Radiation of Chest Skin using Photons 1 - 10 MeV
Beam Radiation of Chest Skin using Photons >10 MeV
Beam Radiation of Back Skin using Photons <1 MeV
Beam Radiation of Back Skin using Photons 1 - 10 MeV
Beam Radiation of Back Skin using Photons >10 MeV
Beam Radiation of Abdomen Skin using Photons <1 MeV
Beam Radiation of Abdomen Skin using Photons 1 - 10 MeV
Beam Radiation of Abdomen Skin using Photons >10 MeV
Beam Radiation of Buttock Skin using Photons <1 MeV
Beam Radiation of Buttock Skin using Photons 1 - 10 MeV
Beam Radiation of Buttock Skin using Photons >10 MeV
Beam Radiation of Leg Skin using Photons <1 MeV
Beam Radiation of Leg Skin using Photons 1 - 10 MeV
Beam Radiation of Leg Skin using Photons >10 MeV
Beam Radiation of Left Breast using Photons <1 MeV
Beam Radiation of Left Breast using Photons 1 - 10 MeV
Beam Radiation of Left Breast using Photons >10 MeV
Beam Radiation of Right Breast using Photons <1 MeV
Beam Radiation of Right Breast using Photons 1 - 10 MeV
Beam Radiation of Right Breast using Photons >10 MeV
Beam Radiation of Skull using Photons <1 MeV
Beam Radiation of Skull using Photons 1 - 10 MeV
Beam Radiation of Skull using Photons >10 MeV
Beam Radiation of Maxilla using Photons <1 MeV
Beam Radiation of Maxilla using Photons 1 - 10 MeV
Beam Radiation of Maxilla using Photons >10 MeV
Beam Radiation of Mandible using Photons <1 MeV
Beam Radiation of Mandible using Photons 1 - 10 MeV
Beam Radiation of Mandible using Photons >10 MeV
Beam Radiation of Sternum using Photons <1 MeV
Beam Radiation of Sternum using Photons 1 - 10 MeV
Beam Radiation of Sternum using Photons >10 MeV
Beam Radiation of Rib(s) using Photons <1 MeV
Beam Radiation of Rib(s) using Photons 1 - 10 MeV
Beam Radiation of Rib(s) using Photons >10 MeV
Beam Radiation of Humerus using Photons <1 MeV
Beam Radiation of Humerus using Photons 1 - 10 MeV
Beam Radiation of Humerus using Photons >10 MeV
Beam Radiation of Radius/Ulna using Photons <1 MeV
Beam Radiation of Radius/Ulna using Photons 1 - 10 MeV
Beam Radiation of Radius/Ulna using Photons >10 MeV
Beam Radiation of Pelvic Bones using Photons <1 MeV
Beam Radiation of Pelvic Bones using Photons 1 - 10 MeV
Beam Radiation of Pelvic Bones using Photons >10 MeV
Beam Radiation of Femur using Photons <1 MeV
Beam Radiation of Femur using Photons 1 - 10 MeV
Beam Radiation of Femur using Photons >10 MeV
Beam Radiation of Tibia/Fibula using Photons <1 MeV
Beam Radiation of Tibia/Fibula using Photons 1 - 10 MeV
Beam Radiation of Tibia/Fibula using Photons >10 MeV
Beam Radiation of Other Bone using Photons <1 MeV
Beam Radiation of Other Bone using Photons 1 - 10 MeV
Beam Radiation of Other Bone using Photons >10 MeV
Beam Radiation of Kidney using Photons <1 MeV
Beam Radiation of Kidney using Photons 1 - 10 MeV
Beam Radiation of Kidney using Photons >10 MeV
Beam Radiation of Ureter using Photons <1 MeV
Beam Radiation of Ureter using Photons 1 - 10 MeV
Beam Radiation of Ureter using Photons >10 MeV
Beam Radiation of Bladder using Photons <1 MeV
Beam Radiation of Bladder using Photons 1 - 10 MeV
Beam Radiation of Bladder using Photons >10 MeV
Beam Radiation of Urethra using Photons <1 MeV
Beam Radiation of Urethra using Photons 1 - 10 MeV
Beam Radiation of Urethra using Photons >10 MeV
Beam Radiation of Cervix using Photons <1 MeV
Beam Radiation of Cervix using Photons 1 - 10 MeV
Beam Radiation of Cervix using Photons >10 MeV
Beam Radiation of Uterus using Photons <1 MeV
Beam Radiation of Uterus using Photons 1 - 10 MeV
Beam Radiation of Uterus using Photons >10 MeV
Beam Radiation of Prostate using Photons <1 MeV
Beam Radiation of Prostate using Photons 1 - 10 MeV
Beam Radiation of Prostate using Photons >10 MeV
Beam Radiation of Testis using Photons <1 MeV
Beam Radiation of Testis using Photons 1 - 10 MeV
Beam Radiation of Testis using Photons >10 MeV
Beam Radiation of Head and Neck using Photons <1 MeV
Beam Radiation of Head and Neck using Photons 1 - 10 MeV
Beam Radiation of Head and Neck using Photons >10 MeV
Beam Radiation of Chest using Photons <1 MeV
Beam Radiation of Chest using Photons 1 - 10 MeV
Beam Radiation of Chest using Photons >10 MeV
Beam Radiation of Abdomen using Photons <1 MeV
Beam Radiation of Abdomen using Photons 1 - 10 MeV
Beam Radiation of Abdomen using Photons >10 MeV
Beam Radiation of Hemibody using Photons <1 MeV
Beam Radiation of Hemibody using Photons 1 - 10 MeV
Beam Radiation of Hemibody using Photons >10 MeV
Beam Radiation of Whole Body using Photons <1 MeV
Beam Radiation of Whole Body using Photons 1 - 10 MeV
Beam Radiation of Whole Body using Photons >10 MeV
Beam Radiation of Pelvic Region using Photons <1 MeV
Beam Radiation of Pelvic Region using Photons 1 - 10 MeV
Beam Radiation of Pelvic Region using Photons >10 MeV
Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session
Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session
References
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2007
National Comprehensive Cancer Network (NCCN). 2007. Clinical Practice Guidelines in Oncology™. Head and Neck Cancers - v.1.2007. Available at www.nccn.org. Last accessed February 18, 2008.
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2020
Meng, Y., Luo, W., Wang, W., et al. Intermediate dose volume parameters, not low dose bath, is superior to predict radiation pneumonitis for lung cancer treated with intensity modulated radiotherapy. Froniters in Oncology. 2020:10: 584756 |
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2019
Appel, S., Bar, J., Ben-Nun, A., et al. Campartive effectiveness of intensity modulated radiation therapy to 3 dimensional conformal radiation in locally advanced lung cancer: pathological and clinical outcomes. British Journal of Radiology (BJR). 2019;92: 20180960 |
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2017
Chun, S.G., Hu, C., Choy, H., et al. Impact of intensity modulated radiation therapy technique for locally advanced non small cell lung cancer: a secondary analysis of the NRG oncology RTOG 0617 randomized clinical trial. Journal of Clinical Oncology: 2017:35(1) |
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2013
Shirvani, S.M., Jiang, J., Gomex, D.R., et al. Intensity modulated radiotherapy for stage III non small cell lung cancer in eh United States: predictors of use and association with toxicities. Lung Cancer. 2013;82(2): doi:10.1016/j.lungcan.2013.08.015 |
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2022
National Comprehensive Cancer Network (NCCN). 2022. NCCN Guidelines: Non-Small Cell Lung Cancer. V2.2022 Available at www.nccn.org. Last accessed March 16, 2022. |
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2018
Jagsi, R., Griffith KA, Moran JM, et al. A randomized comparison of radiation therapy techniques in the management of nodepositive breast cancer: primary outcomes analysis. Int J Radiat Oncol Biol Phys. 2018 Aug 1;101(5):1149-1158. |
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2020
Meattini, I. Marrazzo, L., Saieva, C., et al. Acclerated Partial Breast Irradiation Compared with Whole Breast Irradiation for Early Breast Cancer: Long Term Results of the Randomized Phase III APBI-IMRT-Florence Trial. J Clinical Oncology. 2020; Aug 24:ICO2000650. doi: 10.1200/JCO.20.00650 |
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2019
Whelan, TJ, Julian, JA., Berrang, TS., et al. RAPID Trial Investigators. External Beam Accelerated Partial Breast Irradiation Versus Whole Breast Irradiation after Breast Conserving Surgery in Women with Ductal Carcinoma in SITU and Node Negative breast cancer: A Randomized Controlled Trial. Lancet. 2019;394(10215):2165-2172 |
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2022
Hunte SO, Clark CH, Zyuzikov N, Nisbet A. Volumetric modulated arc therapy (VMAT): a review of clinical outcomes-what is the clinical evidence for the most effective implementation? Br J Radiol. 2022 Aug 1;95(1136):20201289. doi: 10.1259/bjr.20201289. Epub 2022 Jul 4. PMID: 35616646; PMCID: PMC10162061. |
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2016
Ren W, Sun C, Lu N, Xu Y, Han F, Liu YP, Dai J. Dosimetric comparison of intensity-modulated radiotherapy and volumetric-modulated arc radiotherapy in patients with prostate cancer: a meta-analysis. J Appl Clin Med Phys. 2016 Nov 8;17(6):254-262. doi: 10.1120/jacmp.v17i6.6464. PMID: 27929498; PMCID: PMC5690508. |
Revisions
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09-25-2023
Updated description, references and added NOTE: Volumetric modulated arc therapy (VMAT) is a form of IMRT for clarification. |
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08-29-2022
Added new indication for recurrent tumors or target tissue that includes the far medial chest wall, internal mammary nodal area, or sternum; with or withot intact breast. |
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02-24-2022
Adding the indication of lung cancer with criteria |
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02-18-2020
Removed diagnosis codes attached to PCS codes |
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01-31-2020
Added 77399 |
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01-13-2015
Added new 2015 code G6015, Added new 2015 code G6016
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12-19-2014
Added new codes 77385 77386 for 2015
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02-21-2013
corrected spelling
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05-31-2012
., .
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05-30-2012
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, ., Policy criteria updated regarding use in Breast Cancer, Policy updated with Breast Cancer criteria
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04-20-2012
Database entry
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05-18-2011
Policy updated as follows:
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11-04-2009
Policy updated to include treatment of cervical, endometrial and anal cancers, CNS tumors close to the optic nerve or brain stem and repeat irradiation of fields including the spinal cord as scientifically validated.
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09-17-2008
Policy updated with minor clarifications, no change to policy intent.
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03-05-2008
Policy revised to include coverage for head and neck cancer.
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