Intensity Modulated Radiation Therapy (IMRT)
|
|
- Belinda Williams
- 5 years ago
- Views:
Transcription
1 Intensity Modulated Radiation Therapy (IMRT) Policy Number: Original Effective Date: MM /09/2004 Line(s) of Business: Current Effective Date: HMO; PPO 06/24/2011 Section: Radiology Place(s) of Service: Outpatient 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 A. IMRT is covered (subject to Limitations/Exclusions and Administrative Guidelines) for the following indications: 1. Tumors of the central nervous system, including the brain, brain stem and spinal cord. 2. Head and neck cancers defined as cancers arising from the oral cavity and lip, larynx, hypopharynx, oropharynx, nasopharynx, paranasal sinuses, nasal cavity and salivary glands. 3. Prostate cancer B. IMRT may be covered (Subject to Limitations/Exclusions and Administrative Guidelines) for other indications not listed above with precertification 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 irregularly shaped and in close proximity to critical structure(s) as documented by the dose volume histogram (DVH).
2 Intensity Modulated Radiation Therapy 2 2. The volume of interest must be covered with narrow margins to adequately protect immediately adjacent structures. 3. An immediately adjacent volume has been previously irradiated and abutting portals must be established with high precision. 4. Additional maneuvers to reduce the gross tumor volume (GTV), clinical target volume (CTV), or planning target volume (PTV) margins have proven insufficient to produce an acceptable dose distribution. 5. The target volume is concave and critical normal tissues are within that concavity 6. 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. 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 IMRT is not covered as a replacement therapy for conventional and 3-D conformal radiation therapy methods. IV. Administrative Guidelines A. Precertification is required except for the conditions in Appendix A. 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 Intensity Modulated Radiation Therapy 3 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. 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: CPT Codes Description Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specification Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session 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 Appendix A. 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. Codes that do not require precertification: ICD-9 Codes Description Malignant neoplasm of lip, oral cavity, and pharynx, code range nasal cavities of the accessory sinuses, code range
4 Intensity Modulated Radiation Therapy Larynx, code range 185 Prostate Eye, code range Brain, code range pituitary gland and craniopharyngeal duct Secondary malignant neoplasm of brain and spinal cord Benign neoplasm of cranial nerves cerebral meninges Benign neoplasm of other endocrine glands and related structures, pituitary gland and craniopharyngeal duct (pouch) pineal gland ICD-10 codes are provided for your information. These will not become effective until 10/1/2013: ICD-10 Codes C00.0-C00.9 C01 C02.0-C02.9 C03.0-C03.9 C04.0-C04.9 C05.0-C05.9 C06.0-C06.9 C07 C08.0-C08.9 C09.0-C09.9 C10.0-C10.9 C11.0-C11.9 C12 C13.0-C13.9 Description Malignant neoplasm of lip, code range Malignant neoplasm of base of tongue Malignant neoplasm of other and unspecified parts of tongue, code range Malignant neoplasm of gum, code range Malignant neoplasm of floor of mouth, code range Malignant neoplasm of hard palate, code range Malignant neoplasm of other and unspecified parts of mouth, code range Malignant neoplasm of parotid gland Malignant neoplasm of other and unspecified major salivary glands Malignant neoplasm of tonsil, code range Malignant neoplasm of oropharynx, code range Malignant neoplasm of nasopharynx, code range Malignant neoplasm of pyriform sinus Malignant neoplasm of hypopharynx, code range
5 Intensity Modulated Radiation Therapy 5 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 C32.0-C32.9 C61 C C69.92 C71.0-C71.9 Malignant neoplasm of the accessory sinuses, code range Malignant neoplasm of the larynx, code range Malignant neoplasm prostate Malignant neoplasm of eye and adnexa, code range Malignant neoplasm of brain, code range 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 V. 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
6 Intensity Modulated Radiation Therapy 6 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/ Gregoire V, De Neve W, et. al. Intensity-Modulated radiation therapy for head and neck carcinoma. The Oncologist 2007; 12; International Radiosurgery Association (IRSA). Radiosurgery Practice Guidelines for IMRT. Copyright IRSA 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): 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): 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): National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology. Breast Cancer. Version NCCN. Clinical Practice Guidelines in Oncology. Prostate Cancer.v NCCN Clinical Practice Guidelines in Oncology. Non-Small Cell Lung Cancer V NCCN Clinical Practice Guidelines in Oncology. Anal Carcinoma. Version Palmetto GBA. LCD for Intensity Modulated Radiation Therapy (IMRT) L Revision effective date 12/23/ 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): 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): 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.
Intensity Modulated Radiation Therapy (IMRT)
Intensity Modulated Radiation Therapy (IMRT) Policy Number: Original Effective Date: MM.05.006 03/09/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 03/01/2015 Section: Radiology
More informationIntensity Modulated Radiation Therapy (IMRT)
Intensity Modulated Radiation Therapy (IMRT) Policy Number: Original Effective Date: MM.05.006 03/09/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 05/01/2017 Section: Radiology
More informationStereotactic Radiosurgery and Stereotactic Body Radiation Therapy
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Policy Number: Original Effective Date: MM.05.008 05/12/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 03/01/2013 Section:
More informationCorporate Medical Policy
Corporate Medical Policy Intensity Modulated Radiation Therapy (IMRT) of Head and Neck File Name: Origination: Last CAP Review: Next CAP Review: Last Review: intensity_modulated_radiation_therapy_imrt_of_head_and_neck
More informationStereotactic Radiosurgery and Stereotactic Body Radiation Therapy
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Policy Number: Original Effective Date: MM.05.008 05/12/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 04/01/2017
More informationStereotactic Radiosurgery and Stereotactic Body Radiation Therapy
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Policy Number: Original Effective Date: MM.05.008 05/12/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 11/20/2015
More informationStereotactic Radiosurgery and Stereotactic Body Radiation Therapy
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Policy Number: Original Effective Date: MM.05.008 05/12/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 04/01/2015
More informationStereotactic Radiosurgery and Stereotactic Body Radiation Therapy
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Policy Number: Original Effective Date: MM.05.008 05/12/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 04/01/2014 Section:
More informationClinical Policy: Intensity-Modulated Radiotherapy Reference Number: CP.MP.69 Coding Implications Last Review Date: 02/18 Revision Log
Clinical Policy: Intensity-Modulated Radiotherapy Reference Number: CP.MP.69 Coding Implications Last Review Date: 02/18 Revision Log See Important Reminder at the end of this policy for important regulatory
More informationEvaluation of Whole-Field and Split-Field Intensity Modulation Radiation Therapy (IMRT) Techniques in Head and Neck Cancer
1 Charles Poole April Case Study April 30, 2012 Evaluation of Whole-Field and Split-Field Intensity Modulation Radiation Therapy (IMRT) Techniques in Head and Neck Cancer Abstract: Introduction: This study
More informationOriginal Date: April 2016 Page 1 of 7 FOR CMS (MEDICARE) MEMBERS ONLY
National Imaging Associates, Inc. Clinical guidelines STEREOTACTIC RADIATION THERAPY: STEREO RADIOSURGERY (SRS) AND STEREOTACTIC BODY RADIATION THERAPY (SBRT) CPT4 Codes: Please refer to pages 5-6 LCD
More informationThe objective of this lecture is to integrate our knowledge of the differences between 2D and 3D planning and apply the same to various clinical
The objective of this lecture is to integrate our knowledge of the differences between 2D and 3D planning and apply the same to various clinical sites. The final aim will be to be able to make out these
More informationNegative Pressure Wound Therapy (NPWT)
Negative Pressure Wound Therapy (NPWT) Policy Number: Original Effective Date: MM.01.005 11/19/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 01/01/2015 Section: DME Place(s) of Service:
More informationI. Conventional External Beam Teletherapy including 3-D Conformal Teletherapy A. Tumor Mapping and Clinical Treatment Planning
National Imaging Associates, Inc. Clinical guidelines RADIATION ONCOLOGY INCLUDING INTENSITY MODULATED RADIATION THERAPY (IMRT) CPT4 Codes: Refer to pages 21-22 LCD ID Number: L34652 J 5 = IA, KS, MO,
More informationIMRT - the physician s eye-view. Cinzia Iotti Department of Radiation Oncology S.Maria Nuova Hospital Reggio Emilia
IMRT - the physician s eye-view Cinzia Iotti Department of Radiation Oncology S.Maria Nuova Hospital Reggio Emilia The goals of cancer therapy Local control Survival Functional status Quality of life Causes
More informationA STUDY OF PLANNING DOSE CONSTRAINTS FOR TREATMENT OF NASOPHARYNGEAL CARCINOMA USING A COMMERCIAL INVERSE TREATMENT PLANNING SYSTEM
doi:10.1016/j.ijrobp.2004.02.040 Int. J. Radiation Oncology Biol. Phys., Vol. 59, No. 3, pp. 886 896, 2004 Copyright 2004 Elsevier Inc. Printed in the USA. All rights reserved 0360-3016/04/$ see front
More informationEfficient SIB-IMRT planning of head & neck patients with Pinnacle 3 -DMPO
Investigations and research Efficient SIB-IMRT planning of head & neck patients with Pinnacle 3 -DMPO M. Kunze-Busch P. van Kollenburg Department of Radiation Oncology, Radboud University Nijmegen Medical
More informationGrowth Hormone Therapy
Growth Hormone Therapy Policy Number: Original Effective Date: MM.04.011 05/21/1999 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 05/23/2014 Section: Prescription Drugs Place(s)
More informationThis LCD recognizes these two distinct treatment approaches and is specific to treatment delivery:
National Imaging Associates, Inc. Clinical guidelines STEREOTACTIC RADIOSURGERY (SRS) AND STEREOTACTIC BODY RADIATION THERAPY (SBRT) CPT4 Codes: 77371, 77372, 77373 LCD ID Number: L33410 J-N FL Responsible
More informationTorisel (temsirolimus)
Torisel (temsirolimus) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective Date: 10/01/2015 Current Effective Date: 11/1/2017 POLICY A. INDICATIONS The indications below
More informationMedical Policy An Independent Licensee of the Blue Cross and Blue Shield Association
Intensity Modulated Radiation Therapy (IMRT) Page 1 of 19 Medical Policy An Independent Licensee of the Blue Cross and Blue Shield Association Title: See also: Intensity Modulated Radiation Therapy (IMRT)
More informationCorporate Medical Policy
Corporate Medical Policy Intensity Modulated Radiation Therapy (IMRT) of Abdomen and File Name: Origination: Last CAP Review: Next CAP Review: Last Review: intensity_modulated_radiation_therapy_imrt_of_abdomen_and_pelvis
More informationSomatuline Depot (lanreotide)
Somatuline Depot (lanreotide) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date: 10/01/2015 Current Effective Date: 12/01/2017TBD POLICY A. INDICATIONS The indications
More informationA VMAT PLANNING SOLUTION FOR NECK CANCER PATIENTS USING THE PINNACLE 3 PLANNING SYSTEM *
Romanian Reports in Physics, Vol. 66, No. 2, P. 401 410, 2014 A VMAT PLANNING SOLUTION FOR NECK CANCER PATIENTS USING THE PINNACLE 3 PLANNING SYSTEM * M. D. SUDITU 1,2, D. ADAM 1,2, R. POPA 1,2, V. CIOCALTEI
More informationCorporate Medical Policy
Corporate Medical Policy Intensity-Modulated Radiation Therapy (IMRT) of the Prostate File Name: Origination: Last CAP Review: Next CAP Review: Last Review: intensity_modulated_radiation_therapy_imrt_of_the_prostate
More informationNIA MAGELLAN HEALTH RADIATION ONCOLOGY CODING STANDARD. Dosimetry Planning
NIA MAGELLAN HEALTH RADIATION ONCOLOGY CODING STANDARD Dosimetry Planning CPT Codes: 77295, 77300, 77301, 77306, 77307, 77321, 77316, 77317, 77318, 77331, 77399 Original Date: April, 2011 Last Reviewed
More informationIntensity Modulated Radiation Therapy (IMRT): Cancer of the Head and Neck or Thyroid. Original Policy Date
MP 8.01.26 Intensity Modulated Radiation Therapy (IMRT): Cancer of the Head and Neck or Thyroid Medical Policy Section Therapy Issue 12/2013 Original Policy Date 12/2013 Last Review Status/Date Reviewed
More informationPositive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea
Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea Policy Number: Original Effective Date: MM.01.009 11/01/2009 Line(s) of Business: Current Effective Date: HMO; PPO
More informationBevacizumab (Avastin)
Bevacizumab (Avastin) Policy Number: Original Effective Date: MM.04.001 09/14/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 03/01/2014 Section: Prescription Drugs Place(s) of Service:
More informationBortezomib (Velcade)
Bortezomib (Velcade) Policy Number: Original Effective Date: MM.04.003 03/09/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 06/01/2015 Section: Prescription Drugs Place(s)
More informationErythropoiesis Stimulating Agents (ESA)
Erythropoiesis Stimulating Agents (ESA) Policy Number: Original Effective Date: MM.04.008 04/15/2007 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 06/01/2015 Section: Prescription
More informationBariatric Surgery MM /11/2001. HMO; PPO; QUEST 05/01/2012 Section: Surgery Place(s) of Service: Outpatient; Inpatient
Bariatric Surgery Policy Number: Original Effective Date: MM.06.003 09/11/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 05/01/2012 Section: Surgery Place(s) of Service: Outpatient;
More informationPerjeta (pertuzumab)
Perjeta (pertuzumab) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective Date: 10/01/2015 Current Effective Date: 01/01/201809/16/2018 POLICY A. INDICATIONS The indications
More informationPositive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea
Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea Policy Number: Original Effective Date: MM.01.009 11/01/2009 Line(s) of Business: Current Effective Date: HMO; PPO;
More informationKyphoplasty and Vertebroplasty
Kyphoplasty and Vertebroplasty Policy Number: Original Effective Date: MM.06.007 01/11/2005 Line(s) of Business: Current Effective Date: HMO; PPO 02/01/2012 Section: Surgery Place(s) of Service: Inpatient;
More informationInsulin Pumps - External
Insulin Pumps - External Policy Number: Original Effective Date: MM.01.004 04/01/2011 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 04/01/20174/1/2018 Section: DME Place(s) of
More informationCLINICAL MEDICATION POLICY
CLINICAL MEDICATION POLICY Policy Name: Opdivo (nivolumab) injection Policy Number: Approved By: Medical Management, Clinical Pharmacy Products: Highmark Health Options Application: All participating hospitals
More informationEvaluation of Three-dimensional Conformal Radiotherapy and Intensity Modulated Radiotherapy Techniques in High-Grade Gliomas
1 Carol Boyd Comprehensive Case Study July 11, 2013 Evaluation of Three-dimensional Conformal Radiotherapy and Intensity Modulated Radiotherapy Techniques in High-Grade Gliomas Abstract: Introduction:
More informationInternational Multispecialty Journal of Health (IMJH) ISSN: [ ] [Vol-3, Issue-9, September- 2017]
Dosimetric evaluation of carcinoma nasopharynx using Volumetric Modulated Arc Therapy (VMAT): An institutional experience from Western India Dr. Upendra Nandwana 1, Dr. Shuchita Pathak 2, Dr. TP Soni 3,
More informationIntensity Modulated Radiation Therapy (IMRT): Central Nervous System Tumors. Original Policy Date
MP 8.01.36 Intensity Modulated Radiation Therapy (IMRT): Central Nervous System Tumors Medical Policy Section Therapy Issue 12/2013 Original Policy Date 12/2013 Last Review Status/Date Created with literature
More informationTHE TRANSITION FROM 2D TO 3D AND TO IMRT - RATIONALE AND CRITICAL ELEMENTS
THE TRANSITION FROM 2D TO 3D AND TO IMRT - RATIONALE AND CRITICAL ELEMENTS ICTP SCHOOL ON MEDICAL PHYSICS FOR RADIATION THERAPY DOSIMETRY AND TREATMENT PLANNING FOR BASIC AND ADVANCED APPLICATIONS March
More informationPosterior Tibial Nerve Stimulation
Posterior Tibial Nerve Stimulation Policy Number: Original Effective Date: MM.02.025 01/01/2015 Lines of Business: Current Effective Date: HMO; PPO; QUEST Integration 02/01/2015 Section: Medicine Place(s)
More informationContinuous Glucose Monitoring System
Continuous Glucose Monitoring System Policy Number: Original Effective Date: MM.02.003 03/13/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 4/1/2018 Section: DME Place(s)
More informationGazyva (obinutuzumab)
Gazyva (obinutuzumab) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective Date: 10/01/2015 Current Effective Date: 01/01/201807/01/2018 POLICY A. INDICATIONS The indications
More informationDefining Target Volumes and Organs at Risk: a common language
Defining Target Volumes and Organs at Risk: a common language Eduardo Rosenblatt Section Head Applied Radiation Biology and Radiotherapy (ARBR) Section Division of Human Health IAEA Objective: To introduce
More informationTorisel (temsirolimus)
Torisel (temsirolimus) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date: 10/01/2015 Current Effective Date: 11/01/2017TBD03/01/2017 POLICY A. INDICATIONS The indications
More informationPRIOR AUTHORIZATION Prior authorization is recommended and obtained via the online tool for participating providers.
Medical Coverage Policy Intensity-Modulated Radiotherapy: Central Nervous System Tumors EFFECTIVE DATE: 02 15 2016 POLICY LAST UPDATED: 09 05 2017 OVERVIEW Radiotherapy (RT) is an integral component in
More informationOxygen and Oxygen Equipment
Oxygen and Oxygen Equipment Policy Number: Original Effective Date: MM.01.008 12/01/2010 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 09/01/2013 Section: DME Place(s) of Service: Home I.
More informationContinuous Glucose Monitoring System
Continuous Glucose Monitoring System Policy Number: Original Effective Date: MM.02.003 03/13/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 04/01/2016 Section: DME Place(s)
More informationCancer in Estonia 2014
Cancer in Estonia 2014 Estonian Cancer Registry (ECR) is a population-based registry that collects data on all cancer cases in Estonia. More information about ECR is available at the webpage of National
More information3/25/15. Guidance Number: MCG-225 Revision Date(s):
Subject: Intensity Modulated Radiation Therapy (IMRT) Original Effective Date: 3/25/15 Guidance Number: MCG-225 Revision Date(s): DESCRIPTION OF PROCEDURE/SERVICE/PHARMACEUTICAL Intensity-modulated radiation
More informationContinuous Glucose Monitoring System
Continuous Glucose Monitoring System Policy Number: Original Effective Date: MM.02.003 03/13/2001 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 04/01/2017 Section: DME Place(s)
More informationCancer Association of South Africa (CANSA)
Cancer Association of South Africa (CANSA) Fact Sheet on ICD-10 Coding of Neoplasms Introduction The International Statistical Classification of Diseases and Related Health Problems, 10 th Revision (ICD-10)
More informationPolysomnography and Sleep Studies
Polysomnography and Sleep Studies Policy Number: Original Effective Date: MM.02.016 09/14/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 05/01/2014 Section: Medicine Place(s)
More informationProtocol. Intensity-Modulated Radiation Therapy (IMRT): Cancer of the Head and Neck or Thyroid
Intensity-Modulated Radiation Therapy (IMRT): Cancer of the (80148) Medical Benefit Effective Date: 01/01/14 Next Review Date: 03/15 Preauthorization No Review Dates: 09/09, 09/10, 03/11, 03/12, 09/12,
More informationVelcade (bortezomib)
Velcade (bortezomib) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date: 03/09/2004 Current Effective Date: 05/01/2017 POLICY A. INDICATIONS The indications below
More informationApplied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder
Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder Policy Number: Original Effective Date: MM.12.022 01/01/2016 Line(s) of Business: Current Effective Date: HMO; PPO; Fed 87; FEP;
More informationOxygen and Oxygen Equipment
Oxygen and Oxygen Equipment Policy Number: Original Effective Date: MM.01.008 12/01/2010 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 08/25/2017 Section: DME Place(s) of Service:
More informationOriginal Article. Teyyiba Kanwal, Muhammad Khalid, Syed Ijaz Hussain Shah, Khawar Nadeem
Original Article Treatment Planning Evaluation of Sliding Window and Multiple Static Segments Technique in Intensity Modulated Radiotherapy for Different Beam Directions Teyyiba Kanwal, Muhammad Khalid,
More informationSubject: Image-Guided Radiation Therapy
04-77260-19 Original Effective Date: 02/15/10 Reviewed: 01/25/18 Revised: 01/01/19 Subject: Image-Guided Radiation Therapy THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION
More informationVelcade (bortezomib)
Velcade (bortezomib) Line(s) of Business: HMO; PPO; QUEST Integration Medicare Advantage Original Effective Date: 03/09/2004 Current Effective Date: 03/01/2018 POLICY A. INDICATIONS The indications below
More informationMeasurement of Dose to Critical Structures Surrounding the Prostate from. Intensity-Modulated Radiation Therapy (IMRT) and Three Dimensional
Measurement of Dose to Critical Structures Surrounding the Prostate from Intensity-Modulated Radiation Therapy (IMRT) and Three Dimensional Conformal Radiation Therapy (3D-CRT); A Comparative Study Erik
More informationLow-Molecular-Weight Heparin
Low-Molecular-Weight Heparin Policy Number: Original Effective Date: MM.04.019 10/15/2007 Line(s) of Business: Current Effective Date: HMO; PPO 10/28/2011 Section: Prescription Drugs Place(s) of Service:
More informationPopulations Interventions Comparators Outcomes Individuals: With head and neck cancer. Comparators of interest are: 3-dimensional conformal
Intensity-Modulated Radiotherapy: Cancer of the Head and (80148) Medical Benefit Effective Date: 07/01/15 Next Review Date: 03/19 Preauthorization No Review Dates: 09/09, 09/10, 03/11, 03/12, 09/12, 09/13,
More informationA TREATMENT PLANNING STUDY COMPARING VMAT WITH 3D CONFORMAL RADIOTHERAPY FOR PROSTATE CANCER USING PINNACLE PLANNING SYSTEM *
Romanian Reports in Physics, Vol. 66, No. 2, P. 394 400, 2014 A TREATMENT PLANNING STUDY COMPARING VMAT WITH 3D CONFORMAL RADIOTHERAPY FOR PROSTATE CANCER USING PINNACLE PLANNING SYSTEM * D. ADAM 1,2,
More informationProphylactic Mastectomy
Prophylactic Mastectomy Policy Number: Original Effective Date: MM.06.010 01/01/2009 Line(s) of Business: Current Effective Date: HMO; PPO 07/22/2011 Section: Surgery Place(s) of Service: Inpatient I.
More informationProtocol. Intensity-Modulated Radiation Therapy (IMRT): Central Nervous System Tumors
Intensity-Modulated Radiation Therapy (IMRT): Central Nervous (80159) Medical Benefit Effective Date: 03/01/14 Next Review Date: 03/15 Preauthorization No Review Dates: 07/12, 07/13, 03/14 The following
More informationTreatment Planning Evaluation of Volumetric Modulated Arc Therapy (VMAT) for Craniospinal Irradiation (CSI)
Treatment Planning Evaluation of Volumetric Modulated Arc Therapy (VMAT) for Craniospinal Irradiation (CSI) Tagreed AL-ALAWI Medical Physicist King Abdullah Medical City- Jeddah Aim 1. Simplify and standardize
More informationPage 1. Helical (Spiral) Tomotherapy. UW Helical Tomotherapy Unit. Helical (Spiral) Tomotherapy. MVCT of an Anesthetized Dog with a Sinus Tumor
Helical (Spiral) Tomotherapy Novel Clinical Applications of IMRT Linac Ring Gantry CT Detector X-Ray Fan Beam Binary Multileaf Collimator Binary MLC Leaves James S Welsh, MS, MD Department of Human Oncology
More informationDosimetric Comparison of Intensity-Modulated Radiotherapy versus 3D Conformal Radiotherapy in Patients with Head and Neck Cancer
Dosimetric Comparison of Intensity-Modulated Radiotherapy versus 3D Conformal Radiotherapy in Patients with Head and Neck Cancer 1- Doaa M. AL Zayat. Ph.D of medical physics, Ayadi-Al Mostakbl Oncology
More informationIntensity-Modulated Radiation Therapy (IMRT): Head, Neck, Thyroid and Brain Cancers
Intensity-Modulated Radiation Therapy (IMRT): Head, Neck, Thyroid and Brain Cancers Policy Number: 8.01.48 Last Review: 11/2013 Origination: 11/2009 Next Review: 11/2014 Policy Blue Cross and Blue Shield
More informationHIGHMARK RADIATION THERAPY AUTHORIZATION PROGRAM
HIGHMARK RADIATION THERAPY AUTHORIZATION PROGRAM ADMINISTRATIVE GUIDE Program effective with service dates beginning January 1, 2012 2011-2016 Highmark Inc. All rights reserved. TABLE OF CONTENTS IN THIS
More informationApplied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder
Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder Policy Number: Original Effective Date: MM.12.022 01/01/2016 Line(s) of Business: Current Effective Date: HMO; PPO; Fed 87; FEP;
More informationTreatment of exceptionally large prostate cancer patients with low-energy intensity-modulated photons
JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS, VOLUME 7, NUMBER 4, FALL 2006 Treatment of exceptionally large prostate cancer patients with low-energy intensity-modulated photons Mei Sun and Lijun Ma a University
More informationPotential benefits of intensity-modulated proton therapy in head and neck cancer van de Water, Tara Arpana
University of Groningen Potential benefits of intensity-modulated proton therapy in head and neck cancer van de Water, Tara Arpana IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's
More informationRisk of a second cancer after radiotherapy
Risk of a second cancer after radiotherapy Francesco d Errico University of Pisa, Italy Yale University, USA Medical radiological procedures worldwide 2.5 billion diagnostic radiological examinations 78%
More informationAlimta (pemetrexed) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage
Alimta (pemetrexed) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date: 09/01/2007 Current Effective Date: TBD003/01/201703/01/2018 POLICY A. INDICATIONS The indications
More informationWhat is head and neck cancer? How is head and neck cancer diagnosed and evaluated? How is head and neck cancer treated?
Scan for mobile link. Head and Neck Cancer Head and neck cancer is a group of cancers that start in the oral cavity, larynx, pharynx, salivary glands, nasal cavity or paranasal sinuses. They usually begin
More informationHead and Neck Service
Head and Neck Service University of California, San Francisco, Department of Radiation Oncology Residency Training Program Head and Neck and Thoracic Service Educational Objectives for PGY-5 Residents
More informationNCCN GUIDELINES ON PROTON THERAPY (AS OF 4/23/18) BONE (Version , 03/28/18)
BONE (Version 2.2018, 03/28/18) NCCN GUIDELINES ON PROTON THERAPY (AS OF 4/23/18) Radiation Therapy Specialized techniques such as intensity-modulated RT (IMRT); particle beam RT with protons, carbon ions,
More informationModel Policy. Coverage of Proton Therapy
Model Policy Coverage of Proton Therapy Last Revised - February 2019 INTRODUCTION Proton therapy is a technologically advanced method to deliver curative radiation doses to cancerous tumors. The unique
More informationArtificial Disc Replacement, Cervical
Artificial Disc Replacement, Cervical Policy Number: Original Effective Date: MM.06.001 02/01/2010 Line(s) of Business: Current Effective Date: HMO; PPO 11/01/2011 Section: Surgery Place(s) of Service:
More informationProtons for Head and Neck Cancer. William M Mendenhall, M.D.
Protons for Head and Neck Cancer William M Mendenhall, M.D. Protons for Head and Neck Cancer Potential Advantages: Reduce late complications via more conformal dose distributions Likely to be the major
More informationHead and Neck Service
Head and Neck Service University of California, San Francisco, Department of Radiation Oncology Residency Training Program Head and Neck and Thoracic Service Educational Objectives for PGY-3 Residents
More informationPolysomnography - Sleep Studies
Polysomnography - Sleep Studies Policy Number: Original Effective Date: MM.02.016 09/14/2004 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST 12/21/2012 Section: Medicine Place(s) of Service:
More informationOPTIMIZATION OF COLLIMATOR PARAMETERS TO REDUCE RECTAL DOSE IN INTENSITY-MODULATED PROSTATE TREATMENT PLANNING
Medical Dosimetry, Vol. 30, No. 4, pp. 205-212, 2005 Copyright 2005 American Association of Medical Dosimetrists Printed in the USA. All rights reserved 0958-3947/05/$ see front matter doi:10.1016/j.meddos.2005.06.002
More informationChapter 2. Level II lymph nodes and radiation-induced xerostomia
Chapter 2 Level II lymph nodes and radiation-induced xerostomia This chapter has been published as: E. Astreinidou, H. Dehnad, C.H. Terhaard, and C.P Raaijmakers. 2004. Level II lymph nodes and radiation-induced
More informationCURRICULUM OUTLINE FOR TRANSITIONING FROM 2-D RT TO 3-D CRT AND IMRT
CURRICULUM OUTLINE FOR TRANSITIONING FROM 2-D RT TO 3-D CRT AND IMRT Purpose The purpose of this curriculum outline is to provide a framework for multidisciplinary training for radiation oncologists, medical
More informationCyramza (ramucirumab)
Cyramza (ramucirumab) Line(s) of Business: HMO; PPO; QUEST Integration Akamai Advantage Original Effective Date: 10/01/2015 Current Effective Date: 03/01/2017TBD03/01/2018 POLICY A. INDICATIONS The indications
More informationLung-Volume Reduction Surgery ARCHIVED
Lung-Volume Reduction Surgery ARCHIVED Policy Number: Original Effective Date: MM.06.008 04/15/2005 Line(s) of Business: Current Effective Date: PPO; HMO; QUEST 03/22/2013 Section: Surgery Place(s) of
More informationRadiotherapy and tumours in veterinary practice: part one
Vet Times The website for the veterinary profession https://www.vettimes.co.uk Radiotherapy and tumours in veterinary practice: part one Author : Aleksandra Marcinowska, Jane Dobson Categories : Companion
More informationPembrolizumab (Keytruda )
Last Review Date: March 14, 2017 Number: MG.MM.PH.10f Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth
More informationRadiologic Therapeutic Procedures
Coverage Summary Radiologic Therapeutic Procedures Policy Number: R-003 Products: UnitedHealthcare Medicare Advantage Plans Original Approval Date: 04/02/2008 Approved by: UnitedHealthcare Medicare Benefit
More informationIntensity-Modulated Radiotherapy (IMRT): Central Nervous System Tumors
Intensity-Modulated Radiotherapy (IMRT): Central Nervous System Tumors Policy Number: 8.01.59 Last Review: 06/2018 Origination: 06/2013 Next Review: 06/2019 Policy Blue Cross and Blue Shield of Kansas
More informationSpecification of Tumor Dose. Prescription dose. Purpose
Specification of Tumor Dose George Starkschall, Ph.D. Department of Radiation Physics U.T. M.D. Anderson Cancer Center Prescription dose What do we mean by a dose prescription of 63 Gy? Isocenter dose
More informationHome Total Parenteral Nutrition for Adults
Home Total Parenteral Nutrition for Adults Policy Number: Original Effective Date: MM.08.007 05/21/1999 Line(s) of Business: Current Effective Date: PPO, HMO, QUEST Integration 05/27/2016 Section: Home
More informationDose prescription, reporting and recording in intensity-modulated radiation therapy: a digest of the ICRU Report 83
Special report Dose prescription, reporting and recording in intensity-modulated radiation therapy: a digest of the ICRU Report 83 Rapid development in imaging techniques, including functional imaging,
More informationREVISITING ICRU VOLUME DEFINITIONS. Eduardo Rosenblatt Vienna, Austria
REVISITING ICRU VOLUME DEFINITIONS Eduardo Rosenblatt Vienna, Austria Objective: To introduce target volumes and organ at risk concepts as defined by ICRU. 3D-CRT is the standard There was a need for a
More information