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 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).
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.
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: http://www.cms.hhs.gov/nationalcorrectcodinited/ 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 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 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
Intensity Modulated Radiation Therapy 4 161.0-161.9 Larynx, code range 185 Prostate 190.0-190.9 Eye, code range 191.0-191.9 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 225.2 cerebral meninges 227.3 Benign neoplasm of other endocrine glands and related structures, pituitary gland and craniopharyngeal duct (pouch) 227.4 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
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 C69.00- 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
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 04/01/08. 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):238-248. 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 2.2011 8. NCCN. Clinical Practice Guidelines in Oncology. Prostate Cancer.v.1.2011 9. NCCN Clinical Practice Guidelines in Oncology. Non-Small Cell Lung Cancer V.2011 10. NCCN Clinical Practice Guidelines in Oncology. Anal Carcinoma. Version 1.2011 11. Palmetto GBA. LCD for Intensity Modulated Radiation Therapy (IMRT) L28272. Revision effective date 12/23/2010 12. 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. 13. 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. 14. 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.