CurrentAetnaPolicy 0590

Intensity Modulated Radiation Therapy

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Defines Aetna's clinical policy on when IMRT (including placement of fiducial markers and image-guidance) is considered medically necessary, lists applicable CPT/HCPCS/ICD-10 codes, and provides background/evidence discussion for various tumor sites. This is part 1 of 3 and contains policy statements, code lists, and background evidence summaries.

Policy Summary

PayerAetna

PolicyIntensity Modulated Radiation Therapy

Policy CodePolicy 0590

Change TypeNo material change

Effective DateFeb 12, 2002

Last ReviewSep 7, 2023

Next Review DateJun 27, 2024

Key ActionFor medical necessity criteria, providers must follow eviCore Healthcare Radiation Therapy Clinical Guidelines; eviCore guidelines determine specific indications and selection criteria for IMRT.

SourceLink

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CurrentAetnaPolicy 0590

Intensity Modulated Radiation Therapy

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Policy Summary

PayerAetna

PolicyIntensity Modulated Radiation Therapy

Policy CodePolicy 0590

Change TypeNo material change

Effective DateFeb 12, 2002

Last ReviewSep 7, 2023

Next Review DateJun 27, 2024

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes reported in this policy update.

3Key medical necessity items (IMRT, fiducials, image guidance)

12Listed Medically Necessary Indications

9Listed CPT/HCPCS codes in Part 1

2ICD-10 code groups listed

1Not Medically Necessary Indication (right breast)

1Dose threshold references (>50 Gy)

Coverage Summary

Policy 0590 (effective 02/12/2002; last reviewed 09/07/2023; next review 06/27/2024) covers Intensity‑Modulated Radiation Therapy (IMRT) and related services. The policy stance is covered with criteria: IMRT (and placement of fiducial markers or use of inter-/intrafraction image guidance) is medically necessary only when specified selection criteria are met. Key threshold definitions include: IMRT is defined as radiation therapy requiring highly sophisticated planning using numerous beamlets to meet dose requirements to tumor and organs at risk; and a critical‑structure benefit is present when IMRT would reduce the probability of grade 2 or 3 radiation toxicity versus 3D CRT in greater than 15% of similar cases. Dose thresholds for certain sites are specified (e.g., esophagus, gallbladder, pancreas: planned dose > 50 Gy).

Key thresholds and definitions

Policy number0590

PayerAetna

Definition of IMRT critical-structure benefit thresholdIMRT would decrease the probability of grade 2 or grade 3 radiation toxicity vs 3D CRT in greater than 15% of similar cases

Dose threshold for esophageal/gallbladder/pancreatic indications> 50 Gy

IMRT definition (planning requirement)Radiation therapy requiring highly sophisticated treatment planning utilizing numerous beamlets to generate dosimetry per assigned dose requirements to tumor and organs at risk

Medical-Necessity Criteria

Medical Necessity

Aetna considers the following interventions medically necessary:

Medical Necessity - required items

IMRT requirement: Intensity modulated radiation therapy (IMRT) for certain indications where critical structures cannot be adequately protected with standard 3-dimensional (3D) conformal radiotherapy
Policy statement
Fiducial markers: Placement of fiducial markers if the above criteria are met, and the radiation target is not clearly visible, and bony anatomy is not sufficient for adequate target alignment
Placement permitted only if IMRT criteria are met
Image guidance: Interfraction image guidance or intrafraction image guidance systems (e.g., Calypso 4D Localization System, RayPilot System) for delivering IMRT and other conformal radiotherapy

Not Medically Necessary / Experimental

Exclusions: IMRT is considered experimental, investigational, and not medically necessary for the following:

Not medically necessary / experimental

Right breast: IMRT is considered experimental and not medically necessary for right breast cancer
Other indications not listed: IMRT is considered experimental and investigational for all other indications not listed as medically necessary

Coding

Covered CPT codes if selection criteria are metCPTCovered

32553	Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-thoracic, single or multiple.
49327	Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple (List separately in addition to code for primary procedure).
49411	Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple.
49412	Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), open, intra-abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if performed, single or multiple (List separately in addition to code for primary procedure).
77301	Intensity modulated radiotherapy planning, including dose-volume histograms for target and critical structure partial tolerance specifications.
77338	Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (MRT), design and construction per IMRT plan.
77385	Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed.
77386	Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed.
77387	Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed.

Covered HCPCS codes if selection criteria are metHCPCSCovered

A4648	Tissue marker, implantable, any type, each.
C9728	Placement of interstitial device(s) for radiation therapy/surgery guidance (eg, fiducial markers, dosimeter), for other than the following sites (any approach): abdomen, pelvis, prostate, retroperitoneum, thorax, single or multiple.
G6015	Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session.
G6016	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.
G6017	Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment.

Covered ICD-10 codes if selection criteria are metICD-10Covered

C00.0-D49.9	Neoplasms (range)
Z51.0	Encounter for antineoplastic radiation therapy

No procedure/diagnosis codes listed in this partmixed

No codes listed

Provider Actions

Prior Authorization

Medical necessity requirement

IMRT is authorized only for the indications listed as medically necessary in the policy. Providers must document why IMRT is required for the case — e.g., proximity of the target to critical structures, prior irradiation requiring abutting portals, need for dose escalation, concave/complex target geometry, or other rationale demonstrating that 3D CRT cannot adequately protect critical structures.

Documentation Required

Apply eviCore radiation therapy clinical guidelines

Follow eviCore Healthcare Radiation Therapy Clinical Guidelines for medical necessity criteria. eviCore determines the specific indications and selection criteria for IMRT and is the reference for prior authorization decisions.

Documentation Required

Background & Evidence

Background: IMRT is a highly sophisticated radiotherapy technique that uses inverse planning and numerous beamlets to produce highly conformal dose distributions that spare adjacent organs at risk. Delivery approaches include dynamic multileaf collimators (MLCs) that modulate beam intensity during treatment and compensator‑based techniques that use custom high‑density modulators to shape the beam. Fiducial markers (e.g., gold seeds, stainless steel screws, or electromagnetic transponders) may be implanted to improve target localization when the target is not clearly visible and bony anatomy is insufficient. Potential benefits include improved critical‑structure sparing and the ability to escalate dose or treat complex/concave targets; potential risks include increased whole‑body or low‑dose exposure with theoretical higher secondary malignancy risk, the possibility of geographic miss with overly tight margins, and added imaging exposure from frequent image guidance. Because IMRT planning and delivery are technically demanding, appropriate expertise, image‑guidance, and quality assurance are required and some uses are recommended to be limited to experienced centers.

Study/Guidance	Key finding
KCE assessment (Van den Steen et al, 2007)	Found weak-to-moderate evidence of toxicity reduction in head/neck, prostate, breast; recommended restriction to experienced centers and need for more long-term data; noted potential increased secondary malignancy risk.
Pignol et al (2008) — RCT in breast cancer	BIMRT reduced acute skin toxicity (moist desquamation) compared with wedge compensation.
Donovan et al (2007) — RCT in breast cancer	BIMRT associated with fewer late adverse effects and better cosmetic outcomes versus wedge compensation/2D RT.
Romesser et al (2021) — prospective phase II, thyroid cancer	IMRT ± concurrent doxorubicin showed 2-year locoregional PFS 79.7%; CC-IMRT had less locoregional failure in post-hoc analysis but small nonrandomized sample (n=27).
Wu et al (2022) — phase II neoadjuvant IMRT in centrally located HCC	Promising 1-, 3-, 5-year OS (94.6%, 75.4%, 69.1%) with acceptable toxicity in single-arm trial (n=38).
ASTRO coding guide / expert panels	Lists common indications supporting IMRT (prostate, CNS, head/neck, select breast, selected thoracic/abdominal, pelvic/retroperitoneal tumors) and clinical planning considerations.

Definitions

Definitions (policy terms)

IMRTFor this policy, radiation therapy requiring highly sophisticated treatment planning utilizing numerous beamlets to generate dosimetry in accordance with assigned dose requirements to the tumor and organs at risk.

IGRTImage-guided radiation therapy, which may include CT, MRI, ultrasound, or X-ray used to direct and guide delivery of radiation (used for planning, setup verification/correction, and follow-up).

Critical structures inadequately protectedSituations where IMRT would decrease probability of grade 2 or grade 3 radiation toxicity vs 3D CRT in >15% of similar cases.

Revision History

Policy Summary

PayerAetna

PolicyIntensity Modulated Radiation Therapy

Policy CodePolicy 0590

Change TypeNo material change

Effective DateFeb 12, 2002

Last ReviewSep 7, 2023

Next Review DateJun 27, 2024

SourceLink

On This Page

Includes systems for continuous intrafraction tracking

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Medically Necessary Indications (Appendix)

IMRT is medically necessary for the following disease-site specific indications when concern exists about damage to surrounding critical structures compared with external beam or 3D conformal radiotherapy:

Medically necessary indications (appendix)

Anal cancer
Anaplastic thyroid cancer
Brain tumors near critical structures: Brain tumors in close proximity to critical structures
Esophageal cancer (dose): Esophageal cancer> 50 Gy
Dose must exceed 50 Gy
Gallbladder cancer (dose): Gallbladder cancer> 50 Gy
Dose must exceed 50 Gy
Head and neck cancer excluding T1/T2 glottic: Head and neck cancer excluding T1 and T2 glottic cancer
Left breast near heart: Left breast cancer if the lesion is in close proximity to the heart or other cardiovascular structures, where 3D CRT would exceed acceptable constraints
Document proximity to heart/cardiovascular structures
Lung cancer near critical structures: Lung cancer if the lesion is in close proximity to the heart or other critical structures
Pancreatic cancer (dose): Pancreatic cancer> 50 Gy
Dose must exceed 50 Gy
Postoperative pelvic radiation for endometrial cancer: Postoperative radiation to pelvis for endometrial cancer
Prostate cancer
T4 rectal cancer with nodal chains: T4 rectal cancer where the treating volume incorporates the external iliac and inguinal lymph node chains

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Clinical Indications/Considerations (ASTRO coding guide summary)

Situational clinical indications (per ASTRO coding guide) where IMRT planning may be clinically indicated include one or more of the following:

Clinical indications/considerations

Prior adjacent irradiation: An immediately adjacent area has been previously irradiated and abutting portals must be established with high precision
Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors with conventional treatment
Concave/convex target geometry: The target volume is concave or convex, and the critical normal tissues are within or around that convexity or concavity
Proximity to critical structures: The target volume is in close proximity to critical structures that must be protected
Narrow margins required: The volume of interest must be covered with narrow margins to adequately protect immediately adjacent structures

Tumor sites commonly supporting IMRT (ASTRO list)

Sites most commonly supporting the use of IMRT (ASTRO list) include any of the following:

Tumor sites commonly supporting IMRT

Prostate carcinoma: Carcinoma of the prostate
CNS tumors: Primary, metastatic or benign tumors of the central nervous system, including the brain, brain stem, and spinal cord
Spine tumors: Primary, metastatic tumors of the spine where spinal cord tolerance may be exceeded by conventional treatment
Head and neck lesions: Primary, metastatic or benign lesions to the head and neck area (aerodigestive tract, orbits, salivary glands, sinuses, skull base)
Re-irradiation that meets requirements for medical necessity (as noted above)
Selected thoracic/abdominal malignancies: Selected thoracic and abdominal malignancies
Selected breast cancers with close proximity to critical structures
Pelvic and retroperitoneal tumors: Other pelvic and retroperitoneal tumors that meet requirements for medical necessity

Justify fiducial marker placement

Placement of fiducial markers is permitted only when IMRT medical necessity criteria are met and when the radiation target is not clearly visible and bony anatomy is insufficient for adequate target alignment. Document the clinical justification and include the applicable procedure codes.

Documentation Required

Use of image guidance with IMRT

Interfraction and intrafraction image-guidance systems used with IMRT (e.g., Calypso, RayPilot) are considered medically necessary when delivering IMRT or other conformal radiotherapy that meets policy criteria. Document use of tracking/localization per fraction and report applicable guidance codes (e.g., G6017, 77387) where performed.

Documentation Required

Dose and anatomic rationale

For indications that depend on dose or anatomy, document the planned dose or anatomic relationship: for esophagus, gallbladder, or pancreas, record that the planned dose exceeds 50 Gy; for left-breast cases, document the lesion's proximity to the heart or cardiovascular structures and that 3D CRT constraints would be exceeded.

Note

Refer to full policy for coverage criteria and billing

Consult the complete Aetna Clinical Policy Bulletin 0590 for the full coverage criteria, prior authorization requirements, documentation expectations, and detailed coding information before submission or billing.