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CurrentAlliance HealthPolicy 1K-6

Radiation Oncology (NC Medicaid Clinical Coverage Policy)

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Defines Medicaid coverage, requirements, and criteria for radiation oncology treatments (external beam, brachytherapy, hyperthermia, SRS/SBRT, IMRT/IGRT/3DCRT) for NC Medicaid beneficiaries and providers.

Policy Summary

PayerAlliance Health

PolicyRadiation Oncology (NC Medicaid Clinical Coverage Policy)

Policy CodePolicy 1K-6

Change TypeNo material changes

Effective Date

Last ReviewAug 15, 2023

Next Review Date

Key ActionVerify each beneficiary's Medicaid eligibility at every encounter and document medical necessity and treatment details per policy requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No prior approval requiredprior approval policy for radiation oncology

90 daystreatment management bundling period

5 treatmentsunit for CPT 77427

1-5 fractionsCPT 77435 course length

45 yrsMinimum age for sole-method breast brachytherapy

Coverage Criteria and Indications

General Criteria Covered

Covered when ALL of the following are met

General medical necessity: a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

General Medicaid medical necessity criteria

Specific Criteria Covered

Covered specific services and conditions

Covered modalities: Local hyperthermia services for a diagnosis of cancer; brachytherapy services for head and neck cancers; respiratory and digestive tract cancers; genitourinary cancers; eye tumors; brain tumors; soft tissue sarcomas; multi-catheter interstitial or balloon brachytherapy (such as MammoSite) for breast cancer.

Policy Summary

PayerAlliance Health

PolicyRadiation Oncology (NC Medicaid Clinical Coverage Policy)

Policy CodePolicy 1K-6

Change TypeNo material changes

Effective Date

Last ReviewAug 15, 2023

Next Review Date

Key ActionVerify each beneficiary's Medicaid eligibility at every encounter and document medical necessity and treatment details per policy requirements.

SourceLink

On This Page

List of covered modalities and broad indications

Breast brachytherapy as sole method: When used as the sole method of breast radiation therapy following breast-conserving surgery, ALL of the following must be met: i. beneficiary is at least 45 years old or is postmenopausal; ii. beneficiary has invasive ductal carcinoma or ductal carcinoma in situ (DCIS); iii. total tumor size (invasive and DCIS) is <= 3 cm; iv. microscopic surgical margins of excision are negative; and v. axillary/sentinel lymph nodes are negative.

Criteria for single-modality breast brachytherapy

Breast brachytherapy in conjunction: Multi-catheter interstitial or balloon brachytherapy (such as MammoSite) is covered for treatment of early-stage breast cancer in conjunction with external whole-breast radiation therapy following breast-conserving surgery.

Adjunct use covered

Covered Indications

Covered when the following are met

General coverage: Local hyperthermia services for a diagnosis of cancer are covered; brachytherapy services are covered for listed cancer sites (head and neck; respiratory and digestive tract; genitourinary; eye; brain; soft tissue sarcomas; multi-catheter interstitial or balloon brachytherapy such as MammoSite for breast).

Brachytherapy for breast cancer is covered either (A) as adjunct to external whole-breast radiation after breast-conserving surgery for early-stage disease, or (B) as the sole method of breast radiation following breast-conserving surgery when ALL specific medical necessity criteria are met.

Sole-method brachytherapy breast criteria: i. Beneficiary is at least 45 years old or is postmenopausal; ii. invasive ductal carcinoma or DCIS; iii. total tumor size (invasive and DCIS) <= 3 cm; iv. microscopic surgical margins negative; v. axillary/sentinel lymph nodes negative.

Treatment Management — Bundled Coverage

Radiation treatment management is bundled and covered when provided as part of radiation therapy care

Bundled services: Treatment management activities (including anesthesia; care of infected skin; checking of treatment charts; verification of dosage; continued patient evaluation, examination, written progress notes; final physical examination; prescription writing; nutritional counseling; pain management; review and revision of treatment plan; routine management of unrelated problems; special care of ostomy; written reports; and follow-up examination and care for 90 days after last treatment) are included in radiation treatment management during the course of treatment and for 90 days following completion.90 days

These services are bundled with radiation oncologist services regardless of which code is billed.

CPT 77427 — Covered with specific requirements

CPT 77427 usage rules

77427 rules: Report one unit for every five treatment sessions; 'weekly' is interpreted as five treatments (not calendar week); services need not be on consecutive days; use when there are three or four sessions beyond a multiple of five at the end of a course; multiple sessions on the same day may be counted separately if there has been a distinct break in therapy; twice-daily treatment requires documentation of physician management for every five treatments; use for external beam treatments only.one unit per 5 sessions

Document physician management when twice-daily treatments are given; applies to external beam only.

CPT 77431 — Covered with specific requirements

CPT 77431 usage rules

77431 rules: Use when one or two treatments comprise the full course of therapy; do not use to report the last one or two days of a longer treatment course; use for external beam treatments only.1-2 treatments

CPT 77432 — Covered with exclusivity rules

CPT 77432 usage rules

77432 rules: Complete course of treatment consists of one session; this code cannot be reported for the same episode of care as CPT 77435; the same physician should not report both 77432 and specified stereotactic radiosurgery services (e.g., 61796–61800 combinations as listed).1 session

Mutual exclusivity with 77435 and certain SRS codes per policy.

CPT 77435 — Covered with specific requirements

CPT 77435 usage rules

77435 rules: Complete course of treatment is one to five fractions; if more than five treatments are given, bill CPT 77427 instead; CPT 77435 cannot be reported for the same episode of care as CPT 77432; the same physician should not report both 77435 and listed stereotactic radiosurgery services (and specified codes such as 63620/63621) as noted in the policy.1-5 fractions

Use 77427 when >5 fractions; observe mutual exclusivity rules.

CPT 77469-77470 — Supplemental procedures

CPT 77469-77470 usage note

77469-77470 rules: Use of CPT codes 77469 and 77470 assumes the procedure is performed one or more times during the course of therapy, in addition to daily or weekly patient management.

These are supplemental dosimetry/related procedures and are billed in addition to patient management when performed.

Under the federal EPSDT provision, Medicaid must cover services for beneficiaries under 21 when the service is medically necessary to correct or ameliorate a health problem identified through screening or evaluation. EPSDT can require coverage beyond ordinary policy limits when provider documentation shows the service meets EPSDT criteria. However, EPSDT does not require coverage for services that are unsafe, ineffective, or experimental/investigational, nor for services that are not medical in nature or not generally accepted as medical practice.

The policy explicitly excludes several specific technologies and scenarios from coverage. These include stereotactic procedures for obsessive-compulsive disorder, epilepsy, Parkinson’s disease, and migraine, as well as neutron beam and proton beam procedures. The policy also excludes Category III CPT codes, electronic/kilovoltage brachytherapy, stereotactic body radiation therapy when delivered in conjunction with other radiation delivery procedures, and stereoscopic x‑ray guidance used with stereotactic radiation management.

The policy considers certain uses of breast brachytherapy experimental or unproven. Brachytherapy following induction chemotherapy for inoperable locally advanced breast cancer, brachytherapy when the tumor is located in an area of insufficient tissue (for example very small breasts or inframammary fold), or when the tumor is multifocal, has extensive nodal involvement, or is lobular carcinoma are listed as not covered. Separately, the policy defines coverage criteria for breast brachytherapy when used as an adjunct to whole‑breast radiation or when used as the sole method of radiation only if all specified criteria (see coverage criteria) are met.

The document’s revision history and attachments show that certain radiation delivery CPT codes listed previously were deleted in earlier revisions; providers should refer to the policy attachments and revision information for specific deleted CPT entries and historical changes.

The policy restricts reporting by the same physician for certain combinations of radiosurgery/stereotactic services and radiation treatment management codes. Specifically, 77432 and 77435 cannot be reported for the same episode of care, and the same physician should not report 77432 or 77435 together with the listed stereotactic radiosurgery services (for example CPTs 61796–61800 and 63620–63621 as referenced).

Services are non‑covered when beneficiaries do not meet eligibility or the policy’s clinical criteria, when services duplicate those of another provider, or when services are experimental, investigational, or part of a clinical trial. The policy also includes an explicit list of specific not‑covered services (see exclusions) that, if billed, may result in claim denials.

Coding, Code Tables, and Key Billing Rules

Not Covered / Excluded CodesCPTNot Covered

Category III CPT codes

Category III CPT codes are excluded from coverage

inv-32: Maximum total tumor size for single-modality breast brachytherapy

Maximum total tumor size<= 3 cm

Applies toTotal tumor size includes invasive and DCIS components

ContextCriterion for using single‑modality (sole-method) breast brachytherapy after breast-conserving surgery

inv-33: Minimum beneficiary age for single-modality breast brachytherapy

Minimum beneficiary age>= 45 years or postmenopausal

IndicationRequired when brachytherapy is used as the sole method of breast radiation following breast-conserving surgery

Applies toBeneficiaries with invasive ductal carcinoma or DCIS

inv-34: Maximum total tumor size for sole-method brachytherapy (breast)

Maximum total tumor size (sole-method)<= 3 cm

ScopeTotal tumor size includes invasive and DCIS when using brachytherapy as the sole breast radiation method

Required alongsideNegative microscopic margins and negative axillary/sentinel lymph nodes

inv-35: Treatment management follow-up period

Follow-up period included in treatment management90 days after last treatment

Included activitiesFollow-up examination and care bundled with radiation oncologist services during course and for 90 days post-treatment

Billing implicationCertain CPTs mapped to treatment management are considered bundled for this 90-day period

inv-36: Unit reporting for CPT 77427

Unit reporting ruleReport one unit for every five treatment sessions for CPT 77427

'Weekly' interpretation'Weekly' is interpreted as five treatments (not calendar week)

Session countingServices need not be on consecutive days; multiple sessions same day may be counted separately if distinct break in therapy

inv-37: CPT 77435 course length

Complete course length for 774351 to 5 fractions — complete course is one to five fractions

If >5 fractionsIf more than five treatments are given, bill CPT 77427 instead of 77435

Mutual exclusivity77435 cannot be reported for same episode of care as CPT 77432

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required (when applicable)

If the service, product, or procedure requires prior approval, the fact that the beneficiary is under 21 years of age does NOT eliminate the requirement for prior approval. Refer to NCTracks Provider Claims and Billing Assistance Guide and the EPSDT provider page for additional information and instructions on prior approval processes. Providers must follow any prior authorization requirements applicable to radiation oncology services as directed by NCTracks and Medicaid bulletins.

NCTracks Provider Claims and Billing Assistance Guide: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html
EPSDT provider page: https://medicaid.ncdhhs.gov/

Billing Rule

Billing and Rates

Providers shall bill their usual and customary charges. For a schedule of Medicaid rates and reimbursement guidance, refer to the NC Medicaid website and applicable Medicaid fee schedules and bulletins. Institutional claims must follow National Uniform Billing Guidelines unless directed otherwise.

Medicaid rate schedule and reimbursement: https://medicaid.ncdhhs.gov/
Institutional claim billing: National Uniform Billing Guidelines

Denial Risk

Specific Not-Covered Services

Medicaid does not cover specific services and procedures listed as not covered. Billing these services may result in claim denial.

Stereotactic procedures for obsessive-compulsive disorder; epilepsy, recurrent seizures, or convulsions; Parkinson's disease; or migraine headaches
Neutron beam procedures
Proton beam procedures
Category III CPT codes
Brachytherapy for breast cancer in specified situations (see policy for details)
Electronic/kilovoltage brachytherapy
Stereotactic body radiation therapy in conjunction with other radiation delivery procedures
Stereoscopic x-ray guidance in conjunction with stereotactic radiation treatment management procedures

Billing Rule

Claim Type Compliance

Claims must comply with National Coding Guidelines and be submitted on the appropriate claim type. Professional services should be billed on CMS-1500/837P. Institutional claims must follow National Uniform Billing Guidelines. Failure to submit the correct claim type or to follow billing format requirements may trigger processing issues or denials.

Professional (CMS-1500/837P transaction)
Institutional claims: follow National Uniform Billing Guidelines
All claims must comply with National Coding Guidelines

Denial Risk

Improper Use of CPT Codes May Be Denied

Improper use of CPT codes or reporting codes outside stated requirements may result in claim denial. Providers must follow the CPT-specific billing rules for radiation treatment management and stereotactic services.

Do not report 77435 when more than five fractions are given; use 77427 for >5 fractions.
77432 cannot be reported for the same episode of care as 77435.
77427 is reported as one unit for every five treatment sessions; document physician management for every five treatments when twice-daily treatment is given.
Use the most specific CPT/HCPCS code available; unlisted codes only when no specific code exists.

Note

Provider Resources

Providers shall comply with NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and NC Medicaid clinical coverage policies for specific coverage, prior authorization direction, and reimbursement. These resources contain operational details and any updates affecting claims processing and authorizations.

NCTracks Provider Claims and Billing Assistance Guide: https://www.nctracks.nc.gov/content/public/providers/providermanuals.html
Medicaid bulletins and fee schedules: https://medicaid.ncdhhs.gov/
Clinical coverage policies: NC Medicaid

Prior Authorization

EPSDT and Prior Approval Note

If the service requires prior approval, beneficiaries under 21 remain subject to the prior approval requirement; EPSDT exceptions require provider documentation demonstrating medical necessity and how the service meets EPSDT criteria.

EPSDT does not eliminate prior approval requirements; provider must document medical necessity to support any EPSDT exception.

Background and Scope

Radiation oncology is the medical specialty that uses high‑energy ionizing radiation to treat malignant neoplasms and some non‑malignant conditions. The specialty includes multiple modalities such as external beam radiotherapy, brachytherapy, SRS/SBRT, IMRT/IGRT, and 3D conformal radiation therapy, and it encompasses a multidisciplinary process of treatment planning, simulation, physics/dosimetry, and physician treatment management intended to deliver safe and effective therapy.

Key Definitions

inv-59: Brachytherapy definition

DefinitionPlacement of small encapsulated radioactive elements ('seeds' or 'sources') in or near the tumor to deliver a high dose to the tumor and lower dose to surrounding tissue.

Common termsAlso referred to as placement of 'seeds' or 'sources' (interstitial, intracavitary)

RoleUsed as adjunct or sole method for specified cancer sites including breast (with criteria)

inv-60: SRS / SBRT definition

SRS vs SBRTSRS refers to treatment of intracranial lesions; SBRT refers to treatment of the spine and other anatomical sites

TechniqueBoth deliver highly focused, high-dose radiation to the target while minimizing dose to surrounding tissue

Typical useSRS intracranial; SBRT for spine and other sites

inv-61: IMRT definition

DefinitionIMRT uses computer-controlled x-ray accelerators to deliver conformal, modulated beam intensities, allowing dose to conform to the 3-dimensional tumor shape for normal tissue sparing.

CapabilityControls/modulates intensity of individual beams for precise dose distribution

Comparative noteProvides greater intensity modulation than 3D-CRT

inv-62: Radiation treatment management

DefinitionRadiation treatment management represents the physician's professional services overseeing a course of radiation therapy, including review of portal films, dosimetry and dose delivery, treatment setup, and beneficiary examinations to assess response to treatment.

Typical activitiesReview of portal films, dosimetry/dose delivery and parameters, treatment setup review, examination and management of response

Billing implicationThese professional services are bundled with certain CPTs during treatment and for 90 days after completion

inv-63: Treatment management includes activities such as evaluation, verification of dosage, prescription writing, follow-up care for 90 days post-treatment, and other listed services which are bundled with radiation oncologist services.

Bundled activities exampleIncludes evaluation, verification of dosage, prescription writing, and follow-up care for 90 days post-treatment

Other included itemsAnesthesia, care of infected skin, checking treatment charts, review/revision of treatment plan, written reports, and routine management tasks are bundled

Billing notePayments for radiation oncologist services are bundled with these activities regardless of which code is billed