Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.28
    OpenPayerPolicy UpdatesRadiation OncologyAmbetter Nevada IMRT Coverage Update Prior Auth | …
    Ask Trek AI about this page
    ModifiedAmbetter NevadaPolicy CP.MP.69

    Intensity-Modulated Radiotherapy (IMRT)

    Customize your policy alerts

    Sign up for Ambetter Nevada Policy CP.MP.69 alerts

    Get alerted when Policy CP.MP.69 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Medical necessity criteria and coding implications for intensity-modulated radiotherapy (IMRT) for non‑Medicare health plans affiliated with Centene; describes indications by age, operability, prior radiation, and cancer site-specific uses.

    Policy Summary
    PayerAmbetter Nevada
    PolicyIntensity-Modulated Radiotherapy (IMRT)
    Policy CodePolicy CP.MP.69
    Change TypeCriteria updatesadded site-specific indicationsoperational note for Medicare cross-reference
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization for IMRT with supporting clinical documentation and include applicable IMRT planning and delivery codes.
    SourceLink
    POLICY UPDATE CHANGES

    Added note to policy to refer to MC.CP.MP.69 for Medicare criteria and specified 'non - Medicare' health plans in Policy/Criteria I.

    Removed several breast-specific quantitative parameters, leaving homogeneity of dose as the breast criterion and updated left-sided breast and APBI wording.

    Added new site-specific indications including uterine neoplasms, pancreatic cancer, and stage III non-small cell lung cancer.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    8+Site groups
    6Procedure codes referenced
    Medicare refPayer-specific note
    47References

    Medical Necessity and Site-Specific Indications

    General Indications

    IMRT is medically necessary for non‑Medicare Centene-affiliated health plans when ANY of the following indications are met:

    Top-level indications: A. Age < 18 years with a solid tumor; B. Medically inoperable patient with diagnosis of cancer where dose escalation is required; C. Primary malignant or benign bone tumors; D. Re-irradiation where cumulative critical structure dose would exceed tolerance dose; E. Indications by cancer site as listed below.

    See site-specific indications for details.

    Site-Specific Indications

    Site-specific indications (any of the following per site):

    Central nervous system: Ocular tumors including intraocular melanomas; tumors that approach or are located at the base of skull; primary CNS tumors, primary spine, or metastatic tumors to the spine or spinal cord where organ-at-risk tolerance may be exceeded with 3-D conformal treatments; primary and metastatic tumors requiring craniospinal irradiation; brain metastases requiring hippocampal-sparing whole brain radiotherapy.

    [[chunk 2]]

    Head and neck: Definitive, adjuvant, or palliative treatment of primary or secondary head and neck cancers or draining lymphatics of the neck (including but not limited to nasopharynx, nasal cavity, paranasal sinuses, oropharynx, oral cavity, hypopharynx, larynx, thyroid, salivary glands); cutaneous tumors with cranial nerve invasion to base of skull, cavernous sinus, and/or brainstem; mucosal melanoma; occult (unknown) primary malignancies of the head and neck.

    [[chunk 2]]

    Breast: Bilateral breast cancers requiring nodal treatment on at least one side; patients with unfavorable anatomy (e.g., pectus excavatum) that would deliver unacceptably high doses to organs-at-risk with conventional techniques; early-stage breast cancer in which dose to the heart is unacceptably high with conventional cardiac-sparing techniques; accelerated partial breast irradiation (APBI), regardless of laterality; patients in whom internal mammary lymph nodes are targeted; patients with limited ipsilateral arm range of motion requiring arms-down positioning; post-mastectomy radiotherapy in patients with bilateral implant-based reconstruction; whole breast radiotherapy in patients with bilateral augmentation implants.

    [[chunk 3]]

    Thoracic: Primary or secondary tumors of the mediastinum (including thymic tumors, mediastinal tumors, mediastinal lymphomas and thoracic sarcomas); early-stage lung cancer for which SBRT is not feasible due to anatomic considerations; locally advanced lung cancer in which IMRT significantly reduces dose to normal tissues (examples: bilateral mediastinal disease, paraspinal tumors, N3 disease, reducing esophageal dose); malignant pleural mesothelioma.

    [[chunk 3]]

    Gastrointestinal: Hepatocellular carcinoma, bile duct, gallbladder and cholangiocarcinoma; primary cancers of the esophagus and gastroesophageal junction; abdominal malignancies including primary pancreatic, gastric and adrenal cancers; primary and secondary liver cancers; anal and colorectal cancers.

    [[chunk 3]]

    Sarcomas: Retroperitoneal sarcomas; desmoid tumors; extremity sarcomas.

    [[chunk 3]]

    Pelvic/gynecological: Cervical cancer; vulvar and vaginal cancers; endometrial cancer.

    [[chunk 4]]

    Genitourinary: Prostate cancer; renal cancer; bladder cancer; penile cancer; ureteral cancer.

    [[chunk 4]]

    The list of indications in this policy is intended to describe common clinical situations in which IMRT may be medically necessary for non‑Medicare Centene-affiliated health plans, but it is not an exhaustive catalog of all possible uses. The policy text explicitly notes additions and revisions over time and that site-specific items have been added; therefore, clinicians and reviewers should recognize that other clinically appropriate indications may exist beyond those listed and assess requests against the medical necessity principles in this document and supporting evidence.

    Where a proposed IMRT use is not specifically enumerated in the site-specific lists, prior authorization reviewers should evaluate the submitted clinical documentation for the same elements required by the policy (e.g., patient age, operability, prior radiation dose for re-irradiation, tumor anatomy and proximity to critical structures) and apply the medical necessity criteria rather than assuming denial solely because an indication is not verbatim in the list.

    If a member is covered by a state Medicaid program, any state Medicaid coverage provisions that conflict with this clinical policy take precedence. Providers should consult the applicable state Medicaid manual and follow state-specific coverage rules when those differ from the criteria in this document.

    The policy excerpt does not list explicit conditions labeled as "not medically necessary". Importantly, the inclusion or absence of specific procedure codes in the policy is informational only: inclusion or exclusion of any codes does not guarantee coverage. Providers must supply clinical documentation to demonstrate medical necessity and should follow current professional coding guidance when submitting claims.

    Procedure and Billing Codes

    Referenced CPT CodesCPT
    77301Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications.
    77338Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan.
    77385Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple.
    77386Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex.
    Referenced HCPCS/G CodesHCPCS
    G6015Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session.
    G6016Compensator-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.
    Pediatric standard — IMRT/VMAT
    StatementIMRT and VMAT are the standard of care for treatment of many pediatric cancers.
    ContextThis standard is noted within the policy background describing IMRT/VMAT use in pediatric populations and guideline recommendations (e.g., NCCN).
    Implication for CoverageRequests for IMRT/VMAT in pediatric cancers should be evaluated recognizing these techniques are standard when clinically indicated per site-specific criteria.

    Prior Authorization, Documentation, and Billing Requirements

    Prior Authorization

    Prior authorization required for IMRT with CPT/HCPCS and clinical rationale

    Prior authorization is required when submitting IMRT services; include the applicable IMRT planning and delivery CPT/HCPCS codes and clinical rationale that meets the policy criteria.

    • Include IMRT planning code 77301 and any relevant delivery codes (77385, 77386) or HCPCS G-codes (G6015, G6016) on the authorization request.
    • Provide clinical rationale tied to the policy indications (e.g., age <18 with a solid tumor; medically inoperable requiring dose escalation; re-irradiation with cumulative critical structure dose concerns; or a listed site-specific indication).
    Prior Authorization

    Plan-level prior authorization and administrative policies may apply

    Verify plan-level prior authorization and administrative requirements before submitting requests — this clinical policy is effective as of the Health Plan–determined date and may be subject to additional Health Plan procedures.

    • Check the member's Evidence of Coverage/contract for plan-specific prior authorization processes and effective dates.

    Clinical and Technical Background

    Intensity-modulated radiotherapy (IMRT) delivers external beam radiation with variable beam intensity across treatment fields to shape dose distributions tightly around target volumes and spare adjacent critical structures. Treatment planning is a multi-step process (including target and organ-at-risk contouring and generation of dose-volume histograms) that enables dose escalation to tumors while limiting exposure to nearby normal tissues. The technique can improve dose homogeneity and reduce acute toxicity in selected settings but requires additional planning, quality assurance, and resources compared with conventional techniques.

    Key Definitions

    Definition of IMRT
    DefinitionIntensity‑modulated radiotherapy (IMRT): technology that delivers highly conformal external beam radiation to targets using beams whose intensity varies across the treatment fields to spare adjacent normal tissues.
    PlanningIMRT planning is a multi‑step process including contouring of targets and organs-at-risk and generation of dose‑volume histograms to optimize target coverage and normal tissue sparing.
    Clinical considerationsIMRT enables simultaneous treatment of multiple target subvolumes to different dose levels but may increase planning/QA time and low‑dose exposure to larger volumes of normal tissue.
    Definition of Clinical Policy
    PurposeA clinical policy provides a guide to medical necessity used to assist in making coverage decisions and administering benefits.
    Scope
    Policy Summary
    PayerAmbetter Nevada
    PolicyIntensity-Modulated Radiotherapy (IMRT)
    Policy CodePolicy CP.MP.69
    Change TypeCriteria updatesadded site-specific indicationsoperational note for Medicare cross-reference
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization for IMRT with supporting clinical documentation and include applicable IMRT planning and delivery codes.
    SourceLink
    On This Page
    Medical Necessity and Site-Specific IndicationsProcedure and Billing CodesPrior Authorization, Documentation, and Billing RequirementsClinical and Technical BackgroundKey Definitions
  1. Follow any Health Plan-level administrative policies and procedures that govern prior authorization submissions.
    2. Note

    Follow plan operational requirements for IMRT requests

    Follow any operative provider actions required by the Health Plan (see plan portal or authorization guidance) when preparing and submitting IMRT requests.

    • Confirm submission channels, forms, and any plan-specific preauthorization identifiers.
    • Comply with any additional plan instructions communicated via provider notices or portals.
    Note

    Confirm and follow any additional provider actions required by the Health Plan

    Adhere to any additional operative provider actions or updates specified by the Health Plan for IMRT; confirm requirements at time of request submission.

    • Monitor plan communications for changes to submission requirements or effective dates.
    • Ensure authorized personnel complete required attestations or confirmations per plan instructions.
    Documentation Required

    Submit required clinical and coding documentation with authorization

    Submit documentation supporting the indication per policy and include applicable IMRT planning and delivery code documentation.

    • Clinical details: patient age, operability status, prior radiation dose if re-irradiation is being considered, tumor site and anatomic details demonstrating the need for IMRT.
    • Coding details: include IMRT plan code 77301 and any delivery codes (77385, 77386) or HCPCS G6015/G6016 as applicable.
    Documentation Required

    Documentation must comply with coverage documents and legal requirements

    Providers must follow applicable coverage documents and state/federal requirements; documentation should support medical necessity according to the Health Plan's criteria.

    • Ensure submitted records meet documentation standards required by the Evidence of Coverage, certificate of coverage, and applicable laws or regulations.
    • Maintain sufficient clinical records to demonstrate how the requested IMRT meets the policy's medical necessity indications.
    Denial Risk

    Denial risk for IMRT requests lacking policy-supported indications

    Requests that do not meet the policy's listed medical necessity indications for non‑Medicare plans may be denied.

    • Examples of at-risk requests include cases not meeting indications such as age <18 solid tumor, medically inoperable with need for dose escalation, primary bone tumors, or re-irradiation where critical structure tolerance would be exceeded.
    • Provide complete clinical justification and supporting documentation to reduce denial risk.
    Note

    Coverage subject to member's plan documents and contract terms

    Coverage decisions and benefit administration remain subject to the terms, conditions, exclusions and limitations in the member's coverage documents and contract.

    • Confirm coverage is consistent with the member's Evidence of Coverage, certificate of coverage, or contract of insurance.
    • When state Medicaid provisions conflict with this policy, state Medicaid coverage provisions take precedence.
    It is based on review of standards of practice, peer‑reviewed literature, guidelines, regulatory status, and expert clinical input but does not constitute a contract or guarantee of payment.
    ApplicationCoverage decisions using the clinical policy remain subject to all terms, conditions, exclusions and limitations of the applicable coverage documents.