Prior Authorization Required for Radiation Planning and Delivery

Prior authorization is required for radiation therapy planning and delivery codes. Providers must submit supporting clinical records (treatment planning documents, dosimetry, simulation notes, and justification for modality) to demonstrate that medical necessity criteria are met for the specific cancer type and treatment intent.

• Include radiation treatment planning codes (e.g., CPT 77261-77263, 77295, 77301, 77316-77318) and treatment delivery codes (e.g., 77401, 77402, 77407, 77412, 77771-77772) on authorization requests as applicable.
• Failure to provide required documentation may result in authorization delays or denial.

Coverage Decisions and Administration of Benefits

Coverage decisions and the administration of benefits are governed by this clinical policy together with the member's coverage documents and applicable legal/regulatory requirements. This policy is a guide to medical necessity and does not guarantee payment or coverage. Providers should verify contract terms and plan-level procedures when submitting prior authorizations and claims.

• Coverage decisions are subject to the terms, conditions, exclusions and limitations of the member's evidence of coverage, certificate of coverage, policy, or contract.
• State Medicaid provisions take precedence over this policy when conflicts exist; Medicare NCDs/LCDs and CMS guidance should be reviewed for Medicare members.

Documentation and Contractual Obligations

Providers must follow standard documentation and contractual requirements when requesting services. Documentation submitted must support that the medical necessity criteria in this policy are satisfied for the specific diagnosis and treatment intent (definitive, adjuvant, or palliative).

• Required documentation includes: clinical notes, pathology reports, imaging studies, surgical consults or records (if applicable), treatment planning records, and rationale if surgery was not performed or was declined.
• Providers are expected to comply with their contractual obligations and any Health Plan-level administrative policies and procedures; this clinical policy does not replace contractual rules.

Surgery Preferred Prior to Radiation When Feasible

When clinically feasible, surgical excision is the preferred primary treatment for skin cancers. Radiation therapy is indicated when the member is not a surgical candidate, declines surgery, surgery would compromise function or cosmesis, resection is not feasible for adjuvant reasons, or other policy-specified criteria are met.

• Document why surgery is not performed (e.g., patient refusal, medical comorbidity, anticipated unacceptable functional/cosmetic outcome).
• For recurrent disease in a previously irradiated field, radiation is generally not routinely repeated unless supported by clinical rationale and documentation.

Not Medically Necessary Procedures

Electronic surface brachytherapy and image-guided superficial radiation therapy (IGSRT) are considered not medically necessary for treatment of any skin cancer due to insufficient evidence on long-term safety and efficacy. Authorization requests for these modalities may be denied.

• Examples of not medically necessary procedures: Electronic surface brachytherapy; IGSRT.

Provider Responsibilities and Coding

Providers are expected to submit complete and accurate supporting records with prior authorization requests and to follow coding guidance. Inclusion or omission of CPT/HCPCS codes in this policy is informational and does not guarantee coverage; verify coding and billing with current professional resources before claim submission.

• Reference up-to-date coding sources for CPT and HCPCS codes related to treatment planning, simulation, dosimetry, brachytherapy, and treatment delivery (see coding implications section).
• Providers are independent contractors and remain responsible for clinical decision-making and documentation.