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    v1.0.31
    OpenPayerPolicy UpdatesRadiation OncologyArkansas BCBS Breast Irradiation Coverage | OpenPa…
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    CurrentArkansas Blue Cross and Blue ShieldPolicy 2009036

    Intensity Modulated Radiation Therapy

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    Coverage criteria for whole breast irradiation and breast boost irradiation, including permitted treatment fractions under specified clinical circumstances.

    Policy Summary
    PayerArkansas Blue Cross and Blue Shield
    PolicyIntensity Modulated Radiation Therapy
    Policy CodePolicy 2009036
    Change TypeMaterial amendment
    Effective DateSep 1, 2026
    Next Review DateN/A
    Key ActionVerify that individuals receiving 17-28 fractions of whole breast irradiation meet at least one qualifying clinical circumstance.
    SourceLink
    POLICY UPDATE CHANGES

    Coverage criteria were updated for whole breast irradiation and breast boost irradiation fractionation.

    15-16 fractionsStandard whole breast irradiation course
    17-28 fractionsExtended whole breast irradiation with qualifying criteria
    Up to 8 fractionsBreast boost with qualifying criteria
    Up to 5 fractionsBreast boost without qualifying criteria

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    Whole Breast and Breast Boost Irradiation

    Standard Whole Breast Irradiation

    Whole breast irradiation should be delivered in 15–16 fractions.

    Standard whole breast irradiation: Whole breast irradiation should be delivered in 15–16 fractions.15–16 fractions

    Extended Whole Breast Irradiation

    Whole breast irradiation of 17–28 fractions is appropriate when at least one of the following qualifying circumstances is present.

    Qualifying circumstances for 17–28 fractions of whole breast irradiation

    • Nodal regions requiring treatment: Lymph node involvement requires treatment of the supraclavicular or internal mammary nodal regions.
    • Mastectomy or breast reconstruction has been performed.
    • Dose inhomogeneity with 3D conformal radiotherapy: Treatment will be delivered with 3D conformal radiotherapy, and the treatment plan results in breast tissue receiving greater than 105% of the prescription dose.>105% of prescription dose

      Both 3D conformal radiotherapy and the specified dose inhomogeneity are required.

    • Concurrent chemotherapy will be administered.

      This does not include trastuzumab or endocrine therapy.

    Whole Breast Irradiation Without Extended-Course Criteria

    When the individual does not meet any criterion for 17–28 fractions, up to 16 fractions of whole breast irradiation are considered medically necessary.

    No qualifying criterion for extended-course irradiation: The individual does not meet any qualifying criterion for 17–28 fractions of whole breast irradiation.Up to 16 fractions

    Up to 16 fractions are considered medically necessary in this circumstance.

    Breast Boost Irradiation

    Breast boost irradiation is appropriate according to whether the individual meets the criteria for 17–28 fractions of whole breast irradiation.

    Breast boost fraction limits

    • Extended-course criteria fulfilled: The individual has fulfilled at least one criterion for 17–28 fractions of whole breast irradiation.Up to 8 additional boost fractions
    • Extended-course criteria not fulfilled: The individual has not fulfilled any criterion for 17–28 fractions of whole breast irradiation.Up to 5 additional boost fractions

    Fractionation Coverage Requirements

    Denial Risk

    Support qualifying criteria for an extended course

    Whole breast irradiation delivered in 17-28 fractions is appropriate only when the individual meets at least one qualifying criterion. If none applies, up to 16 fractions of whole breast irradiation are considered medically necessary; an additional breast boost is limited to up to 5 fractions.

    • Lymph node involvement requiring treatment of the supraclavicular or internal mammary nodal regions.
    • Mastectomy or breast reconstruction has been performed.
    • Treatment with 3D conformal radiotherapy and breast tissue receiving >105% of the prescription dose because of dose inhomogeneity.
    • Concurrent chemotherapy, excluding trastuzumab or endocrine therapy.

    Policy Update Background

    This policy update establishes fractionation criteria for whole breast irradiation (WBI) and limits additional breast boost irradiation according to the applicable clinical circumstances. WBI should generally be delivered in 15–16 fractions; treatment courses of 17–28 fractions are appropriate only when specified qualifying circumstances are present. The update also permits an additional boost of up to 8 fractions when those extended-course criteria are met, or up to 5 fractions when they are not.

    Policy Summary
    PayerArkansas Blue Cross and Blue Shield
    PolicyIntensity Modulated Radiation Therapy
    Policy CodePolicy 2009036
    Change TypeMaterial amendment
    Effective DateSep 1, 2026
    Next Review DateN/A
    Key ActionVerify that individuals receiving 17-28 fractions of whole breast irradiation meet at least one qualifying clinical circumstance.
    SourceLink
    On This Page
    Whole Breast and Breast Boost IrradiationFractionation Coverage RequirementsPolicy Update Background