Prior authorization request form for intensity-modulated radiation therapy (IMRT)
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This document is a Blue Cross NC fax prior-review request form used by providers to request prior authorization for IMRT services across multiple cancer sites; it applies to providers and facilities submitting IMRT requests for North Carolina members.
No material clinical or coverage changes in this revision.
Site-specific Coverage Criteria for IMRT
Head and Neck Cancers
Covered when ALL of the following are met:
Location and cell type must be documented
Location and cell type must be documented
Prostate - Definitive Therapy
Covered when ANY of the following definitive prostate indications are met:
Documentation whether dose‑escalated definitive therapy is planned
Separate checkbox for low metastatic burden indication
Post-prostatectomy (Adjuvant or Salvage)
Covered when ANY of the following post‑prostatectomy indications are met and the prescribed dose is within the stated range:
Specific pathologic risk factors must be documented
Biochemical or local recurrence and absence of distant metastasis must be documented
Sarcoma of the Extremities
Covered when ALL of the following quantitative dosimetric conditions are documented:
Provider must check applicable 3‑D planning findings and demonstrate the absolute percent reduction achieved with IMRT (example: 40% to 25%)
Breast Cancer
Covered when the following site‑specific breast planning criteria are met:
Provider must document that alternatives were considered and provide comparative dosimetry
Document techniques attempted (wedges/field‑in‑field, higher photon energies) and that IMRT avoids hot spots
Document prior radiation and comparative dosimetry; list techniques tried
Specific checkbox for partial breast IMRT indication
Other Chest Cancers
Covered when ALL of the following are met:
Provider must document tumor location and histology
Cancers of the Abdomen and Pelvis
Covered when ANY of the following abdomen/pelvis conditions or tumor‑site indications are met:
Provider must check applicable conditions or tumor types and document location and cell type
Requires documentation of unacceptable normal tissue toxicity with 3‑D planning and location/cell type
Central Nervous System Tumors
Covered when ALL of the following are met:
Location and cell type must be documented
Submission of this fax form constitutes a request for services and is not a guarantee of coverage or payment. The form itself does not list any unconditional exclusions; determinations will be made based on the clinical information and documentation provided.
The form does not enumerate specific conditions that are categorically not medically necessary. Instead, it focuses on collecting detailed clinical and dosimetric justification to support a medical‑necessity determination; providers should supply complete supporting records to enable review.
CPT Codes and Dosimetric Parameters
| 77385 | 77385 |
| 77386 | 77386 |
Submission Requirements and Provider Responsibilities
Prior authorization form completion: CPTs, fractions, place/dates, and provider IDs
Complete the IMRT prior authorization form fields for each request. Identify the requested CPT code(s) (select 77385 and/or 77386), list ICD-10 diagnosis code(s), specify the number of fractions requested, place of service (office or outpatient hospital), and provide the requested dates of service. Include admitting/ordering and servicing/billing provider or facility identifying information (provider/facility name and provider/ facility #, Tax ID or NPI) as indicated on the form.
- Select the appropriate IMRT CPT code(s): 77385 and/or 77386.
- Enter ICD-10 diagnosis code(s).
- Document number of fractions being requested.
- Indicate place of service: Office or Outpatient hospital.
- Provide dates of service and provider/facility identifying details (name, provider or facility #, Tax ID or NPI).
Document site‑specific justification (anatomic/cell type + dosimetric or clinical rationale)
Provide disease site–specific clinical and dosimetric justification on the form. For each tumor site indicated, document the anatomic location and cell type and the site-specific rationale (for example: dosimetric benefit of IMRT versus 3D/conformal planning, prior radiation overlap, quantitative sarcoma criteria, cardiac-sparing justification for left-breast cases, techniques attempted for large breasts, or listed abdomen/pelvis conditions).
- Head/neck, CNS, chest, abdomen/pelvis, breast, sarcoma and prostate sections require location and cell type or checkbox justification as specified.
- For sarcoma, document 3D conformal exposures and that IMRT provides ≥15% absolute reduction in exposed bone circumference or joint-space per the form checkboxes.
- For left-sided whole-breast cases, document that IMRT dosimetry reduces cardiac dose compared with opposed tangents and whether alternatives can avoid cardiac toxicity.
- For abdomen/pelvis, select listed clinical conditions (e.g., prior irradiation overlap, Crohn's disease, hip prosthesis) when applicable.
Signature attestation and availability of supporting medical records
Sign and date the form to attest that you have authority to request prior authorization and that the patient's medical records accurately reflect the information provided; be prepared to provide medical records if Blue Cross NC requests them.
- Signature certifies authority to request prior authorization and that records support the information on the form.
- Blue Cross NC may request medical records to verify information; lack of supporting records may prompt refund requests or other remedies.
Incomplete/insufficient form may delay processing or risk denial
Recognize that submitting the completed form is a request for services and does not guarantee approval; incomplete or missing information may delay processing and could risk denial.
- Submission of the form is only a request and does not guarantee approval.
- An incomplete form may delay processing.
Background and Purpose
The purpose of this IMRT prior‑review fax form is to collect standardized clinical and dosimetric information across multiple tumor sites to support prior authorization decisions. It asks providers to describe the indication (definitive, adjuvant, salvage, or re‑irradiation), document tumor location and cell type where required, and provide site‑specific treatment‑planning justification (for example, dosimetric benefit of IMRT versus 3D/conformal planning or overlapping prior radiation) to demonstrate the need for IMRT.
Definitions and Key Terms
Policy Revision History
Form updated (header shows 'Updated June 2024'); prior-review IMRT fax form version updated.
Document effective date listed in brief core.dates as 2024-06-01.
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