Colorado Rocky Mountain Health Plans radiation policy update

Coverage Criteria and Medical Necessity

Bone metastases (palliative EBRT)

Medically necessary when the following are met:

Bone metastases fractionation: Delivery of up to 10 fractions of radiation therapy for palliative treatment of bone metastases<=10 fractions

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Re-irradiation allowance: Delivery of greater than 10 fractions when treating a site that has previously received radiation therapy (reirradiation)

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Breast adenocarcinoma (EBRT)

Medically necessary fractionation limits for breast cancer:

APBI with IMRT: Delivery of up to five fractions for accelerated partial-breast irradiation (APBI) using intensity-modulated radiation therapy (IMRT)<=5 fractions

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APBI with 3D technique: Delivery of up to 10 fractions for accelerated partial-breast irradiation (APBI) using a 3D technique<=10 fractions

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Standard courses: Delivery of up to 21 fractions (inclusive of a boost to the tumor bed)<=21 fractions

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Extended courses to 33 fractions: Delivery of up to 33 fractions (inclusive of a boost to the tumor bed) when any of the following are present: treatment of supraclavicular and/or internal mammary lymph nodes; postmastectomy radiation therapy; prior thoracic radiation therapy; or connective tissue disorder such as systemic lupus erythematosus or scleroderma<=33 fractions

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Locally advanced non-small cell lung cancer (EBRT)

Medically necessary:

NSCLC fractions: Delivery of up to 35 fractions for definitive EBRT, with or without chemotherapy, for locally advanced non-small cell lung cancer<=35 fractions

RTOG 0617 supports avoiding escalation to 74 Gy; NCCN recommends at least 60 Gy and commonly 60–70 Gy total dose

Prostate adenocarcinoma (EBRT)

Medically necessary fractionation limits for prostate cancer:

Definitive treatment limited metastatic: Delivery of up to 20 fractions for Definitive Treatment in an individual with Limited Metastatic Disease<=20 fractions

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Localized prostate standard: Delivery of up to 28 fractions for localized prostate cancer<=28 fractions

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Extended localized prostate courses: Delivery of up to 45 fractions for localized prostate cancer when any of the following are met: high-risk disease with pelvic lymph node treatment, postprostatectomy radiation therapy, history of inflammatory bowel disease (eg, ulcerative colitis or Crohn disease), or prior pelvic radiation therapy<=45 fractions

Image-Guided Radiation Therapy (IGRT) — medically necessary circumstances

Image guidance is medically necessary under any of the following circumstances:

IGRT with IMRT or PBRT: When used with intensity-modulated radiation therapy (IMRT) or proton beam radiation therapy (PBRT)

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Prior radiation or abutting prior area: When the target has received prior radiation therapy or abuts a previously irradiated area

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Fiducial markers: When implanted fiducial markers are being used for target localization

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Specific 3D-CRT definitive use cases: During definitive treatment using 3D-CRT for listed indications (eg, APBI, breast boost, hypofractionated whole-breast up to five fractions, prone positioning, DIBH for left breast) and during boost treatments for rectal and bladder cancer and for esophageal, gastric, head and neck, hepatobiliary, lung, pancreatic cancer, and soft tissue sarcoma

Palliative radiotherapy for bone metastases — recommended regimens and evidence

Covered when treating symptomatic bone metastases for pain control or complication prevention using evidence-supported conventional palliative regimens:

Accepted conventional palliative regimens: Single-fraction 8 Gy; 20 Gy in 5 fractions; 24 Gy in 6 fractions; 30 Gy in 10 fractions; and for spine compression scenarios also 16 Gy in 2 fractions or 20 Gy in 5 fractions as recommended

ASTRO, ACR, ESTRO and AHRQ systematic reviews support these regimens; single 8 Gy associated with higher retreatment rates

Reirradiation for bone metastases

Covered when prior radiation history and clinical need justify retreatment for pain control or symptom recurrence:

Reirradiation coverage considerations: Reirradiation to the same site is covered when clinically indicated; pooled evidence shows an overall pain response of approximately 58% after reirradiation and retreatment regimens may range from single-fraction to multifraction depending on prior dose and normal tissue constraints

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Partial-breast irradiation (PBI/APBI) for early-stage breast cancer

Covered when patient selection matches trial populations for early-stage disease and modality/dose used align with evidence-based regimens:

Evidence-based APBI/PBI regimens: APBI/PBI (brachytherapy, 3D-CRT, IMRT, proton, intraoperative RT) is an option for appropriately selected early-stage breast cancer; evidence-supported regimens include 30 Gy in 5 fractions APBI (IMRT) and 26 Gy in 5 fractions whole-breast hypofractionation shown noninferior in trials

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Breast cancer: fractionation and partial-breast irradiation

Evidence and guideline-based coverage considerations for WBI, hypofractionated WBI (HF-WBI), and APBI/PBI.

APBI vs WBI trial results: NSABP B-39/RTOG 0413: APBI did not meet equivalence criteria to WBI for ipsilateral breast tumor recurrence at median 10.2 years (IBTR 4.6% APBI vs 3.9% WBI); trial not powered for subgroup or technique-specific equivalence

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External-beam APBI outcomes: Whelan et al. 1-week external-beam APBI was noninferior for IBTR at 8 years (3.0% APBI vs 2.8% WBI) but had higher late toxicity and worse cosmetic outcomes with twice-daily schedule; once-daily schedules require further study

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Hypofractionated WBI (HF-WBI): Multiple randomized trials (eg, START, Whelan, Brunt) support HF-WBI (eg, 40 Gy/15 fx) as noninferior to conventional fractionation with similar or lower acute toxicity and acceptable long-term outcomes when dosed per guidelines

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Locally advanced NSCLC: definitive chemoradiation dosing

Guidance and trial evidence on RT dose for unresectable stage III NSCLC.

Standard vs high-dose RT trial result: RTOG 0617 demonstrated that 74 Gy with concurrent chemotherapy was not superior to 60 Gy and was associated with worse overall survival and increased treatment-related deaths; therefore routine escalation to 74 Gy is not recommended

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NCCN dose recommendation: NCCN: definitive RT commonly prescribed 60–70 Gy with treatment duration of 6–7 weeks; doses of at least 60 Gy should be given and IGRT is appropriate when needed>=60 Gy total dose recommended

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ASCO recommendations for stage III: ASCO (2022) recommends concurrent chemoradiation with a platinum doublet and RT delivered in a total dose of approximately 60 Gy while limiting heart, lung, and esophagus exposure

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Prostate cancer: pelvic nodal RT and hypofractionation

Evidence on WPRT vs prostate-only RT and moderate hypofractionation in localized prostate adenocarcinoma.

WPRT benefit in high-risk prostate cancer: In men with node-negative but high estimated nodal-risk (≥20%) receiving RT with ≥2 years ADT, whole pelvic radiotherapy (WPRT) improved 5-year biochemical failure–free survival (95.0% WPRT vs 81.2% PORT) and disease-free survival compared with prostate-only RT

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Hypofractionation equivalence: Systematic reviews and randomized trials (Cochrane, Catton, Dearnaley) support that moderate hypofractionation (eg, 60 Gy/20 fx) is noninferior to conventional RT for many patients with similar late GU/GI toxicityfraction size up to ~3.4 Gy supported

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Hypofractionation and IGRT coverage rationale

Coverage stance informed by randomized trials and guidelines:

Moderate hypofractionation - general: Moderate hypofractionated EBRT (examples: 60 Gy in 20 fractions; 70 Gy in 28 fractions) is supported by high-quality evidence as noninferior for disease control with similar late GU/GI toxicity and is recommended by ASTRO/AUA/NCCN when appropriatefraction size approximately 240–340 cGy

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Specific regimens supported: Randomized trials support specific regimens such as 60 Gy in 20 fractions; HYPRO (19 × 3.4 Gy) did not establish superiority and raised toxicity concerns

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IGRT use: Daily image-guided localization (eg, daily volumetric IGRT/CBCT) is associated with reduced acute GU and GI toxicity and improved short-term biochemical control; NCCN states daily prostate localization with IGRT is essential

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Clinical indications where IGRT is recommended

IGRT is recommended or strongly recommended in the following clinical scenarios per specialty guidelines:

Indications list: Targets located near or within critical structures; targets in tissue with inherent setup variation; volumes requiring narrow margins to protect adjacent structures; targets subject to daily internal motion; targets adjacent to previously irradiated areas requiring precise abutment; when dose escalation beyond usual doses is planned; when using highly conformal modalities (3D-CRT, IMRT, proton therapy, SBRT)

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Disease-specific guideline recommendations (examples)

Representative guideline recommendations endorsing daily or frequent IGRT:

Soft tissue sarcoma: Strong recommendation for daily IGRT with at least weekly volumetric image guidance for primary localized extremity/truncal and retroperitoneal sarcomas when preoperative RT is planned

ASTRO practice guideline (Salerno et al., 2021) per policy

Liver cancer: Respiratory motion management and daily image guidance are recommended when dose-escalated ultra- or moderately hypofractionated EBRT is used

ASTRO guideline (Apisarnthanarax et al., 2022)

NSCLC (oligometastatic/highly conformal RT): Motion management strategies and image-guided RT delivery are recommended for highly conformal RT using inverse planning

ASTRO and NCCN recommendations (Iyengar et al., 2023; NCCN 2026)

Radiation Therapy Fractionation — Breast Adenocarcinoma

Revised coverage criteria highlights

APBI 3D technique: Delivery of up to 10 fractions for accelerated partial-breast irradiation with 3D technique is allowed<=10 fractions

New explicit fractionation limit for APBI with 3D technique (policy revision)

Connective tissue disorder fractionation: Delivery of up to 33 fractions (inclusive of a boost to the tumor bed) is allowed when the individual has a connective tissue disorder such as systemic lupus erythematosus or scleroderma<=33 fractions

Clarifies connective tissue disorder examples in revised policy

When the specified medical criteria for Image-Guided Radiation Therapy (IGRT) are not met, the use of IGRT is considered not medically necessary. This includes situations where imaging is used solely to align bony landmarks in the absence of implanted fiducial markers (for example, during palliative radiation therapy) and other circumstances that do not meet the conditions listed as medically necessary in the policy (e.g., not used with IMRT/PBRT, not for targets abutting prior radiation, not for situations requiring narrow margins or motion management).

When providing external beam radiation therapy for breast cancer, delivery of more than 33 fractions (inclusive of any boost to the tumor bed) is not medically necessary. The policy allows exceptions (up to 33 fractions) only when listed criteria apply (for example, treatment of supraclavicular/internal mammary nodes, postmastectomy RT, prior thoracic RT, or specified connective tissue disorders).

For locally advanced non-small cell lung cancer treated with external beam radiation (with or without chemotherapy), delivery of more than 35 fractions is not medically necessary. The policy specifies a maximum of up to 35 fractions for these definitive regimens.

When delivering external beam radiation therapy for localized prostate cancer, treatment courses that exceed 45 fractions (inclusive of any boost) are not medically necessary, except where the policy explicitly allows extended courses (up to 45 fractions) for defined high‑risk situations (e.g., pelvic nodal treatment, postprostatectomy radiation, prior pelvic RT, or history of inflammatory bowel disease).

The large NSABP B‑39/RTOG 0413 equivalence trial did not demonstrate overall equivalence of accelerated partial‑breast irradiation (APBI) to whole‑breast irradiation (WBI) for ipsilateral breast tumor recurrence at median 10.2 years (IBTR 4.6% APBI vs 3.9% WBI). Because APBI did not meet the trial’s predefined equivalence criteria overall, selection of APBI should follow the trial‑specific eligibility, technique, and dosing constraints and not be assumed equivalent to WBI for all patients.

Because NSABP B‑39/RTOG 0413 could not establish APBI equivalence to WBI overall, APBI should be restricted to patients and techniques consistent with the evidence base and guideline‑recommended populations. Coverage and selection should align with trial eligibility, modality‑specific dose schedules, and guideline recommendations rather than assuming broad equivalence for all early‑stage breast cancer patients.

Randomized trial evidence (RTOG 0617) showed that escalating dose to 74 Gy (in 2 Gy fractions) with concurrent chemotherapy for unresectable stage III NSCLC was associated with worse overall survival and increased treatment‑related harms compared with standard‑dose therapy. Therefore routine escalation to 74 Gy with concurrent chemotherapy is not routinely indicated and is considered not medically necessary in the absence of compelling, case‑specific justification.

The HYPRO randomized trial (19 fractions of 3.4 Gy) did not establish the hypofractionated regimen as a new standard for intermediate‑ or high‑risk prostate cancer: efficacy outcomes were not superior and reports documented higher acute genitourinary and gastrointestinal toxicity. For these reasons the HYPRO schedule (3.4 Gy × 19 fractions) is not adopted as preferred standard practice and should be approached cautiously or considered nonpreferred unless specific justification is documented.

In guideline and coding resources, IGRT is not indicated for superficial treatment of skin cancers when imaging is used only for superficial/orthovoltage setups, and IGRT is likewise not indicated solely for alignment of bony landmarks without implanted fiducials. Such uses do not meet the clinical scenarios in which IGRT is described as medically necessary (for example, use with IMRT/PBRT, targets abutting prior RT, need for narrow margins, or implanted fiducials).

The policy has removed a prior blanket exclusion that declared IGRT not medically necessary for superficial treatment of skin cancer (including superficial radiation therapy and electronic brachytherapy) when listed criteria are not met. This earlier exclusion language was intentionally eliminated in the current revision; refer to the revised Coverage Criteria for the current IGRT guidance.

Use of IGRT solely to align bony landmarks in the absence of implanted fiducial markers (for example, during palliative radiation therapy) is explicitly listed as not medically necessary. The policy identifies this scenario as an inappropriate indication for IGRT because it does not satisfy the documented circumstances (such as need for soft‑tissue localization, implanted markers, prior RT abutment, or use with high‑conformality techniques) that justify image‑guided localization.

Routine escalation of dose to 74 Gy delivered in 2 Gy fractions with concurrent chemotherapy for unresectable stage III NSCLC is not medically necessary, based on trial results showing worse median overall survival and increased treatment‑related harms compared with standard‑dose concurrent chemoradiation. Such dose escalation should not be pursued routinely and requires clear, case‑specific rationale if considered.

The HYPRO regimen (19 fractions of 3.4 Gy) raised concerns because it failed noninferiority testing for acute GU/GI toxicity and did not demonstrate superiority for efficacy; subsequent reports of 5‑year outcomes did not establish this hypofractionation schedule as a new standard. Because of higher acute toxicity and insufficient superiority data, the HYPRO 3.4 Gy × 19‑fraction schedule is not recommended as routine standard practice.

Applicable Codes and Coding Guidance

Referenced CPT/HCPCS for radiation therapy and special servicesmixed

77331	Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician.
77370	Special medical radiation physics consultation.
77387	Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed.
77399	Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services.
77402	Radiation treatment delivery; Level 1 (e.g., single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed.
77407	Radiation treatment delivery; Level 2, single-isocenter (e.g., 3D or IMRT), photons, including imaging guidance, when performed.
77412	Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (e.g., 2D, 3D, or IMRT) or a single-isocenter photon therapy (e.g., 3D or IMRT) with active motion management, or total skin electrons, or mixed-electron/photon field(s), including imaging guidance, when performed.
77436	Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting.
77437	Surface radiation therapy; superficial, delivery, 150 kV, per fraction (e.g., electronic brachytherapy).
77438	Surface radiation therapy; orthovoltage, delivery, > 150-500 kV, per fraction.

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CPT Codes and ClarificationsCPT

77402	Radiation treatment delivery — Level 1 (Conventional single electron field, multiple electron fields, or 2D photons)
77407	Radiation treatment delivery — Level 2 (Standard single-isocenter 3D or IMRT/VMAT)
77412	Radiation treatment delivery — Level 3 (multiple isocenters with photon therapy, single-isocenter with active motion-management, total-skin electrons, or mixed electron/photon fields)
77387-26	Professional component of image-guided radiation therapy (IGRT)
77436	Megavoltage planning/imaging/treatment — note: should not be reported during superficial/surface/orthovoltage therapy
77437	Megavoltage planning/imaging/treatment — see policy guidance
77438	Megavoltage planning/imaging/treatment — see policy guidance
77439	Megavoltage planning/imaging/treatment — see policy guidance
77331	Special dosimetry — measurement of radiation dose at a specific point using specialized devices (typical 1–6 measurements)
77301	IMRT planning — includes special dosimetry

Hypofractionation fraction size (cGy)

Hypofractionation fraction size240–340 cGy per fraction (external beam)

Definition sourceDefined in Description of Services as external beam RT fraction size between 240 and 340 cGy

Applicable regimens exampleModerate hypofractionation examples referenced elsewhere (e.g., 300 cGy × 20 = 60 Gy)

Hypofractionation fraction size (cGy) — duplicate

Hypofractionation fraction size (repeat)240-340 cGy per fraction (external beam)

Clinical noteUsed to characterize moderate hypofractionation schedules in prostate and other disease sites

Provider Actions, Prior Authorization, and Documentation

Note

Plan-determined coverage and medical records

Coverage is determined by the member-specific benefit plan and applicable laws. Medical records documentation may be required to assess whether the member meets clinical criteria for coverage but does not guarantee coverage.

Benefit coverage is member-plan dependent; inclusion of a code or service in this policy does not guarantee coverage.
Medical records may be requested to determine benefit applicability and to validate clinical criteria.

Prior Authorization

Prior authorization for complex procedures

Prior authorization may be required for complex radiation therapy procedures, special treatment procedures, or special medical physics consultations. Obtain prior authorization when treatment complexity exceeds standard delivery (e.g., multiple isocenters, active motion management, total-skin electrons, mixed electron/photon fields) or when documentation and written analysis by a qualified medical physicist are necessary.

Prior authorization recommended/required for billing special procedure codes or when Level 3 delivery (CPT 77412) is anticipated.

Background and Rationale

Radiation therapy courses typically include a consultation, simulation and planning (including dosimetry and immobilization), technical preparation and quality assurance, delivery of treatment fractions, and follow‑up care. Fractionation refers to dividing the total prescribed radiation dose into separate treatment sessions; hypofractionation denotes larger per‑fraction doses (policy defines hypofractionation as approximately 240–340 cGy per fraction) administered over fewer sessions, while conventional fractionation uses smaller per‑fraction doses given over more sessions. Image‑guided radiation therapy (IGRT) employs imaging at or near the time of treatment (for example, daily cone‑beam CT) to localize the target, reduce setup uncertainty, and enable tighter margins or dose escalation when clinically appropriate.

Definitions and Terminology

Definitive Treatment — definition

Definitive Treatment — short definitionRadiation treatments delivered with curative intent for cancer

Context sourceDefinition aligned with NCCN and National Cancer Institute descriptions

Clinical implicationDefinitive courses commonly include concurrent chemoradiation where indicated and follow guideline dose ranges

Limited Metastatic Disease (prostate) — definition

Limited Metastatic Disease (prostate)Absence of visceral metastasis or fewer than four bone metastases, with no metastasis outside the vertebral bodies or pelvis

SourceDefined in policy (Parker et al., 2018) applicable to prostate cancer selection

OpenPayer

Fractionation, Image-Guidance, and Special Services

Coverage Criteria and Medical Necessity

Applicable Codes and Coding Guidance

Provider Actions, Prior Authorization, and Documentation

Background and Rationale

Definitions and Terminology