Colorado Rocky Mountain Health Plans Radiation Therapy Coverage

Coverage Criteria

Bone Metastases (Palliative EBRT)

Covered when ALL of the following are met:

Bone metastases EBRT standard: Delivery of up to 10 fractions of radiation therapy for palliative EBRT to a bone metastasis.<=10 fractions

Delivery >10 fractions may be medically necessary for a site that has previously received radiation therapy.

Breast Adenocarcinoma

Covered when ALL of the following are met:

Breast APBI: Delivery of up to 5 fractions for accelerated partial breast irradiation (APBI).<=5 fractions

Breast whole/chest and boost: Delivery of up to 21 fractions (inclusive of a boost to the tumor bed).<=21 fractions

Exceptions allowing up to 33 fractions: Delivery of up to 33 fractions (inclusive of a boost to the tumor bed) when any of the following are met: treatment of supraclavicular and/or internal mammary lymph nodes; post-mastectomy radiation therapy; previous thoracic radiation therapy; or connective tissue disorder (e.g., lupus or scleroderma).<=33 fractions

Locally Advanced Non-Small Cell Lung Cancer

Covered when ALL of the following are met:

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

Delivery >35 fractions is not medically necessary.

Prostate Adenocarcinoma

Covered when ALL of the following are met:

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

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

Prostate localized extended: Delivery of up to 45 fractions for localized prostate cancer when any of the following are met: high-risk disease with pelvic lymph node radiation; post-prostatectomy radiation; history of inflammatory bowel disease (e.g., ulcerative colitis or Crohn's); or prior pelvic radiation therapy.<=45 fractions

Delivery >45 fractions is not medically necessary.

Image-Guided Radiation Therapy (IGRT)

IGRT is medically necessary when ANY of the following are met:

IGRT with advanced techniques/prior RT/fiducials: When used with IMRT or proton beam radiation therapy (PBRT); when the target has received prior radiation or abuts a previously irradiated area; or when implanted fiducial markers are used for localization.

IGRT during specified 3D-CRT Definitive Treatment situations: During Definitive Treatment using 3D-CRT for: breast cancer (including APBI; breast boost with photons; hypofractionated WBI up to 5 fractions; prone positioning; left-sided breast cancer using DIBH), boost treatment of rectal and bladder cancer, esophageal, gastric, head and neck, hepatobiliary, lung, pancreatic cancers, and soft tissue sarcoma.

See policy for breast-specific subconditions.

IGRT with 3D-CRT for other conditions with documentation: IGRT with 3D-CRT may be medically necessary for conditions not listed above when documentation demonstrates one or more of: clinically significant normal tissue sparing with DIBH vs free breathing (comparison plans/DVHs); inability to tolerate immobilization during CT simulation; significant target motion on imaging; or requirement for smaller CTV margins than traditionally used for 3D-CRT.

Evidence- and guideline-based coverage statements

Summarized evidence-based conclusions and guideline recommendations present in the referenced chunks:

Palliative RT for symptomatic bone metastases: Conventional single-fraction (800 cGy/8 Gy x1) and multifraction regimens (e.g., 20 Gy/5 fx, 24 Gy/6 fx, 30 Gy/10 fx) provide equivalent pain relief in many settings; single-fraction regimens have higher retreatment rates but less acute toxicity; SBRT may have a somewhat higher likelihood of pain response in selected patients; re-irradiation can achieve pain response in a substantial proportion of patients.

Based on AHRQ systematic review, meta-analyses, randomized trials (Hartsell), and ASTRO/ESTRO/NCCN guidance.

Guideline-recommended regimens: ASTRO and other guideline groups recommend several acceptable palliative fractionation options (800 cGy x1; 2000 cGy/5 fx; 2400 cGy/6 fx; 3000 cGy/10 fx) and provide specific recommendations for spine indications and re-irradiation.

Guideline consensus supports multiple acceptable fractionations.

Breast radiation coverage summaries

Evidence comparing PBI/APBI and hypofractionated WBI to conventional WBI in early-stage breast cancer:

PBI vs WBI: Partial breast irradiation (PBI/APBI) using multiple modalities (3D-CRT, IMRT, brachytherapy) demonstrates no significant difference versus whole-breast irradiation (WBI) for ipsilateral breast recurrence or overall survival in appropriately selected early-stage patients; IORT showed higher ipsilateral recurrence in some studies. PBI is associated with fewer acute adverse events and similar late adverse events.

Based on AHRQ systematic review and modality-specific trials.

Hypofractionated WBI evidence: Hypofractionated whole-breast irradiation schedules (including five-fraction regimens) have shown non-inferior local control and similar or reduced acute toxicity compared with conventional 50 Gy in 25 fractions; five-fraction schedules were non-inferior in randomized trials (e.g., Brunt et al.).

Requires appropriate verification imaging per trial protocols.

Breast: Hypofractionation and APBI

Covered when consistent with guideline-recommended dose-fractionation schemes and clinical context

Breast HF-WBI and APBI: Whole-breast hypofractionated regimens (e.g., 40 Gy in 15 fractions, 42.5 Gy in 16 fractions) and APBI regimens (e.g., 30 Gy in 5 fractions) are supported for appropriate early-stage patients when delivered per guideline-recommended techniques and imaging verification.

Use of DIBH and DVH comparisons to protect OARs is recommended where applicable.

NSCLC: Definitive chemoradiation dosing

Covered when delivered at guideline-endorsed curative doses with appropriate techniques

Locally advanced NSCLC definitive RT: Definitive chemoradiation for locally advanced NSCLC should use standard-dose RT of approximately 60 Gy in 2 Gy daily fractions; higher dose escalation (e.g., 74 Gy with concurrent chemotherapy) was associated with worse overall survival and increased toxicity and is not supported.>=60 Gy recommended; avoid 74 Gy with concurrent chemotherapy as preferred escalation.

Use IGRT/IMRT as appropriate when organs at risk are proximate to high-dose regions.

Prostate: Moderate hypofractionation

Covered when using evidence-based hypofractionated regimens for localized prostate cancer

Prostate moderate hypofractionation: Moderate hypofractionated EBRT regimens (fraction size approximately 2.4–3.4 Gy; examples include 60 Gy in 20 fractions or 57–60 Gy regimens) are medically appropriate for many low- and intermediate-risk patients and select high-risk patients when pelvic nodes are not treated.fraction size 2.4-3.4 Gy

Counsel patients about small increased acute GU/GI toxicity in some trials; HYPRO regimen (19 × 3.4 Gy) did not show superiority.

Covered with criteria

Guideline-aligned coverage considerations for prostate cancer radiotherapy and IGRT

Prostate hypofractionation candidacy: Moderate hypofractionated EBRT (≈2.4–3.4 Gy/fraction) is recommended for low- and intermediate-risk patients electing radiotherapy and may be considered for selected high-risk patients when pelvic nodes are not treated; daily prostate localization with IGRT is essential for margin reduction and accuracy.

Follow ASTRO/AUA/NCCN guidance and document fractionation regimen and IGRT use in authorization requests.

Pelvic nodal irradiation: For high-risk patients, pelvic nodal irradiation may be offered; when pelvic nodes are treated, IMRT with appropriate nodal doses (e.g., 45–52 Gy) is recommended.

Document fields and intent when prior authorization is requested.

IGRT use and frequency: Daily IGRT (e.g., daily CBCT) for prostate localization is recommended to enable margin reduction and improve treatment accuracy; daily IGRT is associated with reduced acute GU/GI toxicity and improved tumor control metrics compared with less frequent imaging.

Document imaging frequency and QA procedures.

IGRT medically necessary exceptions for Definitive Treatment with 3D-CRT

IGRT may be medically necessary during Definitive Treatment with 3D-CRT when documentation shows ONE OR MORE of the following:

IGRT with 3D-CRT exceptions: DVH comparison: Clinically significant difference in normal tissue sparing between deep inspiration breath hold (DIBH) and free breathing as documented by comparison plans and dose-volume histogram (DVH).

Requires submission of comparison plans/DVHs.

IGRT with 3D-CRT exceptions: immobilization intolerance: Member unable to tolerate immobilization during CT simulation.

Document inability to tolerate immobilization in the record.

IGRT with 3D-CRT exceptions: significant target motion: Significant target motion documented by imaging.

Provide imaging evidence of motion.

Coding and reporting criteria

Guidance extracted from policy history:

Prohibition with 77401: Megavoltage treatment delivery CPT codes listed in the policy (e.g., 77261–77499 group) should not be reported with CPT 77401 throughout the course of treatment.

Applies to the listed CPT codes in the policy clarifications.

Use of 77331 (Special dosimetry): CPT 77331 is intended for dosimetry checks in treatment ports outside normal calculation parameters of the treatment planning system (examples: measuring dose at abutting fields, unusual anatomic situations, unusually small fields, selected brachytherapy situations, verifying dose under bolus).

Report 77331 when scenario matches examples and documentation provided.

Use of 77370 (Special medical radiation physics consultation): CPT 77370 should be reported once for complex circumstances including complex photon/electron interrelationships, brachytherapy, SRS or SBRT, analysis of customized beam modification devices and special blocking procedures, computing fetal dose, or verifying dose under bolus.

Single report per consultation/course when applicable; documentation should justify the consultation.

Indications for CPT 77370

Covered when ANY of the following complex physics consultation circumstances are present:

Situations warranting CPT 77370: Complex interrelationship of photons and electrons.

Situations warranting CPT 77370: Brachytherapy.

Situations warranting CPT 77370: Stereotactic radiosurgery (SRS) or stereotactic body radiation therapy (SBRT).

Situations warranting CPT 77370: Analysis of customized beam modification devices and special blocking procedures.

Situations warranting CPT 77370:

Appropriate use — special medical radiation physics consultation (77370)

CPT 77370 is appropriate and should be reported once when ANY of the following complex circumstances are present:

Situations warranting CPT 77370: Complex interrelationship of photons and electrons; brachytherapy; stereotactic radiosurgery (SRS) or stereotactic body radiation therapy (SBRT); analysis of customized beam modification devices and special blocking procedures; computing the dose to the fetus of a pregnant individual; verifying dose under bolus.

Code should be reported once for the consultation.

Special Codes — When to Report

Codes may be reported once when ALL of the relevant complex conditions apply as described below:

CPT 77370 one-time reporting: Report CPT 77370 once when special medical radiation physics consultation is required for circumstances such as complex photon/electron interrelationships; brachytherapy; SRS/SBRT; analysis of customized beam modification devices and special blocking procedures; computing the dose to the fetus of a pregnant individual; radioisotope treatment; individuals with implanted cardiac devices; fusion by a QMP of 3D image sets from multiple modalities in non-IMRT plans; or verifying dose under bolus.

Documentation should justify the consultation and that it meets the listed criteria.

CPT 77331 usage: Use CPT 77331 for special dosimetry to check dosimetry in treatment ports outside normal planning system parameters (abutting fields, unusual anatomy, unusually small fields, selected brachytherapy situations, verifying dose under bolus).

Provide supporting documentation when reporting.

CPT 77470 one-time reporting: Report CPT 77470 once for special treatment procedures that require extra time/effort (examples: pediatric patients requiring daily anesthesia; total/hemi body irradiation; very difficult setup; combination EBRT and brachytherapy; concurrent cytotoxic chemotherapy and/or targeted therapy; radioimmunotherapy combined with EBRT; hyperthermia; yttrium microsphere therapy). Routine use (e.g., contouring for 3D-CRT/IMRT or routine SBRT/SRS) should not be reported unless extra time/effort is documented.

IGRT is not medically necessary for superficial treatment of skin cancer, including superficial radiation therapy or electronic brachytherapy. ASTRO and the policy state that IGRT should not be used to image solely to align bony landmarks when implanted fiducial markers are not present; such uses do not meet the criteria for IGRT and may be denied if billed as image-guidance services.

AHRQ systematic review evidence found that intraoperative radiotherapy (IORT) was associated with a higher rate of ipsilateral breast recurrence compared with whole-breast irradiation (WBI), with no difference in overall survival; this outcome supports restricting IORT use or considering it cautiously relative to WBI for patients where local control is a priority.

Randomized trial data comparing chemoradiation using standard-dose RT (60 Gy in 2 Gy fractions) versus dose escalation to 74 Gy with concurrent chemotherapy demonstrated worse median overall survival and increased treatment-related harms in the high‑dose arm. Therefore escalation to 74 Gy with concurrent chemotherapy for stage III NSCLC is not supported and may be potentially harmful.

Reports of reirradiation using three-dimensional image‑guided brachytherapy (3D‑IGBT) for recurrent gynecologic malignancies show highly variable local control (approximately 44%–71% at 2–5 years) and a wide range of grade ≥3 toxicities (1.7%–50%); small, heterogeneous series and uncertainty about dose constraints limit firm recommendations. These findings indicate that reirradiation with 3D‑IGBT requires careful case‑by‑case evaluation and detailed documentation of expected benefit versus toxicity before coverage is considered.

Guidelines and the policy clarify that IGRT is not indicated for superficial skin cancer treatments and should not be used solely to align bony landmarks when implanted fiducials are not present. In addition, coding guidance notes that IGRT codes are inappropriate when used to report imaging performed during brachytherapy or when superficial radiation therapy (CPT 77401) is provided.

The policy specifies that a set of megavoltage treatment delivery and related planning/dosimetry codes (including but not limited to CPT codes listed in the policy) should not be reported together with CPT 77401 throughout the course of treatment. Claim lines that combine these megavoltage delivery codes with 77401 may be denied or bundled according to the guidance.

Routine reporting of CPT 77470 for contouring, standard 3D‑CRT/IMRT planning, or routine SBRT/SRS is inappropriate unless documentation demonstrates extra time or effort (for example pediatric daily anesthesia, very difficult setup, combination therapies, or other specified complex circumstances). When additional work is required, supporting documentation must be provided to justify a one‑time report.

The policy enforces fractionation limits by indication: delivery beyond the specified thresholds is considered not medically necessary (for example, >33 fractions for breast cancer inclusive of boost; >35 fractions for locally advanced NSCLC; >45 fractions for localized prostate cancer when extended criteria apply). Exceptions for reirradiation or other clinically justified scenarios require documentation and may be reviewed case by case.

Coding and Billing

Applicable CPT/G- codes referencedmixed

77014	Computed tomography guidance for placement of radiation therapy fields.
77301	IMRT planning (includes special dosimetry).
77331	Special dosimetry (e.g., TLD, microdosimetry).
77370	Special medical radiation physics consultation.
77385	Intensity modulated radiation treatment delivery (IMRT), simple.
77386	Intensity modulated radiation treatment delivery (IMRT), complex.
77387	Guidance for localization of target volume, includes intrafraction tracking.
77399	Unlisted procedure, medical radiation physics/dosimetry/special services.
77401	Radiation treatment delivery, superficial and/or ortho voltage, per day.
77402	Radiation treatment delivery, >=1 MeV; simple.

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Coding Clarifications and NotationsCPT

77401	Superficial radiation therapy (notation added: megavoltage treatment delivery codes should not be reported with 77401).
77261	Planning code listed as not to be reported with 77401.
77262	Planning code listed as not to be reported with 77401.
77263	Planning code listed as not to be reported with 77401.
77332	Planning/delivery code listed as not to be reported with 77401.
77333	Planning/delivery code listed as not to be reported with 77401.
77334	Planning/delivery code listed as not to be reported with 77401.
77306	Dosimetry/planning code listed as not to be reported with 77401.
77307	Dosimetry/planning code listed as not to be reported with 77401.
77316	Code listed as not to be reported with 77401.

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Primary code discussedCPT

77401

Superficial radiation therapy.

CPT codes not reportable with 77401 or discussed in clarificationsCPTNot Covered

77261
77262
77263
77306
77307
77316
77317
77318
77331	Special dosimetry
77332

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Referenced CPT CodesCPTCovered

77370

Special medical radiation physics consultation.

Updated/Highlighted CPT CodeCPTCovered

77370

Special medical radiation physics consultation.

Updated CPT Codes and NotationsCPT

77370	Special medical radiation physics consultation.
77331	Special dosimetry — measurement to check dosimetry outside normal calculation parameters.
77470	Special treatment procedure — one-time reporting for specified complex procedures; routine use not acceptable without documentation.
77401	Referenced in notation regarding reporting prohibitions when provided throughout the course of treatment.

Hypofractionation fraction size — typical per-fraction dose range

Typical per-fraction dose range240–340 cGy per fraction

Quality assurance / daily checks — QA considerations as PTV margins tighten

QA focus as PTV margins tightenEmphasize geometric accuracy assessment in addition to dosimetric accuracy

Frequency of checksImplement daily quality control procedures for CT‑based image‑guidance systems

DocumentationRecord device‑specific QC procedures and verification of imaging‑to‑treatment coordinate registration

Provider Actions and Requirements

Prior Authorization

Provider actions: coding, prior auth, IGRT, and reporting

The following coding lists and billing/reporting guidance are provided for reference and prior authorization purposes. Inclusion of a code does not guarantee coverage. Procedure and diagnosis codes may be used in prior authorization requests and claims review; confirm federal, state, and contract-specific rules for coverage and reimbursement.

Coding list for reference — procedure and diagnosis codes may be used in prior authorization; listing does not imply coverage or guarantee payment (see Applicable Codes).
Prior authorization requests should specify regimen, anatomic site, prior radiation history, and treatment goals to select appropriate fractionation and technique.
For prostate treatments, prior authorization requests must state the fractionation regimen and confirm daily prostate IGRT is planned when requested; include rationale if pelvic nodal irradiation (WPRT) vs prostate-only (PORT) is being considered.
CPT code 77401 (superficial radiation) — megavoltage treatment delivery and numerous planning/dosimetry/physics codes (e.g., 77261-77263, 77306-77307, 77316-77318, 77331, 77333-77336, 77370-77373, 77402, 77407, 77412, 77417, 0394T-0395T, 77427, 77431-77435, 77469, 77470, 77499) should not be reported with 77401 throughout the course of treatment.
CPT 77470 (special treatment procedure) should be reported once for specified complex procedures (see documentation guidance); routine reporting without justification is not acceptable.

Background and Evidence Summary

External beam radiation therapy (EBRT) encompasses techniques such as three‑dimensional conformal RT (3D‑CRT), intensity‑modulated RT (IMRT), stereotactic treatments (SRS/SBRT), and proton beam RT. Image‑guided radiation therapy (IGRT) uses on‑board imaging (for example cone‑beam CT) to localize targets and enable positional corrections prior to delivery. IGRT facilitates margin reduction and improved targeting accuracy but should be applied consistent with indication‑specific criteria and quality‑assurance procedures described in professional guidance.

inv-06 (evidence elements also relevant here): Studies and guideline references summarized

Summarized evidence-based conclusions and guideline recommendations present in the referenced chunks:

Supporting studies and guidelines: Key studies, meta-analyses, and practice guidelines (AHRQ evidence review, Migliorini meta-analysis, Hartsell randomized trial, ASTRO/ESTRO/NCCN guidelines) inform the coverage statements above regarding fractionation choices, comparative effectiveness of single versus multi-fraction palliative RT, and use of IGRT and hypofractionation approaches.

Refer to the cited evidence for study-specific details.

Definitions

Definitive Treatment — Radiation treatments for cancer with curative intent

DefinitionRadiation treatments for cancer with curative intent.

ContextAdded as a formal definition in the policy to clarify use when describing Definitive Treatment scenarios

Implication for IGRTDefinitive Treatment may require IGRT and advanced techniques when delivering curative doses near critical structures

Limited Metastatic Disease (prostate specific) — definition

DefinitionAbsence of visceral metastasis or fewer than four bone metastases with no metastasis outside the vertebral bodies or pelvis.

ApplicabilityUsed specifically for prostate cancer scenarios in which 'limited metastatic disease' candidacy affects fractionation limits

Revision History

2026-04-01policy_update

Template update that removed content/language pertaining to the state of Louisiana.

2025-06-01policy_update

Added language that the policy does not apply to Idaho and Kansas and updated Medical Records Documentation reference; revised breast EBRT services to allow delivery of up to 5 fractions for accelerated partial breast irradiation and added IGRT exceptions when used with 3D‑CRT given specified documentation criteria.

2025-03-01policy_update

Multiple reviews and content revisions including: revised medically necessary services for breast adenocarcinoma (added up to 5 fractions for APBI), added definition of 'Definitive Treatment', clarified IGRT medical necessity when used with 3D‑CRT if documentation shows enumerated criteria, and added coding clarifications for CPT 77401 and CPT 77370 reporting rules.

OpenPayer

Radiation Therapy: Fractionation, Image-Guidance, and Special Services

Coverage Criteria

Coding and Billing

Provider Actions and Requirements

Background and Evidence Summary

Definitions

Revision History