CurrentColorado Rocky Mountain Health PlansPolicy 2026R9016A

IMRT simulation and planning reimbursement (CMS 1500 & UB04)

Defines UnitedHealthcare Medicare Advantage reimbursement rules for intensity modulated radiation therapy (IMRT) simulation and planning billed on CMS 1500 and UB04 forms, and who may be affected (providers billing Medicare Advantage plans).

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyIMRT simulation and planning reimbursement (CMS 1500 & UB04)

Policy CodePolicy 2026R9016A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDo not bill IMRT simulation separately when it is included in CPT 77301 unless the simulation supports a separate, distinct non‑IMRT therapy and is reported appropriately.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysProfessional inclusion lookback

14 daysFacility inclusion window

77301IMRT plan code

77280-77290Simulation codes included

IMRT Simulation and Planning Reimbursement Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

IMRT simulation and planning reimbursement criteria

When billed appropriately, IMRT simulation is considered included in the IMRT plan and not separately reimbursed except in specified circumstances.

For professional (HCFA 1500) claims, CPT 77301 (IMRT plan) includes simulation services (CPT 77280-77290) performed in the development of the IMRT plan; these simulation services should not be reported separately when performed on the same or different dates of service unless an exception applies.

For UnitedHealthcare Medicare Advantage purposes, simulation services with a date of service within 90 days prior to the date of service reported for CPT 77301 will be considered included in the IMRT plan when reported by the Same Group Physician and/or Other Health Care Professional (same Federal Tax Identification number).

Procedure-to-procedure edits that apply to the same date of service should not be circumvented by performing the procedures on different dates; IMRT simulation work is considered part of 77301 and should not be reported separately when included by policy rules.

Facility (UB04) inclusion

For hospital outpatient facility claims under OPPS, the following codes are included in the APC payment for CPT 77301: 77014, 77280, 77285, 77290, 77295, 77306-77321, 77331, and 77370.
Services associated with IMRT planning listed above are included in the APC payment for CPT 77301 even if performed on dates of service up to 14 days prior to the date CPT 77301 is reported.

Exceptions - separate and distinct or subsequent simulations

Simulation services performed in support of a separate and distinct non-IMRT radiation therapy for a different tumor may be separately reimbursed when appropriately reported (e.g., reported with modifier 59 or XU to indicate distinct procedural service).
Subsequent IMRT simulations performed after an IMRT plan has been executed to accommodate changes in the tumor or patient condition may be reimbursed when appropriately reported; multiple subsequent simulations may be reimbursed when billed with appropriate modifiers to indicate distinct services.

Policy aligns with AMA and CMS NCCI guidance but clarifies inclusion across different dates of service and the payer's application of the inclusion windows for professional (90 days) and facility (14 days) claims.

Relevant CPT/HCPCS Codes and Billing Windows

IMRT planning and simulation codesCPTCovered

77301	Intensity modulated radiotherapy plan (IMRT plan) — includes simulation work
77280-77290	Simulation codes — considered included in 77301 when performed in development of the IMRT plan
77014	Simulation/Misc codes included in APC payment for 77301 (facility)
77295, 77306-77321, 77331, 77370	Additional planning/simulation codes included in APC payment for 77301 (facility)

Professional inclusion lookback — 90 days (Same Group inclusion rule)

Lookback periodSimulation services reported within 90 days prior to the date of service for CPT 77301 are considered included in the IMRT plan when reported by the Same Group Physician and/or Other Health Care Professional.

Applies toProfessional (HCFA 1500) claims for IMRT planning (CPT 77301)

Included simulation codesCPT 77280-77290 are considered part of the IMRT plan when performed in development of the plan.

ExceptionServices performed in support of a separate and distinct non‑IMRT radiation therapy for a different tumor may be separately reimbursed when appropriately reported.

Facility inclusion window — 14 days (APC inclusion)

Inclusion windowFor hospital outpatient (OPPS/UB04) billing, listed planning/simulation services are included in the APC payment for CPT 77301 even if performed up to 14 days prior to the 77301 date of service.

Included facility CPT codes77014, 77280, 77285, 77290, 77295, 77306–77321, 77331, 77370 are included in the APC payment for 77301.

Applies toHospital outpatient department claims paid under OPPS (UB04)

Billing reminderHospitals must remember the APC inclusion applies across dates of service within the 14‑day window.

Provider Billing and Authorization Notes

Prior Authorization

No prior authorization information included — verify separately

UnitedHealthcare Medicare Advantage reimbursement policies do not include notations regarding prior authorization requirements; providers remain responsible for submitting accurate claims and should verify any plan-specific authorization requirements separately.

This policy does not state any prior authorization requirements for IMRT simulation or planning.
Verify prior authorization requirements with the enrollee's benefit documents or the plan, as this policy may be updated and local plan rules may differ.

Definitions and Service Stages

Definition — 'Same Group' (Federal Tax ID based)

DefinitionAll physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.

UsageUsed to determine when simulation services reported on different dates are considered included with CPT 77301 for professional claims.

ScopeApplies to determination of Same Group Physician and/or Other Health Care Professional in both professional and facility reimbursement rules.

IMRT service stages — Simulation, Treatment Planning, Treatment Delivery

Stage 1: SimulationProcess of defining relevant normal and abnormal target anatomy and acquiring images/data necessary to develop the optimal radiation treatment process; defines exact treatment position (simulation, no treatment delivery).

Stage 2: Treatment PlanningImaging and contouring the treatment target, radiation dose prescribing, dosimetric planning, calculation, and verification.

Stage 3: Treatment DeliveryIntensity modulated treatment delivery (single or multiple fields/arcs) via spatially and temporally modulated beams per treatment session.