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CurrentevicorePolicy RO.RX.142.A

Radiation oncology coverage and treatment delivery guidelines

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Defines prior authorization, documentation, and medical necessity requirements for radiation oncology treatments (including radiopharmaceuticals and motion management) for Cigna-administered health benefit plans; intended for providers requesting authorization through eviCore.

Policy Summary

Payerevicore

PolicyRadiation oncology coverage and treatment delivery guidelines

Policy CodePolicy RO.RX.142.A

Change TypeNo material changes

Effective DateNov 5, 2026

Next Review Date

Key ActionInclude detailed documentation of consultation, treatment plan, and active motion management workflow (monitoring system, thresholds, and beam on/off criteria) when requesting authorization for CPT 77412.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2026-11-05effective date

77402/77407/77412key CPTs described

Not coveredBgRT stance

352pDocument length

6+AMM doc elements

Coverage Criteria and Medical Necessity

Medical necessity and documentation for treatment delivery and AMM

Covered when ALL of the following are met

General prior auth and documentation: Request includes a detailed Radiation Oncology consultation (history, physical, diagnosis/staging), radiation prescription and treatment plan with technique and number of fractions prescribed, relevant imaging studies used for staging, and reports from other providers as applicable.

Per Prior Authorization Requirements

Code selection logic: Selection of CPT 77402, 77407, or 77412 is based on medical necessity and treatment complexity (number of treatment sites and delivery complexity), not on technology alone.

See Radiation Treatment Delivery definitions and complexity assignment

Documentation for AMM when claiming 77412: When CPT 77412 (complex delivery with Active Motion Management) is claimed, documentation must demonstrate active intrafraction localization/tracking (eg, fiducials or real-time imaging), the monitoring/gating system used, workflow and parameters, how motion is monitored including thresholds and tolerances, description of monitoring continuity and therapist alerts, and methodology for beam-on/beam-off gating criteria.

Policy Summary

Payerevicore

PolicyRadiation oncology coverage and treatment delivery guidelines

Policy CodePolicy RO.RX.142.A

Change TypeNo material changes

Effective DateNov 5, 2026

Next Review Date

SourceLink

On This Page

Passive techniques or setup-only imaging do not qualify; a brief note such as 'DIBH' alone is insufficient.

Active Motion Management (CPT 77412)

Active Motion Management (AMM) is recognized when ALL of the following are met:

AMM requirements

Required documentation: Provide documentation of: the specific respiratory control or breath-hold technique; identification of the real-time monitoring or gating system; workflow/parameters used for AMM; how motion is monitored including thresholds and tolerances; description of continuous monitoring and therapist alerts; and the methodology determining beam-on and beam-off criteria.
A brief notation such as 'DIBH' or 'active motion management' alone is insufficient.

Exclusions from AMM: Techniques that do not meet AMM include: image guidance used solely for initial setup/verification; SGRT used only for positioning/alignment without active respiratory management; ITV-based planning/4DCT without active gating; abdominal compression without real-time beam control; DIBH without continuous tracking and gated delivery; passive free-breathing techniques.

These do not support CPT 77412.

Biology-Guided Radiation Therapy (BgRT)

Biology-Guided Radiation Therapy (BgRT):

BgRT coverage stance: BgRT (eg, devices described with HCPCS G0563) is considered not medically necessary for all indications and diagnoses due to limited clinical evidence despite device clearance.

CMS HCPCS descriptions note requirement for injected radiopharmaceutical and real-time emission-driven beam adjustments.

Coronary artery brachytherapy — Medically necessary indications

Coronary artery brachytherapy is covered when ANY of the following are met:

Medically necessary indications: A single treatment of intracoronary brachytherapy is medically necessary when either: (A) used as an adjunct to percutaneous coronary intervention (PCI) for in‑stent restenosis (ISR) in a native coronary artery or a saphenous vein graft (SVG) stent; OR (B) for recurrent ISR in patients who are not candidates for repeat drug‑eluting stent (DES) placement or coronary artery bypass grafting (CABG).

All other indications are considered not medically necessary; DES is the preferred therapy per society guidance.

Selected Use for Recurrent ISR or SVG ISR

Covered when clinical evidence and society guidance support use in selected patients:

Selected use logic: Brachytherapy may be considered when patient has recurrent in‑stent restenosis or ISR in a saphenous vein graft and drug‑eluting stent (DES) placement is unsuitable or has failed; professional society guidance prioritizes DES and reserves brachytherapy for select cases unfavourable for repeat DES or surgery.

Prior authorization should document that DES is unsuitable and prior interventions/acute revascularization were attempted.

IGRT medical necessity criteria

Covered when ANY of the following are met for IGRT with 3DCRT; IMRT cases: IGRT considered medically necessary when IMRT has been approved and is being utilized.

3DCRT IGRT indications (any): IGRT with definitive 3DCRT is medically necessary for treatment of: hepatobiliary tract; head and neck cancer; Hodgkin and non‑Hodgkin lymphoma; lung cancer; thymoma/thymic carcinoma; prostate cancer; esophageal cancer; gastric cancer; pancreatic cancer; adrenal gland cancer; pelvic cancers when patient is prone on belly board; during breast boost with photons; external beam APBI; left breast when DIBH used; prone breast treatment; inconsistent breast reproducibility; bladder treatment or bladder boost; sarcomas; merkel cell carcinoma; melanoma; and when PTV is close to previously irradiated area.

List treated as ANY (one or more indications)

IMRT and IGRT: IGRT is considered medically necessary when IMRT has been approved and is being utilized.

Per policy IGRT commonly used with IMRT.

Modality-specific billing and coverage rules

Billing and modality-specific rules:

SRS/SBRT billing: For SBRT, IGRT codes are bundled and may not be billed separately; IGRT codes may also not be billed separately with SRS per ASTRO coding guidance.

Billing prohibition is absolute for SRS/SBRT per policy.

IGRT in brachytherapy: Imaging in brachytherapy is medically necessary to verify source position in all but the simplest cases; images may be used for dosimetry and applicable simulation/field verification codes (eg, CPT 77280) are appropriate.

Not medically necessary uses of IGRT: Use of IGRT with superficial radiation therapy, electron beam therapy, and for nonmelanomatous skin cancer (other than merkel cell) is considered not medically necessary.

Neutron Beam Therapy — Not Medically Necessary

Covered when ALL of the following are met

Neutron beam therapy not medically necessary: Neutron beam radiotherapy is considered not medically necessary for all indications and diagnoses.

Universal exclusion for neutron therapy per policy

Proton Beam Therapy — Group 1 (Medically Necessary)

Proton beam therapy is considered medically necessary for curative treatment of ANY of the following when metastatic disease is not present:

Group 1 indications list: Includes: individuals with specified cancer syndromes (eg, NF‑1, Li‑Fraumeni, hereditary retinoblastoma, Lynch, BRCA), re‑irradiation with curative intent when cumulative critical structure dose will exceed tolerance, primary bone tumors, primary ocular/uveal melanoma, base of skull tumors (chordoma, chondrosarcoma), primary CNS tumors (excluding IDH wild‑type glioblastoma), spine/spinal cord tumors where photon tolerance would be exceeded, nonmetastatic craniospinal‑requiring tumors, nasopharynx/nasal cavity/paranasal sinuses, unresected T3/T4 or node‑positive head & neck cancers, thymoma/thymic carcinoma, mediastinal lymphomas, thoracic sarcomas, malignant pleural mesothelioma, hepatocellular cancer/intrahepatic cholangiocarcinoma, retroperitoneal sarcomas, single kidney or transplanted pelvic kidney adjacent targets, and children ≤21 years treated with curative intent.metastatic disease absent

Complete Group 1 list as provided in policy

Esophageal cancer is included among Group 1 indications when nonmetastatic.metastatic disease absent

Appears as a specific Group 1 line item

Proton Beam Therapy — Group 2 (Equivalence / Conditional Coverage)

The evidence does not support definitive benefit of PBT over IMRT for these malignancies; coverage depends on health plan and cost-effectiveness:

Group 2 indications: Includes: locally advanced breast cancer when treating internal mammary nodes; glioblastoma (IDH wild‑type); remaining head & neck cases not in Group 1 (eg, T1/T2 node‑negative, postoperative negative margins, periorbital, ipsilateral treatments); Stage II‑III non‑small cell lung cancer; prostate cancer (intact or postoperative); Hodgkin lymphoma; Non‑Hodgkin lymphoma; pancreatic cancer.coverage depends on plan's definition of medical necessity and comparative cost‑effectiveness

Group 2 list spans multiple entries in policy

Proton Beam Therapy — Group 3 (Not Medically Necessary)

Due to insufficient evidence, PBT is considered not medically necessary for the curative treatment of the following diagnoses:

Group 3 indications: Includes: mucosal melanoma; breast cancer (excluding Group 1 or 2); lung cancer (excluding Group 1 or 2); extrahepatic cholangiocarcinoma; adrenal cancers; gastric cancer; kidney cancer; liver metastases treated with curative intent; colon cancer; anal cancer; ovarian cancer; skin cancer; rectal cancer; bladder cancer; many other diagnoses and palliative or metastatic indications as listed in policy.

Assembled from multiple Group 3 entries in the policy; considered not medically necessary for curative intent.

Chordomas and chondrosarcomas of the skull base (Group 1)

Covered when ALL of the following are met:

Chordoma/chondrosarcoma rationale: These rare skull base tumors are treated primarily by surgery and postoperative radiotherapy; PBT is considered medically necessary postoperatively due to tumor location adjacent to critical CNS structures and documented efficacy despite lack of randomized trials.

Systematic reviews and case series support use in this rare setting.

Uveal melanoma (Group 1)

Covered when ALL of the following are met:

Uveal melanoma rationale: PBT achieves high local control (>95%), cause‑specific survival (~85%), and high eye preservation rates; PBT is considered medically necessary particularly when brachytherapy is not optimal (eg, large tumors) or patient is unsuitable for plaque brachytherapy.

American Brachytherapy Society guidance favors brachytherapy for many medium tumors; PBT preferred for specific large or unsuitable cases.

Sinus tumors (Group 1)

Sinus tumors guidance: NCCN guidelines recommend either IMRT or proton therapy for maxillary, paranasal, or ethmoid sinus tumors; PBT is an accepted option per guideline.

Hepatocellular carcinoma (HCC) — when PBT is medically necessary

Covered when ANY of the following contextual criteria are met (per text):

HCC PBT indications: PBT may be medically necessary for unresectable hepatocellular carcinoma (HCC) when the individual is not optimally treated with radiofrequency ablation, SBRT, transarterial therapies, or photon‑based techniques, taking into account lesion size/number per NRG GI003 and prior therapies.NRG GI003 lesion size criteria apply

Multi‑institutional phase II data show high local control; randomized trials ongoing.

NRG GI003 radiographic size criteria: Per NRG GI003: single lesion ≤15 cm; two lesions: no lesion >10 cm; three lesions: no lesion >6 cm. Portal vein involvement with a single lesion ≥1cm and ≤15 cm is allowed.see values

These size limits support eligibility considerations.

Seminoma (Group 1)

Covered when ALL of the following are considered:

Seminoma rationale: For patients with seminoma where radiation is indicated and reduction of integral dose is clinically important (eg, more advanced disease requiring larger fields), PBT is considered medically necessary due to modeled reductions in dose to organs at risk and potential to reduce secondary malignancy risk.

Routine use in stage I is not indicated; PBT valuable in select higher‑risk scenarios.

High-grade gliomas (Group 2)

Covered stance — investigational/limited evidence context

High‑grade glioma evidence: PBT/IMPT demonstrates dosimetric advantages and small series report acceptable outcomes, but clinical benefit compared to IMRT remains unproven and randomized trials (eg, NCT01854554, NRG BN001) are ongoing.

Existing studies include mixed photon/proton regimens and higher than standard dose regimens with noted necrosis risks.

Low-grade gliomas (Group 2)

Covered stance — limited evidence for clinical outcome benefit

Low‑grade glioma evidence: Dosimetric reductions to normal structures with protons are documented, but clinical outcome benefit is not clearly demonstrated in small, heterogeneous series; evidence remains limited.

Modelled reductions in equivalent uniform dose have not translated into proven clinical toxicity reductions.

Evidence summaries and recommended context for PBT by site

Guidance and evidence summaries by disease site — PBT may be considered in select circumstances but generally lacks conclusive superiority; use within trials/registries is recommended for many indications.

Esophageal cancer summary: Dosimetric studies show reduced low‑dose exposure to heart and lung with PBT; retrospective series suggest lower postoperative complications in some cohorts and a randomized trial and additional prospective trials are ongoing to define clinical benefit.

Interplay and motion effects are important considerations for thoracic targets.

Breast cancer summary: PBT reduces heart and lung dose when internal mammary nodes are treated but may increase entrance skin dose and dermatitis; randomized comparisons (eg, RADCOMP) are ongoing to evaluate clinical outcomes.

Dosimetric advantage may not translate to clear clinical superiority.

Prostate cancer summary: Comparative studies and systematic reviews do not show consistent superiority of PBT over IMRT for efficacy or long‑term toxicity; ASTRO recommends PBT for prostate cancer only within prospective trials or registries until comparative evidence matures.

Multiple randomized and phase II‑III trials are ongoing (eg, PARTIQoL).

Evidence-context coverage statements

Summarized contextual criteria and statements from the excerpt:

Prostate context: ASTRO supports PBT for primary prostate cancer only within prospective clinical trials or registries until comparative efficacy is established; documentation of trial enrollment or registry participation is expected when PBT is proposed.

Multiple ongoing randomized trials cited.

Reirradiation context: PBT may be used for reirradiation when photon reirradiation cannot meet normal tissue constraints; selection should demonstrate dosimetric advantage and justification that photon options are insufficient.

Published reirradiation series report moderate control with nontrivial late toxicity; document dosimetric rationale.

Conditional/Investigational coverage (NSCLC, Pancreas, Thoracic/Upper Abdominal tumors)

Coverage stance for proton beam therapy in reviewed indications is conditional and primarily investigational; when covered, it is generally only within trials/registries or when adequate justification and planning demonstrate expected benefit.

General conditions supporting PBT: Use of PBT may be considered when: (1) enrollment in a prospective clinical trial or registry is documented; (2) detailed imaging and staging and performance status are provided; (3) treatment planning demonstrates that normal tissue constraints can be met and that proton planning offers dosimetric advantage or reduced expected toxicity versus photon plans; and (4) robust motion management/immobilization strategies are implemented for thoracic or upper abdominal targets to mitigate interplay and density‑change effects.

Document trial identifiers or dosimetric comparisons when applicable.

Coverage stance for indicated disease sites

Coverage stance and criteria within this segment

Lymphoma (HL/NHL): Early series and registry reports indicate PBT after chemotherapy is feasible with favorable short‑term relapse‑free or progression‑free survival and low rates of grade 3+ nonhematologic toxicities in reported cohorts, but larger studies with longer follow‑up are needed to confirm benefits.evidence: small series, limited follow‑up

Document disease site, prior chemo, involved‑site intent, and follow‑up when requesting PBT for lymphoma.

Anal cancer: PBT for anal cancer is unproven due to limited data and a pilot study reporting two grade 5 adverse events; clinical use remains investigational.evidence: pilot study N=25 with serious AEs

Dosimetric studies exist but clinical risk cautions use outside trials.

Bladder cancer: Evidence is limited to photon pelvic radiation followed by a proton boost series; standalone PBT efficacy is unproven for bladder cancer.

Document prior photon therapy and rationale if considering proton boost approaches.

Secondary malignancy sole indication: Use of PBT solely to reduce the risk of a secondary malignancy is considered not medically necessary due to lack of direct observational evidence.

Risk projections are model‑based and insufficient for coverage justification.

Adjuvant Therapy

Adjuvant (post-operative) curative treatment:

Adjuvant RT high‑risk features: Up to 30 fractions of 3DCRT or IMRT is considered medically necessary when ANY of the following high‑risk features are present: positive surgical margins; high‑grade tumor or Ki‑67 >10%; capsular rupture or tumor spillage; large tumor size.up to 30 fractions

SBRT is considered not medically necessary for adjuvant treatment of ACC.

Palliative Therapy

Palliative treatment:

Palliative RT: Palliative radiation using 3DCRT is considered medically necessary when palliative intent is documented.up to 15 fractions

Adjuvant (postoperative) radiation for primary adrenocortical carcinoma (ACC)

Covered when ANY of the following high‑risk features are present (up to 30 fractions of 3DCRT or IMRT):

Adjuvant ACC coverage: Presence of positive margins OR presence of high‑grade tumor or Ki‑67 >10% OR rupture of capsule OR large tumor size.up to 30 fractions

SBRT explicitly considered not medically necessary for postoperative ACC.

Palliative radiation for primary ACC

Covered when palliative intent is documented:

Palliative ACC: Palliative radiation for primary ACC using 3DCRT is considered medically necessary when intent is documented.up to 15 fractions

Definitive treatment of anal canal cancer

Covered when definitive external beam photon RT is indicated:

Definitive anal canal RT: External beam photon RT using 3DCRT or IMRT is considered medically necessary for definitive treatment of anal canal cancer.Up to 33 fractions delivered in up to 3 phases

Typically delivered with concurrent chemotherapy per standard of care.

Palliative treatment of anal canal cancer

Covered when palliative intent is documented:

Palliative anal canal RT: Palliative 3DCRT for symptom control in anal canal cancer is considered medically necessary when intent is documented.Up to 10 fractions

Consistent with NCCN palliation regimens.

Bladder cancer — Non‑muscle invasive and muscle‑invasive

Coverage varies by stage and treatment intent:

Non‑muscle invasive bladder carcinoma: Radiation therapy for newly diagnosed non‑muscle invasive bladder carcinoma (stages Ta, Tis, T1) is considered not medically necessary.

Muscle‑invasive bladder carcinoma — bladder preservation: For bladder preservation candidates, 20 fractions (hypofractionation) or up to 37 fractions (conventional) using 3DCRT is considered medically necessary.20–37 fractions

IMRT is medically necessary when overlapping prior RT or when optimized 3D plan exceeds organ at risk tolerances.

Preoperative radiation prior to planned cystectomy is considered not medically necessary.

Postoperative radiation after cystectomy: Up to 33 fractions of 3DCRT is considered medically necessary following cystectomy for individuals with pT3‑T4 disease, positive lymph nodes, and/or positive surgical margins.Up to 33 fractions

Medically inoperable bladder cancer: In medically inoperable individuals, up to 37 fractions using 3DCRT is considered medically necessary.Up to 37 fractions

Non-muscle invasive bladder carcinoma

Not medically necessary

Non‑muscle invasive bladder carcinoma (NMIBC): For newly diagnosed non‑muscle invasive bladder carcinoma (stages Ta, Tis, T1), radiation therapy is considered not medically necessary.

Muscle-invasive bladder carcinoma (T2-T4)

Covered when criteria below are met

Definitive bladder preservation (T2‑T4): Use of 20 fractions (hypofractionation) or up to 37 fractions (conventional) using 3DCRT is medically necessary for individuals undergoing bladder preservation for muscle‑invasive bladder carcinoma.20–37 fractions

IMRT may be used if overlapping prior RT or if 3D plan exceeds OAR tolerances per QUANTEC/NCCN.

Preoperative radiation: Radiation therapy prior to planned cystectomy is considered not medically necessary.

Postoperative radiation: Up to 33 fractions of 3DCRT is medically necessary after cystectomy for pT3‑T4 disease, positive nodes, or positive margins.Up to 33 fractions

Medically inoperable disease: In medically inoperable individuals, up to 37 fractions using 3DCRT is medically necessary.Up to 37 fractions

IMRT indications: IMRT is medically necessary if (1) treatment overlaps a previously irradiated area or (2) an optimized 3D conformal plan exceeds OAR tolerances per QUANTEC or NCCN.

Palliative therapy

Covered when ALL conditions below are met

Palliative radiation for bladder cancer: For symptom relief or metastatic disease, palliative radiation using up to 15 fractions of 3DCRT is considered medically necessary.Up to 15 fractions

Choice of regimen may be individualized based on symptoms and prognosis.

Whole brain radiation therapy (WBRT)

Covered when ALL of the following are met

WBRT standard: Whole brain radiation therapy (WBRT) using conventional isodose planning is considered medically necessary up to 10 fractions (eg, 30 Gy in 10 fractions).Up to 10 fractions

Use of 3DCRT for WBRT is considered not medically necessary.

Short‑course WBRT: Shorter course regimens (eg, 20 Gy in 5 fractions) are appropriate for patients with poor performance status or limited life expectancy.20 Gy in 5 fractions

Hippocampal-avoidance WBRT (HA-WBRT)

Covered when ALL of the following are met

HA‑WBRT criteria: Hippocampal‑avoidance WBRT using IMRT (up to 10 fractions) is medically necessary when KPS ≥70 (or ECOG ≤2), absence of leptomeningeal disease, primary histology is not germ cell or lymphoma, and expected survival ≥4 months; memantine use is supported as per trials.Up to 10 fractions

Benefit emerges with ≥4 months expected survival; follow NRG CC001 criteria.

Stereotactic radiosurgery (SRS)

SRS is medically necessary when ALL of the following criteria are met

General SRS medical necessity: KPS ≥70; systemic disease under control or viable systemic options available; absence of leptomeningeal disease; primary histology not germ cell, small cell, or lymphoma; all lesions treatable in a single plan in 1 fraction (SRS) or 2–5 fractions (fractionated SRS); submission of consultation and restaging studies.

If >5 fractions are needed as part of a single episode of care, each fraction must be billed as 77407.

Initial SRS lesion limit: Initial SRS is medically necessary when total number of brain metastases is ≤10.≤10 lesions

Retreatment SRS is medically necessary when total number of brain metastases treated in the last 12 months is ≤15 and other SRS criteria are met.≤15 lesions in prior 12 months

Postoperative SRS is medically necessary for up to 4 resected and unresected lesions individually <5 cm in size.≤4 lesions, each <5 cm

Submit consultation and restaging studies for review.

Initial Therapy

Covered when ALL of the following are met

Initial SRS criteria: 1) Total brain metastases ≤10; 2) KPS ≥70; 3) Systemic disease under control or good systemic options exist; 4) No leptomeningeal disease; 5) Primary histology not germ cell, small cell, or lymphoma; 6) All lesions treatable in a single fraction (SRS) or up to 5 fractions (fractionated SRS).see text

Based on ASTRO guidance and trial data.

Continuation/Retreatment Therapy

Covered when ALL of the following are met

Repeat SRS criteria: 1) Total number of brain metastases treated in the last 12 months ≤15; 2) KPS ≥70; 3) Systemic disease under control or good systemic options exist; 4) No leptomeningeal disease; 5) Primary histology not germ cell, small cell, or lymphoma; 6) All lesions treatable in a single plan in a single fraction (SRS) or up to 5 fractions for fractionated SRS.see text

Consultation note and restaging studies required for review.

HA-WBRT with Memantine

Covered when ALL of the following are met

HA‑WBRT plus memantine: HA‑WBRT with memantine is medically necessary for individuals meeting criteria similar to NRG CC001 (eg, no leptomeningeal disease, KPS ≥70, primary histology excluding lymphoma/germ cell) and expected survival ≥4 months; both arms in NRG CC001 received memantine with WBRT dose 30 Gy.see text

NRG CC001 supports memantine use and hippocampal avoidance to reduce cognitive decline.

Postoperative SRS

Context and limits from randomized trials

Postoperative SRS considerations: Postoperative SRS improved freedom from local recurrence in selected patients with completely resected brain metastases (eg, Mahajan trial) with cavity size limits (generally ≤4 cm); randomized trials (eg, N107C/CEC.3) show cognitive benefits for SRS vs WBRT but with tradeoffs in local and distant brain control and no OS difference—eligibility often excludes prior cranial radiation, leptomeningeal disease, lesions near optic chiasm/brainstem, and germ cell/small‑cell/lymphoma histologies.see trial text

Use trial criteria to guide postoperative SRS decisions and documentation.

Requests for Optune, MRgFUS (MR‑guided focused ultrasound), GliaSite, and HIPEC are not reviewed under the eviCore radiation oncology program and should be directed to Cigna. In addition, radiation treatments delivered during an inpatient stay (for example, non‑breast intraoperative radiation therapy) are out of scope and must be submitted to the health plan for review.

Image guidance or surface guidance used solely for initial setup, positioning, or passive verification does not meet the policy definition of Active Motion Management (AMM) and therefore does not support billing or coverage for AMM-related codes. Examples that do not qualify include image guidance used only for setup/verification, Surface Guided Radiation Therapy (SGRT) used only for positioning/alignment without active respiratory management, internal target volume (ITV) planning without active respiratory gating, abdominal compression without real‑time beam control, and DIBH when continuous tracking and beam‑gated delivery are not documented.

A single intracoronary brachytherapy treatment is considered medically necessary only when used as an adjunct to percutaneous coronary intervention for in‑stent restenosis (ISR) in a native coronary artery or saphenous vein graft (SVG), or for recurrent ISR when the patient is not a candidate for repeat drug‑eluting stent placement or bypass surgery. All other indications for coronary artery brachytherapy that are not listed above are considered not medically necessary.

Biology‑guided radiation therapy (BgRT) is considered not medically necessary for all indications and diagnoses due to limited clinical evidence despite device clearances; relevant billing codes (e.g., G0563) are noted in the policy but do not alter the clinical coverage determination.

Expanded intracoronary brachytherapy indications—such as treatment of new (de novo) stenosis, restenosis at unstented sites of prior PCI, or routine primary prevention of restenosis after stent implantation—are unsupported by sufficient evidence and therefore are considered not medically necessary.

Reiterating the policy position, BgRT is not medically necessary for all indications given the limited clinical evidence base; inclusion of device or HCPCS codes in the document does not equate to support for clinical coverage.

The use of IGRT with superficial radiation therapy or with electron beam therapy is considered not medically necessary. Likewise, IGRT (including ultrasound) for nonmelanomatous skin cancers (other than Merkel cell carcinoma) is considered not medically necessary except where the clinical criteria elsewhere in the policy explicitly permit image guidance.

Neutron beam radiotherapy is considered not medically necessary for all indications and diagnoses and is therefore excluded from coverage under the policy.

For many medium‑sized uveal melanomas, brachytherapy is the preferred or suitable treatment. Proton beam therapy (PBT) is an accepted and medically necessary option particularly for larger lesions or when brachytherapy is not suitable, but brachytherapy remains the recommended approach for many medium lesions per specialty guidance.

There is no compelling evidence that proton beam therapy is medically necessary for primary treatment of prostate cancer; comparative effectiveness data do not demonstrate clear superiority over IMRT, and major specialty guidance recommends use within prospective clinical trials or registries rather than routine adoption.

The role of PBT for localized prostate cancer remains unclear as comparative efficacy evidence is evolving; ASTRO recommends coverage with evidence development and supports proton therapy for prostate cancer primarily in the context of clinical trials or registries.

Routine use of proton beam therapy for the primary treatment of locally‑advanced non‑small cell lung cancer and pancreatic cancer is not supported outside of prospective clinical trials or registries. Existing reports are largely single‑institution or dosimetric studies and do not demonstrate consistent outcome advantages over photon techniques.

Use of proton beam therapy solely to reduce the theoretical risk of a secondary malignancy is considered not medically necessary; available data are modeled or hypothesis‑generating and lack direct observational evidence to justify PBT for this purpose alone.

The references section in this document contains bibliographic citations and does not include additional explicit coverage exclusion statements; it should not be interpreted as adding coverage restrictions beyond the policy text.

Stereotactic body radiation therapy (SBRT) is explicitly considered not medically necessary for adjuvant (postoperative) treatment of primary adrenocortical carcinoma (ACC); the policy supports up to 30 fractions of 3DCRT or IMRT for adjuvant intent when high‑risk features are present and up to 15 fractions for palliative intent.

The policy excludes SBRT for postoperative adjuvant treatment of ACC and also states that radiation given in the preoperative setting prior to a planned cystectomy for bladder cancer is considered not medically necessary.

Radiation therapy for newly diagnosed non‑muscle invasive bladder carcinoma (stages Ta, Tis, T1) is considered not medically necessary per the policy and NCCN guidance referenced in the discussion.

Radiation therapy administered in the preoperative setting prior to a planned cystectomy is explicitly considered not medically necessary and therefore is excluded for routine coverage.

Primary histologies of germ cell, small cell, or lymphoma are excluded from consideration for stereotactic radiosurgery (SRS) under the SRS eligibility criteria and are therefore not appropriate indications for SRS per this policy.

As noted above, Biology‑guided radiation therapy (BgRT) is considered not medically necessary for all indications because clinical evidence demonstrating utility is limited; this statement is reiterated in the policy exclusions.

Routine intracoronary brachytherapy is not supported for primary prevention after stent implantation or for de novo lesions because benefits are transient and a late catch‑up phenomenon has been observed; such expanded uses are therefore considered not medically necessary.

The policy specifies that IGRT used in conjunction with superficial radiation therapy, electron beam therapy, and for most nonmelanomatous skin cancers (except Merkel cell carcinoma) is considered not medically necessary and should not be billed or authorized for those indications.

Proton beam therapy categorized as Group 3 in the policy is considered not medically necessary for curative treatment of the listed diagnoses due to insufficient evidence; providers should refer to the Group 3 list when assessing PBT appropriateness.

Use of PBT for high‑grade gliomas lacks sufficient evidence to demonstrate superiority to IMRT; available series are small and heterogeneous and randomized data are pending, so PBT remains unproven for routine curative use in this indication.

The policy states that proton beam therapy for primary prostate cancer is not supported as medically necessary on a routine basis given the absence of consistent comparative outcome or long‑term toxicity benefit versus IMRT; ASTRO and the policy emphasize use within trials or registries.

The role of PBT for localized prostate cancer remains uncertain pending ongoing randomized trials and the accumulation of comparative effectiveness data; ASTRO recommends coverage with evidence development rather than routine coverage.

PBT is characterized as investigational/unproven for several disease sites (for example locally advanced NSCLC, pancreatic cancer, anal cancer, bladder, cervical/endometrial, gastric, rectal, and many soft tissue sarcomas) where the evidence is limited to dosimetric studies or small series; routine clinical use outside of prospective trials or convincing dosimetric‑to‑clinical benefit demonstrations is not supported.

The policy reiterates that use of proton beam therapy solely to lower modeled or theoretical secondary malignancy risk is considered not medically necessary because direct observational evidence is lacking.

The document's references section lists supporting literature but does not itself include additional statements designating treatments as 'not medically necessary'; coverage determinations are made in the policy text.

The policy explicitly states that SBRT is not medically necessary for adjuvant treatment of primary adrenocortical carcinoma (ACC); adjuvant management instead endorses up to 30 fractions of 3DCRT or IMRT when indicated by high‑risk features.

Stereotactic body radiation therapy in the postoperative adjuvant setting for ACC is considered not medically necessary, and requests for SBRT in this setting are subject to denial per the policy.

Radiation therapy delivered in the preoperative setting prior to a planned cystectomy for bladder cancer is considered not medically necessary and is excluded from routine coverage.

Use of 3DCRT for whole‑brain radiation therapy (WBRT) in place of conventional isodose WBRT planning is considered not medically necessary; the policy specifies that WBRT should be planned with conventional isodose technique and that 3DCRT is not appropriate for WBRT.

Hippocampal‑avoidance WBRT (HA‑WBRT) may be omitted in patients with limited expected survival; the policy notes it is reasonable to forego HA‑WBRT in patients with an expected survival of 4 months given that trial benefits emerge with longer follow‑up.

Coding and Billing (CPT / HCPCS / Modifiers)

Radiation treatment delivery CPT codesCPT

77402	Radiation treatment delivery, >=1 MeV; simple Radiation treatment delivery; Level 1
77407	Radiation treatment delivery, >=1 MeV; intermediate Radiation treatment delivery; Level 2
77412	Radiation treatment delivery, >=1 MeV; complex Radiation treatment delivery; Level 3

Active Motion ManagementCPT

77412

Active motion management

BgRT-related HCPCSHCPCS

G0563

Stereotactic body radiation therapy, treatment delivery, per fraction including image guidance and real-time positron emissions-based delivery adjustments

Coronary artery brachytherapy CPTCPT

77770	HDR radionuclide interstitial or intracavitary brachytherapy; 1 channel
77771	HDR radionuclide interstitial or intracavitary brachytherapy; 2 to 12 channels
77772	HDR radionuclide interstitial or intracavitary brachytherapy; over 12 channels

IGRT-related CPT examplesCPT

77387	Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed.
77439	Surface radiation therapy, superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment.

Neutron Beam Therapy CPTCPT

77423

High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s).

Codes not billable with IGRTCPT

77370	Image guidance code (not to be billed based on use of IGRT per policy).
77470	Image guidance code (not to be billed based on use of IGRT per policy).

Neutron therapy CPT codes tableCPT

77423

High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s).

Proton therapy CPT codes tableCPT

77520	Proton treatment delivery; simple, without compensation.
77522	Proton treatment delivery; simple, with compensation.
77523	Proton treatment delivery; intermediate.
77525	Proton treatment delivery; complex.

Referenced CPT examples / managed codes tableCPT

77407

Radiation treatment delivery, >=1 MeV; intermediate Radiation treatment delivery; Level 2, single isocenter (e.g., 3D or IMRT), photons, including imaging guidance, when performed.

Listed CPT codes (document note)CPT

77407

Radiation treatment delivery, >=1 MeV; intermediate Radiation treatment delivery; Level 2, single isocenter (e.g., 3D or IMRT), photons, including imaging guidance, when performed.

Referenced radiation delivery CPT/HCPCS codesmixed

77407	Radiation treatment delivery, >=1 MeV; intermediate Radiation treatment delivery; Level 2, single isocenter (e.g., 3D or IMRT), photons, including imaging guidance, when performed.
77371	Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based.
77372	Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based.
77373	Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions.
77402	Radiation treatment delivery, >=1 MeV; simple Radiation treatment delivery; Level 1, including imaging guidance, when performed.
G0339	Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment.

Listed CPT codes (table)CPT

77402	Radiation treatment delivery, >=1 MeV; simple Radiation treatment delivery; Level 1
77407	Radiation treatment delivery, >=1 MeV; intermediate Radiation treatment delivery; Level 2, single isocenter
77412	Radiation treatment delivery, >=1 MeV; complex Radiation treatment delivery; Level 3
77770	Guidance, when performed HDR radionuclide interstitial or intracavitary brachytherapy; 1 channel
77771	HDR radionuclide interstitial or intracavitary brachytherapy; 2 to 12 channels
77772	HDR radionuclide interstitial or intracavitary brachytherapy; over 12 channels

Complexity assignment — Selection based on number of treatment sites and complexity

Basis for assignmentSelection of 77402, 77407, or 77412 is based on medical necessity and treatment complexity (number of treatment sites, target, field arrangements, dose planning, prescribed dose, and number of isocenters)

Level 1 (77402) examplesSimple treatments: single electron field, multiple electron fields, or single‑isocenter 2D photons (skin, electron breast boost, bone mets, whole brain)

Level 2 (77407) examplesIntermediate: single‑isocenter 3DCRT or IMRT without active motion management (e.g., prostate, many head & neck, pelvic tumors)

Level 3 (77412) criteriaComplex cases: multiple isocenters, single‑isocenter with active motion management, total skin electrons, or mixed electron/photon fields

Daily IGRT methods — Only one IGRT method or technique allowed daily

Daily IGRT ruleOnly one IGRT method or technique is allowed to be used/billed per patient per treatment day

IMRT contextIGRT is considered medically necessary when IMRT has been approved and is being utilized

3DCRT context examplesIGRT with definitive 3DCRT is medically necessary for select sites (e.g., hepatobiliary, head & neck, lung, prostate, lymphoma)

HCC lesion size limits (NRG GI003) — radiographic size criteria

Single‑lesion limitSingle lesion ≤ 15 cm in greatest dimension (NRG GI003 radiographic criteria)

Two‑lesion limitFor two lesions, no lesion may exceed 10 cm in greatest dimension

Three‑lesion limitFor three lesions, no lesion may exceed 6 cm in greatest dimension

SBRT optimal dose for HCC — dosing and constraints (50 Gy/5 fx guidance)

Preferred SBRT regimen for HCC50 Gy delivered in 5 fractions (optimal guidance)

Mean liver dose targetMean liver dose goal of 13.0 Gy when delivering 50 Gy in 5 fractions

Additional liver constraintLiver Veff < 25% expected with the optimal regimen

Dose reduction guidanceIf constraints cannot be met, reduce dose as low as 30 Gy (with adjusted MLD guidance) per protocol

Mean liver dose constraint for conformal RT — numerical planning constraint

Conformal RT mean liver dose constraintMean liver dose (liver minus GTV) ≤ 28 Gy when using conventional 2 Gy fractions

Clinical contextConstraint intended to protect hepatic reserve when using conformal photon techniques

Apply vs. hepatic functionConsider patient hepatic reserve (Child‑Pugh) when interpreting constraint and modality selection

Ki-67 threshold used as high-risk feature

Ki‑67 high‑risk threshold> 10%

Context of useUsed as a high‑risk feature to support adjuvant radiation for adrenocortical carcinoma (ACC)

Documentation expectationPathology report should document Ki‑67 value to support adjuvant RT decision‑making

Adjuvant RT recommended dose range (per ESE/NCCN citations)

Recommended adjuvant dose range50–60 Gy delivered in approximately 2 Gy fractions

Modality optionsAdjuvant therapy may be delivered with 3DCRT or IMRT per institutional practice and guideline citations (ESE/NCCN)

Fractionation limit for ACCUp to 30 fractions of 3DCRT or IMRT for adjuvant treatment of ACC when high‑risk features present

Maximum lesions for initial SRS — ≤ 10 lesions

Initial SRS lesion capTotal brain metastases ≤ 10 for initial stereotactic radiosurgery

Performance criteriaPatient selection typically requires KPS ≥70 and controlled systemic disease

Fractionation noteSRS may be single fraction or up to 5 fractions for fractionated SRS per criteria

Retreatment lesions limit (last 12 months) — ≤ 15 lesions

Retreatment lesions limit (12 months)Total brain metastases treated in the last 12 months ≤ 15

Retreatment eligibilityRetreatment with SRS requires meeting general SRS criteria (KPS ≥70, no leptomeningeal disease, controllable systemic disease)

Documentation requirementSubmit consultation note and restaging studies to verify prior treatments and systemic control

Maximum metastases count for SRS — <= 10 initial; <= 15 in last 12 months for retreatment

SRS metastases limits summaryInitial SRS: ≤ 10 total brain metastases; Retreatment (within last 12 months): ≤ 15 total treated metastases

Common eligibility conditionsKPS ≥70, controlled systemic disease or available systemic options, absence of leptomeningeal disease, primary histology not germ cell/small cell/lymphoma

Plan logisticsAll lesions must be treatable in a single treatment plan (single fraction SRS or up to 5 fractions for fractionated SRS)

Prior Authorization, Documentation, and Operational Guidance

Prior Authorization

PA applies per health plan; code listing ≠ PA

Prior authorization requirements vary by the member's health plan; the presence of CPT/HCPCS codes in the policy's code tables does not by itself mean the code is managed or requires prior authorization, and prior authorization of a listed code is not a guarantee of payment. Providers must refer to the applicable health plan or Certificate/Evidence of Coverage for specific PA and payment rules.

Prior Authorization

Document AMM (CPT 77412) with realtime tracking and workflow

When requesting CPT 77412 (Active Motion Management), submit documentation showing active intrafraction localization/tracking (e.g., fiducials or real‑time imaging), the specific monitoring/gating system, workflow and parameters, motion thresholds/tolerances, and beam on/off gating criteria; setup-only image guidance or brief notations (eg, “DIBH”) alone are insufficient.

Prior Authorization

BgRT codes noted — BgRT considered not medically necessary

BgRT-related HCPCS (for example G0563) are listed in the coding tables, but the policy states Biology‑Guided Radiation Therapy (BgRT) is considered not medically necessary for all indications; include that BgRT coding does not imply clinical or PA acceptance.

Prior Authorization

When requesting coronary brachytherapy, justify DES unsuitability

For coronary artery brachytherapy requests, prior authorization should document that drug‑eluting stents (DES) are unsuitable or not an option and present clinical justification (e.g., recurrent ISR or SVG ISR where DES/bypass are not viable).

Note

Code listing alone does not establish PA requirement

The inclusion of CPT codes in the policy's tables (e.g., 77387, 77439) does not, by itself, indicate those codes are managed or require prior authorization — check the member's health plan for management and PA details.

Prior Authorization

CPT codes for neutron and proton delivery listed — check plan for PA

The policy lists neutron (77423) and proton delivery CPT codes (77520, 77522, 77523, 77525); inclusion in the policy's tables does not automatically imply these codes require prior authorization — follow the applicable health plan for PA requirements.

Prior Authorization

PBT for HCC: show prior therapies and NRG GI003 size/number criteria

For PBT in unresectable HCC, prior authorization should document that the patient is not optimally treated with radiofrequency ablation, arterial therapies, SBRT, or photon techniques and include lesion size/number per NRG GI003 radiographic criteria when applicable.

NRG GI003 lesion-size criteria (single lesion ≤15 cm; two lesions: none >10 cm; three lesions: none >6 cm) must be documented when applicable

Prior Authorization

Prostate PBT generally only within trials/registries (ASTRO CED)

ASTRO supports Coverage With Evidence Development for prostate PBT; when requesting PBT for prostate cancer, document trial or registry enrollment per ASTRO recommendations.

Prior Authorization

Document trial enrollment or dosimetric justification for PBT/reirradiation

When PBT is proposed within a clinical trial or for reirradiation based on dosimetric advantage, prior authorization should include trial/registry identifiers or a clear dosimetric justification demonstrating advantage over photon planning.

Provide trial/registry identifier(s) (e.g., NCT numbers) when applicable
For reirradiation, include plan comparisons showing proton vs photon normal‑tissue constraints

Prior Authorization

Verify trial/registry enrollment for investigational PBT indications

For PBT requests in locally advanced NSCLC or pancreatic cancer, prior authorization should verify enrollment in an ongoing trial or registry when applicable and provide clinical rationale if treated outside a study.

Prior Authorization

Expect detailed justification for PBT in unproven indications

For indications with limited clinical evidence (anal, bladder, cervical/endometrial, gastric, rectal, soft tissue sarcoma), prior authorization should include detailed clinical rationale referencing limited data and explain why photon therapy or standard approaches are insufficient.

Note

References section does not define PA rules

The references section lists sources only and does not specify prior authorization rules; it should not be interpreted as defining PA requirements.

Prior Authorization

Policy notice: code listing ≠ managed/PA; check health plan

The policy reiterates that inclusion of a code in the document's tables does not imply it is managed or requires prior authorization — providers should check the applicable health plan for PA requirements.

Note

Prior Authorization

PA required for SRS/fractionated SRS — submit consult and staging

Although many CPT codes are listed in tables, prior authorization is specifically required by the payer table for stereotactic radiosurgery (SRS)/fractionated SRS delivery codes; submit consultation and staging/restaging imaging to support eligibility.

Include Radiation Oncology consultation note and relevant restaging studies
Document KPS/ECOG, systemic disease control, and lesion treatability per SRS criteria

Note

Code table present — listing not a PA/payment guarantee

The policy's code table lists radiation delivery and brachytherapy CPT codes but reiterates that listing does not imply prior authorization is required or guarantee payment; verify with the applicable health plan and submit clinical documentation to support medical necessity.

Note

Out‑of‑scope treatments must be directed to Cigna

Requests for Optune, MRgFUS, GliaSite, HIPEC, and certain inpatient radiation treatments (e.g., non‑breast IORT) are out‑of‑scope for eviCore and should be directed to Cigna.

Step Therapy

Sequence: brachytherapy only as adjunct for ISR when DES unsuitable

For coronary artery brachytherapy, a single treatment is considered medically necessary only as an adjunct to PCI for in‑stent restenosis (native artery or SVG) or for recurrent ISR when DES or bypass are not options; prior authorization should reflect this sequence.

Step Therapy

DES preferred first — document why DES not an option before brachytherapy

Professional society guidance prioritizes drug‑eluting stents (DES) over brachytherapy; prior authorization should document why DES is not suitable before approving brachytherapy.

Step Therapy

Follow disease‑specific dosing/technique when PBT determined necessary

When PBT is determined to be medically necessary, follow disease‑specific dosing and technique guidance; if PBT is considered investigational/unproven, disease guidelines for medically necessary photon dosing/technique still apply.

Step Therapy

Sequence for HCC: consider ablation/arterial/SBRT/photons before PBT

For HCC, consider ablative and arterial therapies or conformal EBRT/SBRT before PBT when clinically appropriate; prior authorization for PBT should document why these options are not optimal.

Step Therapy

Step: consider standard photon therapy before prostate PBT; prefer trials

Comparative evidence does not support routine substitution of PBT for IMRT in prostate cancer; consider standard photon therapy first and document trial/registry enrollment if PBT is requested.

Step Therapy

Prostate PBT: evidence‑development pathway — document trial/registry

ASTRO recommends coverage with evidence development for prostate PBT; document prospective trial or registry participation and identifiers when applicable.

Note

Step Therapy

If PBT used as proton boost after photon therapy, document prior photon RT

When PBT is proposed after prior photon pelvic radiation (for example as a boost in bladder or gynecologic cases), prior authorization should document the prior photon treatment and why proton boost is needed.

Note

No step therapy sequences specified in this policy

The policy contains no step‑therapy sequences for these treatments; there are no mandatory step therapy requirements in this material — management decisions depend on the health plan and clinical justification.

Note

Documentation Required

Submit comprehensive Radiation Oncology consult, plan, imaging, and reports

Required documentation to support medical necessity includes a detailed Radiation Oncology consultation (history, physical, diagnosis/stage), radiation prescription and treatment plan with technique and fractions, imaging studies used for staging, and relevant reports from other treating providers.

Documentation Required

AMM documentation: system, workflow, thresholds, and gating details required

For Active Motion Management, provide specific documentation of the active respiratory control/breath‑hold technique, identify the real‑time monitoring/gating system, describe workflow and parameters, motion monitoring thresholds/tolerances, monitoring continuity and therapist alerts, and beam‑on/beam‑off gating methodology; a brief notation (eg 'DIBH') is insufficient.

Specify the system used for intrafraction motion tracking
Describe gating thresholds and beam‑off triggers
Clarify whether monitoring is continuous during beam on

Note

Documentation Required

Document prior interventions and acute revascularization to justify brachytherapy

When requesting brachytherapy for recurrent ISR, submit documentation showing prior interventions and successful acute revascularization and justify why brachytherapy is indicated (e.g., SVG‑ISR evidence), including relevant trial or registry data where applicable.

Billing Rule

Refer to Certificate/Evidence of Coverage for PA/payment terms

The Certificate of Coverage/Evidence of Coverage defines payment terms; providers must verify plan‑specific management (including PA and payment) with the applicable health plan.

Billing Rule

Coding tables: inclusion ≠ PA or payment guarantee — submit clinical support

Coding tables are provided for convenience, but inclusion of a code does not imply it requires prior authorization nor guarantee payment; provide full clinical documentation to support medical necessity and contact the health plan for PA rules.

Documentation Required

Provide registry/trial identifiers and eligibility when PBT delivered in studies

When PBT is delivered within a registry or prospective trial (especially for prostate or investigational indications), include registry/trial documentation and identifiers (e.g., PARTIQoL NCT01617161) and eligibility details in the authorization request.

Documentation Required

Submit staging, performance status, motion management and plan comparisons for PBT

For PBT and other investigational uses, required clinical and planning documentation should include staging imaging (e.g., PET/CT), performance status, motion management/immobilization details, and plan comparisons demonstrating that proton planning meets normal tissue constraints when available.

Documentation Required

Document NRG GI003 lesion size/number and lack of acceptable photon/ablative options for HCC

When selecting PBT for HCC, prior authorization and documentation should include tumor lesion size and number per NRG GI003 radiographic criteria and explain why photon/ablative/arterial/SBRT approaches are not acceptable.

Single lesion ≤15 cm; two lesions: none >10 cm; three lesions: none >6 cm (NRG GI003)

Note

Denial Risk

Incomplete documentation for out‑of‑guideline requests risks denial

Requests that fall outside guideline criteria require medical records documenting the individual's clinical status and rationale for exception; without this information, medical necessity cannot be established and may be denied.

Denial Risk

Duplicate or similar requests require additional clinical detail

Similar or duplicate requests to recently approved treatments will require additional individualized clinical information to determine medical necessity and may be denied without it.

Denial Risk

Brief notations (e.g., 'DIBH') are insufficient — risk of denial

A brief notation such as 'DIBH', 'active motion management', or 'SGRT' alone will not meet medical necessity; requests lacking detailed AMM documentation (system, thresholds, workflow) can be denied.

Note

Denial Risk

Expanded brachytherapy indications unsupported — denial risk

Use of intracoronary brachytherapy for expanded indications (new stenosis, unstented-site restenosis, or routine primary prevention after stent implantation) is unsupported by evidence and may not meet medical necessity.

Denial Risk

PA of a listed code is not a payment guarantee

Inclusion of a code in the policy or a prior authorization does not guarantee payment; providers should be aware that PA of a listed code is not a payment guarantee and plan rules govern coverage.

Denial Risk

Requests deemed NMN/experimental may be denied — supply guideline rationale

Requests determined to be not medically necessary or considered experimental, investigational or unproven may be denied; refer to disease‑specific guideline criteria and provide exception rationale if applicable.

Denial Risk

Hepatic reserve (Child‑Pugh) affects SBRT/PBT suitability

For HCC, sufficient hepatic reserve (Child‑Pugh A) is important; lack of adequate hepatic reserve (e.g., Child‑Pugh B/C) may preclude SBRT and affect modality appropriateness and authorization outcome.

SBRT safety data are limited in Child‑Pugh B; document hepatic reserve

Denial Risk

Prostate PBT requests face coverage caution — prefer trials/registries

There is no compelling evidence that PBT is routinely medically necessary for primary prostate cancer; prior authorization requests for prostate PBT should document trial enrollment or strong justification and may be at risk for noncoverage absent evidence‑development participation.

Denial Risk

Reirradiation with PBT requires dosimetric justification vs photon

Use of PBT for reirradiation must be justified by demonstrating that photon reirradiation cannot cover the target without exceeding normal tissue constraints; absence of such dosimetric justification may risk denial.

Denial Risk

Trial/registry expectation for PBT in NSCLC and pancreas

PBT for the primary treatment of locally‑advanced lung or pancreatic cancer is generally expected to be delivered within prospective trials or registries; lack of trial/registry participation may increase risk of noncoverage or require substantial justification.

Denial Risk

PBT solely for secondary malignancy risk reduction is NMN

PBT solely to reduce theoretical secondary malignancy risk is considered not medically necessary and may be denied; include evidence if claiming reduced secondary malignancy risk.

Denial Risk

SBRT for adjuvant or primary ACC is not medically necessary

Requests for SBRT for adrenocortical carcinoma (ACC), including SBRT in the postoperative adjuvant setting, are considered not medically necessary and may be denied.

Denial Risk

Preoperative RT before planned cystectomy is NMN — risk of denial

Radiation therapy in the preoperative setting prior to planned cystectomy for bladder cancer is considered not medically necessary and may be denied; document treatment intent and staging to avoid inappropriate requests.

Denial Risk

Omit consult/restaging studies at risk of denial for SRS/repeat SRS

Failure to submit the Radiation Oncology consultation note and relevant restaging studies (for SRS or repeat SRS requests) may result in denial because systemic disease control, prior treatments, and performance status cannot be verified.

Denial Risk

Insufficient AMM documentation risks denial

Active Motion Management claims that lack detailed documentation (system, workflow, thresholds, continuous monitoring evidence) are inadequate; brief notations or setup‑only imaging descriptions will not meet medical necessity and may be denied.

Documentation Required

Brachytherapy requests require prior‑intervention evidence to avoid denial

Clinical justification for brachytherapy must demonstrate prior interventions, successful acute revascularization, and why brachytherapy is indicated (e.g., recurrent ISR or SVG‑ISR), or the request may be denied as unsupported.

Background and Evidence Context

Radiation treatment delivery complexity is categorized by CPT codes: 77402 (simple delivery), 77407 (intermediate delivery), and 77412 (complex delivery). Assignment among these levels is determined by treatment complexity, number of treatment sites, isocenters, and technical requirements such as active motion management.

This section provides the references cited throughout the policy, listing the supporting literature used for evidence summaries and rationale; it does not itself impose coverage restrictions or requirements.

Definitions and Key Terms

Active Motion Management (AMM) — intrafraction localization and tracking definition

DefinitionActive Motion Management (AMM) = intrafraction localization and real‑time tracking/gating of target or patient motion to optimize beam delivery during respiration (e.g., fiducials, real‑time imaging, gating)

PurposeUsed to synchronize beam delivery with respiratory cycle to minimize target motion and spare normal tissues

Relation to CPTAMM is referenced in CPT 77412 criteria when claiming complex single‑isocenter photon therapy with active motion control

Passive motion management — definition and examples

DefinitionPassive motion management = techniques that do not actively regulate breathing during delivery (e.g., added margins, 4D planning, rescanning) and do not provide continuous real‑time tracking/gating

ExamplesITV‑based planning, abdominal compression without real‑time control, SGRT used solely for positioning/alignment without respiratory gating

ImplicationPassive techniques do not meet criteria for CPT 77412 AMM documentation

AMM — short code/term definition

Short term definitionAMM — abbreviation for Active Motion Management involving intrafraction localization and tracking of respiratory motion

Coding linkageAMM is the qualifier for complex single‑isocenter photon therapy under CPT 77412

Key technologiesIncludes breath‑hold with continuous tracking, gating, tumor tracking with fiducials or real‑time imaging

DIBH (as AMM requirement) — DIBH alone does not qualify as AMM without continuous tracking

DIBH requirementDIBH alone does not qualify as AMM unless continuous tracking of respiratory motion with image guidance and beam‑gated delivery is used

Documentation noteA brief note 'DIBH' without details of continuous monitoring and beam gating is insufficient for AMM coding

Implication for billingClaims for CPT 77412 citing DIBH must include evidence of continuous tracking/gating to be supported

BgRT — definition: uses injected radiopharmaceutical emissions during delivery

DefinitionBiology‑guided radiation therapy (BgRT) uses an injected radiopharmaceutical to provide emission data during delivery that are used to control or adjust beam delivery in near real time

Regulatory status vs. coverageAlthough specific BgRT devices have FDA clearance, clinical evidence is limited and BgRT is considered not medically necessary for all indications in this policy

Coding exampleBgRT HCPCS example: G0563 referenced in coding tables

Intracoronary brachytherapy (ICBT / VBT) — definition for catheter-based localized radiation to coronary lumen

DefinitionIntracoronary brachytherapy (ICBT/VBT) = catheter‑based localized delivery of beta or gamma radiation to the coronary artery lumen to inhibit neointimal proliferation and reduce in‑stent restenosis

Clinical roleHistorically effective for ISR of native coronaries and saphenous vein grafts; now reserved for select recurrent ISR cases when DES or bypass are not options

Evidence noteRandomized trials and meta‑analyses demonstrate DES superiority in many settings, limiting brachytherapy to selected uses

Drug-eluting stent (DES) — definition and clinical context

DefinitionDrug‑eluting stent (DES) = a coronary stent that releases antiproliferative medication (e.g., sirolimus, paclitaxel) to reduce neointimal hyperplasia and restenosis

Clinical contextDES are the preferred therapy for most in‑stent restenosis cases and have shown superior outcomes vs brachytherapy in multiple trials/meta‑analyses

ImplicationPrior authorization for brachytherapy should document that DES is unsuitable when that is the reason for selecting brachytherapy

IGRT — definition and purpose

DefinitionImage‑guided radiation therapy (IGRT) = use of imaging at or near time of treatment to place the isocenter appropriately and verify target localization

PurposeApplied to improve setup accuracy and target localization, commonly used with IMRT and select 3DCRT cases

Billing noteWhen IGRT is approved, only one method may be used/billed per day; certain IGRT codes (77370/77470) should not be billed based on IGRT use per policy

IMRT — definition and relation to IGRT necessity

DefinitionIMRT = intensity‑modulated radiation therapy; a photon delivery technique that often requires IGRT for safe and accurate delivery

Relation to IGRTIGRT is considered medically necessary when IMRT is approved and being utilized

Coding implicationSelection of treatment delivery codes should reflect complexity of IMRT cases (may support 77407 or 77412 depending on other factors)

Group 1 (PBT) — definition of Group 1 indications

Group 1 definitionPBT Group 1 = indications where proton beam therapy is considered medically necessary for curative intent when no metastatic disease is present (e.g., select pediatric tumors, skull base chordoma/chondrosarcoma, uveal melanoma, certain CNS and sarcoma indications, HCC in select contexts)

Coverage conditionUse typically contingent on absence of metastatic disease and disease‑specific criteria

Coding linkageProton delivery CPT codes 77520/77522/77523/77525 correspond to Group 1 indications in coding table

Group 2 (PBT) — definition of Group 2 indications

Group 2 definitionGroup 2 = indications where evidence does not show definitive benefit of PBT over IMRT; PBT may be considered equivalent to photons and coverage depends on plan definitions and cost‑effectiveness

ExamplesIncludes select glioblastoma IDH wild‑type, stage II–III NSCLC, prostate cancer, some head & neck cases and others listed in policy

Coverage implicationPBT for Group 2 indications may be limited or denied where plans require most cost‑effective equivalent therapy

Group 3 (PBT) — definition of Group 3 indications (not medically necessary)

Group 3 definitionGroup 3 = diagnoses for which PBT is considered not medically necessary due to insufficient evidence of clinical benefit

ExamplesIncludes mucosal melanoma, many breast and lung cases outside Group 1/2, adrenal cancers, gastric, rectal, bladder, and other listed sites

Policy stanceUse of PBT for Group 3 curative indications is classified as not medically necessary

Neutron beam radiotherapy stance — not medically necessary for all indications

StanceNeutron beam radiotherapy is considered not medically necessary for all indications and diagnoses

RationaleLimited research and lack of substantial clinical effectiveness data across multiple tumor types

Operational noteOnly a single clinical neutron facility in the U.S. is noted in discussion (limited availability)

PBT — definition and dosimetric advantages (Bragg Peak)

DefinitionProton beam therapy (PBT) = charged‑particle radiation using the Bragg Peak to concentrate dose at depth, providing potential normal tissue sparing compared to photons

Dosimetric advantageBragg Peak allows reduced exit dose and lower integral dose to surrounding normal tissues, potentially sparing hepatic parenchyma or cardiac/lung structures

Delivery caveatPBT dose distributions are sensitive to tissue density changes and organ motion, requiring robust motion management and planning

SBRT — definition and common use in HCC

DefinitionSBRT = stereotactic body radiation therapy; highly conformal external beam radiation used for small to moderate number of lesions (commonly used for inoperable HCC)

HCC roleSBRT is a mainstay for inoperable HCC with specific lesion‑number and size constraints and defined liver dose constraints

Dose contextSBRT dosing guidance for HCC described (50 Gy/5 fx optimal with constraints) per NRG GI003 and institutional experience

Total Toxicity Burden (TTB) — trial endpoint definition

DefinitionTotal Toxicity Burden (TTB) = a composite trial endpoint that aggregates multiple adverse events (e.g., pleural effusion, atrial fibrillation) to compare overall toxicity burden between treatment arms

Trial contextUsed as primary endpoint in at least one randomized PBT vs IMRT esophageal trial though not a widely validated clinical endpoint

Interpretation cautionTTB reductions may not directly equate to validated clinical benefits such as survival or validated quality‑of‑life measures

IMPT — intensity-modulated proton therapy definition

DefinitionIMPT = Intensity‑Modulated Proton Therapy, a proton delivery technique that modulates beam intensity to conform dose to complex targets

BenefitAllows improved conformality and sparing of adjacent critical structures compared to passive scattering techniques in certain cases

Planning complexityIMPT increases sensitivity to motion and density changes and generally requires robust planning and verification

Coverage with evidence development — ASTRO approach definition

DefinitionCoverage with evidence development (CED) = ASTRO‑supported approach recommending PBT coverage when delivered within prospective clinical trials or registries to generate comparative effectiveness data

ApplicationOften applied to indications like prostate or locally advanced lung/pancreas where randomized data are pending

DocumentationPrior authorization should document trial/registry enrollment or intention to collect prospective outcomes data

Interplay effects / dose uncertainty — definition and relevance to PBT

DefinitionInterplay effects/dose uncertainty = variations in delivered proton dose caused by organ motion and tissue density changes that can lead to underdosing of target or overdosing of normal tissues

Clinical relevanceParticularly important for thoracic and upper abdominal targets (e.g., pancreas, liver) where respiratory motion and tissue interfaces exist

MitigationRequires robust motion management, adaptive planning, and careful plan verification for safe PBT delivery

Coverage with Evidence Development (CED) — definition per ASTRO citation

DefinitionCoverage with Evidence Development (CED) = providing PBT coverage contingent on participation in prospective trials or registries to collect comparative effectiveness data (ASTRO‑endorsed concept)

Intended useApplied when comparative benefit is unproven and high‑quality randomized data are being collected

Prior authorization implicationRequests may require documentation of trial enrollment or planned prospective data collection

Involved-site / involved nodal PBT — definition from lymphoma series

DefinitionInvolved‑site / involved‑nodal PBT = proton radiation targeted to initially involved lymph nodes/sites following chemotherapy, as reported in lymphoma series

Clinical contextUsed in Hodgkin and selected non‑Hodgkin lymphoma to limit dose to heart/lungs while treating nodal disease after chemo

Evidence noteExisting outcome data are from small series and registries with limited follow‑up

Secondary malignancy risk — definition and evidence caveat

DefinitionSecondary malignancy risk = the potential for a new cancer induced by prior radiotherapy; current evidence is limited and largely model‑based

Policy stanceUse of PBT solely to reduce secondary malignancy risk is considered not medically necessary due to lack of direct observational evidence

Evidence caveatExisting studies are hypothesis‑generating with limited follow‑up and methodological limitations

NCCN Guidelines — definition and role as cited references

DefinitionNCCN Guidelines = National Comprehensive Cancer Network clinical practice guidelines cited for site‑specific treatment recommendations

RoleUsed as referenced authoritative guidance supporting modality, dose, and patient selection statements throughout the policy

Citation practicePolicy references specific NCCN versions (e.g., breast, CNS, esophageal) as supporting sources

High-risk features for adjuvant RT — defined features (margins, grade, Ki-67, capsule rupture, tumor size, nodal involvement)

High‑risk features listedPositive surgical margins; high tumor grade or Ki‑67 >10%; capsular rupture/tumor spillage; large tumor size; regional lymph node involvement

Use casePresence of any listed high‑risk feature supports consideration of adjuvant postoperative radiation (e.g., ACC) up to specified fraction limits

DocumentationPathology and operative reports should document margins, grade/Ki‑67, and evidence of capsule rupture to support adjuvant RT requests

High‑risk features for ACC adjuvant RT — positive margins, high grade or Ki‑67 >10%, etc.

ACC high‑risk criteria (examples)Positive margins; high grade or Ki‑67 >10%; capsular rupture or tumor spillage; large tumor size (e.g., >8 cm per retrospective series)

Adjuvant fraction limitUp to 30 fractions of 3DCRT or IMRT for adjuvant treatment when any high‑risk feature present

Palliative optionUp to 15 fractions of 3DCRT for palliative treatment of ACC

Definitive therapy for anal canal cancer — definition and typical fractionation

DefinitionDefinitive therapy for anal canal cancer = external beam photon RT using 3DCRT or IMRT often with concurrent chemotherapy

Typical fractionationUp to 33 fractions delivered in up to 3 phases for definitive treatment

Guideline basisSupported by RTOG 0529 data for IMRT approaches with concurrent chemo

Ideal bladder preservation candidate — definition and selection criteria

Ideal bladder preservation candidateTumor <5 cm (NCCN suggests <6 cm), visibly complete TURBT, absence of extensive multifocal CIS, no moderate/severe hydronephrosis, and no ureteral obstruction

Recommended sequenceTURBT followed by chemoradiation (concurrent cisplatin) delivering pelvic RT 40–45 Gy then response assessment and consolidation RT if complete response

Fractionation optionsBladder preservation regimens described range 20–37 fractions depending on approach and patient factors

SRS eligibility — performance status and disease control criteria

SRS eligibility core criteriaKPS ≥70; systemic disease controlled or treatable; absence of leptomeningeal disease; primary histology not germ cell/small cell/lymphoma; lesions treatable in single plan (1–5 fractions)

Initial lesion limitInitial SRS appropriate for up to 10 brain metastases

Evidence basisSelection criteria align with ASTRO clinical practice guideline and trial evidence summarized in policy

HA-WBRT — hippocampal-avoidance whole-brain radiotherapy definition

HA‑WBRT definitionHippocampal‑avoidance whole‑brain radiotherapy (HA‑WBRT) = IMRT technique designed to spare the hippocampal regions to reduce neurocognitive decline

Trial contextUse with memantine was employed in randomized trial NRG CC001 demonstrating reduced cognitive decline vs standard WBRT

Eligibility caveatHA‑WBRT may be reasonably omitted in patients with expected survival < 4 months

SRS eligibility (initial management) — <=10 brain metastases, KPS ≥70, controlled systemic disease

Initial SRS eligibility (summary)Patients for initial SRS should have total brain metastases ≤10, KPS ≥70, controlled systemic disease or viable systemic options, no leptomeningeal disease, primary histology not germ cell/small cell/lymphoma

FractionationLesions must be treatable in single fraction (SRS) or up to 5 fractions (fractionated SRS)

DocumentationSubmission of consultation note and restaging imaging required to verify eligibility

Revision History

2026-11-05policy_effectiveLatest

Policy RO.RX.142.A became effective on 2026-11-05.

2026-?version_reference

Document labeled v3.0.2026 in multiple policy sections indicating 2026 versioning (exact revision dates for intermediate updates not provided in excerpt).