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.
No material clinical or coverage changes in this revision.
Coverage Criteria and Medical Necessity
Medical necessity and documentation for treatment delivery and AMM
Covered when ALL of the following are met
Per Prior Authorization Requirements
See Radiation Treatment Delivery definitions and complexity assignment
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.
These do not support CPT 77412.
Biology-Guided Radiation Therapy (BgRT)
Biology-Guided Radiation Therapy (BgRT):
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:
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:
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.
List treated as ANY (one or more indications)
Per policy IGRT commonly used with IMRT.
Modality-specific billing and coverage rules
Billing and modality-specific rules:
Billing prohibition is absolute for SRS/SBRT per policy.
Neutron Beam Therapy — Not Medically Necessary
Covered when ALL of the following are met
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:
Complete Group 1 list as provided in policy
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 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:
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:
Systematic reviews and case series support use in this rare setting.
Uveal melanoma (Group 1)
Covered when ALL of the following are met:
American Brachytherapy Society guidance favors brachytherapy for many medium tumors; PBT preferred for specific large or unsuitable cases.
Sinus tumors (Group 1)
Hepatocellular carcinoma (HCC) — when PBT is medically necessary
Covered when ANY of the following contextual criteria are met (per text):
Multi‑institutional phase II data show high local control; randomized trials ongoing.
These size limits support eligibility considerations.
Seminoma (Group 1)
Covered when ALL of the following are considered:
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
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
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.
Interplay and motion effects are important considerations for thoracic targets.
Dosimetric advantage may not translate to clear clinical superiority.
Multiple randomized and phase II‑III trials are ongoing (eg, PARTIQoL).
Evidence-context coverage statements
Summarized contextual criteria and statements from the excerpt:
Multiple ongoing randomized trials cited.
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.
Document trial identifiers or dosimetric comparisons when applicable.
Coverage stance for indicated disease sites
Coverage stance and criteria within this segment
Document disease site, prior chemo, involved‑site intent, and follow‑up when requesting PBT for lymphoma.
Dosimetric studies exist but clinical risk cautions use outside trials.
Document prior photon therapy and rationale if considering proton boost approaches.
Risk projections are model‑based and insufficient for coverage justification.
Adjuvant Therapy
Adjuvant (post-operative) curative treatment:
SBRT is considered not medically necessary for adjuvant treatment of ACC.
Palliative Therapy
Palliative treatment:
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):
SBRT explicitly considered not medically necessary for postoperative ACC.
Palliative radiation for primary ACC
Covered when palliative intent is documented:
Definitive treatment of anal canal cancer
Covered when definitive external beam photon RT is indicated:
Typically delivered with concurrent chemotherapy per standard of care.
Palliative treatment of anal canal cancer
Covered when palliative intent is documented:
Consistent with NCCN palliation regimens.
Bladder cancer — Non‑muscle invasive and muscle‑invasive
Coverage varies by stage and treatment intent:
IMRT is medically necessary when overlapping prior RT or when optimized 3D plan exceeds organ at risk tolerances.
Non-muscle invasive bladder carcinoma
Not medically necessary
Muscle-invasive bladder carcinoma (T2-T4)
Covered when criteria below are met
IMRT may be used if overlapping prior RT or if 3D plan exceeds OAR tolerances per QUANTEC/NCCN.
Palliative therapy
Covered when ALL conditions below are met
Choice of regimen may be individualized based on symptoms and prognosis.
Whole brain radiation therapy (WBRT)
Covered when ALL of the following are met
Use of 3DCRT for WBRT is considered not medically necessary.
Hippocampal-avoidance WBRT (HA-WBRT)
Covered when ALL of the following are met
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
If >5 fractions are needed as part of a single episode of care, each fraction must be billed as 77407.
Submit consultation and restaging studies for review.
Initial Therapy
Covered when ALL of the following are met
Based on ASTRO guidance and trial data.
Continuation/Retreatment Therapy
Covered when ALL of the following are met
Consultation note and restaging studies required for review.
HA-WBRT with Memantine
Covered when ALL of the following are met
NRG CC001 supports memantine use and hippocampal avoidance to reduce cognitive decline.
Postoperative SRS
Context and limits from randomized trials
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)
| 77412 | Active motion management |
| G0563 | Stereotactic body radiation therapy, treatment delivery, per fraction including image guidance and real-time positron emissions-based delivery adjustments |
| 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. |
| 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). |
| 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). |
| 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. |
| 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. |
| 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. |
| 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 |
Prior Authorization, Documentation, and Operational Guidance
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.
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.
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.
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).
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.
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
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.
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
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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: 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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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)
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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
Revision History
Policy RO.RX.142.A became effective on 2026-11-05.
Document labeled v3.0.2026 in multiple policy sections indicating 2026 versioning (exact revision dates for intermediate updates not provided in excerpt).
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