CurrentFidelis CarePolicy N/A

Radiation Oncology Utilization Review Matrix (CPT/HCPCS billing groupings)

Defines CPT and temporary HCPCS G-code groupings managed by National Imaging Associates (NIA) for Fidelis Care's Radiation Oncology program to guide claims adjudication and allowable billed substitutions when an authorized procedure exists.

Policy Summary

PayerFidelis Care

PolicyRadiation Oncology Utilization Review Matrix (CPT/HCPCS billing groupings)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionWhen a listed family procedure is authorized by NIA, submit any one of the listed allowable billed groupings on the claim provided member eligibility, appropriate rebundling and diagnosis coding, and service performed within the authorization validity period.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~60CPT/HCPCS codes listed (approximate count from matrix)

MultipleAllowable billed groupings per authorized CPT (substitution allowed within listed group)

Policy Snapshot

This Radiation Oncology Utilization Review Matrix (CPT/HCPCS billing groupings) is CURRENT and defines the CPT and temporary HCPCS G-code groupings managed by National Imaging Associates (NIA) on behalf of Fidelis Care to guide claims adjudication and allowable billed substitutions when an authorized procedure exists.

Policy Snapshot

PayerFidelis Care

PolicyRadiation Oncology Utilization Review Matrix (CPT/HCPCS billing groupings)

Policy CodeN/A

StatusCURRENT

Key ActionUse allowable billed groupings for claims when an authorized CPT exists

Effective

Policy Summary

PayerFidelis Care

PolicyRadiation Oncology Utilization Review Matrix (CPT/HCPCS billing groupings)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

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

Authorization & Substitution Rules

Prior Authorization

NIA manages authorization for listed CPTs

National Imaging Associates, Inc. manages utilization review/authorization for the CPT codes listed in this matrix on behalf of Fidelis Care; authorization must exist for substitution group to apply.

Confirm authorization with NIA before submitting an alternate allowable billed code.

Billing Rule

Allowable billed groupings substitution rule

If a procedure within a listed family is authorized by NIA, any one of the listed 'Allowable Billed Groupings' may be submitted on the claim representing that service, provided member eligibility at time of service, appropriate re-bundling rules, appropriate diagnosis code, and service performed within authorization validity period.

Member eligible at time of service
Appropriate re-bundling rules applied
Claim includes an appropriate diagnosis code
Service performed within the authorization validity period

Documentation Required

Authorization & eligibility requirements

Claims are allowable under these groupings only when the member is eligible at the time of service and the service is performed within the authorization validity period; claims must include an appropriate diagnosis code and follow rebundling rules.

Member eligibility at time of service is required
Service must be within the authorization validity period
Include an appropriate diagnosis code on the claim
Apply applicable re-bundling rules

Billing Rule

Exact-match requirement when not listed

If a family of CPT codes is not listed in this matrix, an exact match is required between the authorized CPT code and the billed CPT code; if no exact match, adjudicate accordingly.

Billing Rule

Temporary HCPCS G-code handling

Medicare-created temporary HCPCS G codes will not be authorized separately but are payable as part of the allowed billable group if the corresponding CPT code is authorized.

Do not request separate authorization for Medicare temporary HCPCS G-codes
G-codes are payable only when the corresponding CPT in the group is authorized

Code Groupings & Allowed Substitutions

CT Guidance / IGRTCPT|HCPCS|mixedCovered

77014	CT Guidance - Planning & IGRT
77387	IGRT
G6001	Temporary HCPCS G-code (IGRT group)
G6002	Temporary HCPCS G-code (IGRT group)
G6017	Temporary HCPCS G-code (IGRT group)

Stereotactic Radiation Therapy / Gamma KnifeCPT|HCPCS|mixedCovered

77371	Treatment Deliveries - Gamma Knife
77372	Treatment Deliveries - Stereotactic Radiation Therapy
77373	Treatment Deliveries - Stereotactic Radiation Therapy
G0339	Temporary HCPCS G-code (Stereotactic group)
G0340	Temporary HCPCS G-code (Stereotactic group)

IMRTCPT|HCPCS|mixedCovered

77385	Treatment Deliveries - IMRT - Simple
77386	Treatment Deliveries - IMRT - Complex
G6015	Temporary HCPCS G-code (IMRT group)
G6016	Temporary HCPCS G-code (IMRT group)

External Beam Radiation Therapy (EBRT)CPT|HCPCS|mixedCovered

77401	Treatment Deliveries - EBRT
77402	Treatment Deliveries - EBRT > 1 MeV; simple
77407	Treatment Deliveries - EBRT > 1 MeV; intermediate
77412	Treatment Deliveries - EBRT > 1 MeV; complex
G6003	Temporary HCPCS G-code (EBRT group)
G6004	Temporary HCPCS G-code (EBRT group)
G6005	Temporary HCPCS G-code (EBRT group)
G6006	Temporary HCPCS G-code (EBRT group)
G6007	Temporary HCPCS G-code (EBRT group)
G6008	Temporary HCPCS G-code (EBRT group)

1–10 of 16

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Port FilmsCPTCovered

77417

Port Films

Neutron BeamCPTCovered

77423

Treatment Deliveries - Neutron Beam

Intraoperative Radiation Therapy (IORT)CPTCovered

77424	Treatment Deliveries - IORT, X-ray or Electron, single treatment session
77425	Treatment Deliveries - IORT, X-ray or Electron

Proton BeamCPTCovered

77520	Treatment Deliveries - Proton Beam
77522	Treatment Deliveries - Proton Beam
77523	Treatment Deliveries - Proton Beam
77525	Treatment Deliveries - Proton Beam

HyperthermiaCPTCovered

77600	Treatment Deliveries - Hyperthermia
77605	Treatment Deliveries - Hyperthermia
77610	Treatment Deliveries - Hyperthermia
77615	Treatment Deliveries - Hyperthermia
77620	Treatment Deliveries - Hyperthermia

Brachytherapy (LDR/HDR)CPT|HCPCS|mixedCovered

77761	Brachytherapy, LDR
77762	Brachytherapy, LDR
77763	Brachytherapy, LDR
77767	Brachytherapy (group member)
77768	Brachytherapy, HDR - Skin Surface
77770	Brachytherapy - Interstitial
77771	Brachytherapy, HDR - Intracavitary/Interstitial
77772	Brachytherapy, HDR - Intracavitary/Interstitial
77778	Brachytherapy, LDR (grouping to 77789)
77789	Brachytherapy, LDR (other)

1–10 of 14

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Clinical / Administrative Context

This matrix contains the CPT-4 codes for which National Imaging Associates, Inc. (NIA) manages utilization review/authorization for Fidelis Care's Radiation Oncology program and is designed to assist in the resolution of claims adjudication and claims questions related to services authorized by NIA. The Allowable Billed Groupings indicate that if a given procedure is authorized, any one of the listed procedure codes in that family may be submitted on a claim for that service provided the member is eligible at the time of service, appropriate rebundling rules are applied, the claim includes an appropriate diagnosis code, and the service is performed within the authorization validity period. If a family of CPT codes is not listed, an exact match between the authorized CPT and the billed CPT is required; Medicare temporary HCPCS G-codes will not be separately authorized but are payable as part of the allowed billable group when the corresponding CPT code is authorized.

What Providers Must Do

Billing Rule

Allowable billed groupings substitution rule

Verify member eligibility at the time of service
Ensure the correct diagnosis code is included on the claim
Confirm applicable re-bundling rules are followed
Bill a listed allowable code within the family only when authorization exists

Billing Rule

Exact-match requirement when not listed

If a family of CPT codes is not listed in this matrix, ensure the billed CPT exactly matches the authorized CPT to avoid adjudication issues.

Billing Rule

Temporary HCPCS G-code handling

Medicare temporary HCPCS G-codes will not be authorized separately; bill G-codes only as payable when the corresponding CPT code in the allowed billable group is authorized.

Do not submit G-codes seeking separate authorization
Bill G-codes only when the corresponding authorized CPT is present in the member's authorization

Documentation Required

Authorization & eligibility requirements

Verify member eligibility at time of service
Confirm service date is within the authorization validity period
Include an appropriate diagnosis code
Apply applicable re-bundling rules

Prior Authorization

NIA manages authorization for listed CPTs

National Imaging Associates, Inc. manages utilization review/authorization for the CPT codes listed in this matrix on behalf of Fidelis Care; authorization must exist for substitution group to apply.

Contact NIA to verify or obtain authorization before billing an alternate allowable code
Do not assume substitution applies without confirmed NIA authorization

OpenPayer

Radiation Oncology Utilization Review Matrix (CPT/HCPCS billing groupings)

Policy Snapshot

Authorization & Substitution Rules

Code Groupings & Allowed Substitutions

Defined Terms

Clinical / Administrative Context

What Providers Must Do

Policy Update Changes