Prior authorization required

Prior authorization (PA) is required for all CPT/HCPCS codes listed in Section 3 of this policy unless the member's benefit plan states otherwise.

Unlisted planning code (77299) requires review

Unlisted planning code 77299 requires individual clinical review and written justification from the radiation oncologist explaining why no established code applies.

• "Unlisted planning code (77299): Requires individual clinical review and written justification" (Section 4A/4A notes)

Prior authorization requires performance status and indication justification

Prior authorization requests must include documented performance status and indication‑specific justification (e.g., oligometastatic intent, re‑irradiation rationale, prior RT records) as required by the applicable delivery or modality criteria.

• Prior auth must document performance status (KPS/ECOG) where required and include indication‑specific rationale
• For proton cases, identify which ASTRO Core Criterion (A, B, or C) is met

Proton beam therapy: Group 1 covered; Group 2 requires enrollment

Proton beam therapy: Group 1 indications are covered when criteria are met; Group 2 indications require patient enrollment in an IRB‑approved clinical trial or multi‑institutional registry with prospective data collection for coverage.

• Group 1: covered when core criteria met (pediatric, CNS, skull base, select adult indications)
• Group 2: coverage conditional on documented enrollment in qualifying trial/registry

Advance authorization and documentation for unlisted/special codes

Advance authorization is required for unlisted procedure codes (77299, 77399, 77799) with written clinical justification; HCPCS A9699 requires documentation of the specific agent and indication per policy.

• 77299/77399/77799: not covered without advance authorization and written justification
• A9699: requires documentation of specific agent, clinical indication, and ordering physician credentials

Proton therapy prior authorization: enrollment or dosimetric justification required

Many adult proton therapy indications require prior authorization to confirm either enrollment in a qualifying trial/registry or submission of patient‑specific comparative dosimetry demonstrating dosimetric superiority over IMRT.

• Proton therapy for many adult indications requires trial/registry enrollment or individual comparative dosimetry
• Absence of required comparative dosimetry for Group 2 or outside Group 1 is grounds for denial

Prior authorization requirements vary by state; federal emergency exceptions apply

Prior authorization requirements and processes vary by state; federal rules prohibit PA for emergency radiation therapy (e.g., malignant spinal cord compression). State laws may also affect PA timelines, exemptions, and reviewer qualifications.

• State variations include Texas PA Gold Card, Maryland NCCN mandate, Indiana/Georgia step‑therapy prohibitions and PA response timelines
• No PA may be required for emergency radiation (No Surprises Act/continuity of care protections)

Full policy reference for prior authorization and documentation

This callout consolidates provider actions and documentation expectations from the full policy where a specific chunk reference was not singularly assigned.

• Refer to Section 4 Universal Prerequisites and Section 3 code list for full PA and documentation requirements

77470 special treatment procedure code: coverage requires documented complex circumstances

Special treatment procedure code 77470 is payable only when one or more specified complex circumstances are documented (e.g., coordinated cytotoxic therapy timing, proton therapy, TBI, pediatric anesthesia, reconstruction of prior plan).

• 77470 is covered in addition to primary RT delivery when listed special circumstances apply and are documented

No step therapy sequencing specified in excerpt

No step therapy sequencing requirements are specified in these policy excerpts; step therapy is not generally applied in this policy text.

Prostate PBT requires documented dosimetric advantage and informed‑consent discussion

For prostate proton therapy (adult patients), prior authorization must include documentation of a documented dosimetric advantage over photon therapy and that the patient was informed of alternative photon, brachytherapy, surgery, and surveillance options.

• Required: CT/MRI confirming T/N stage; DVH demonstrating critical structure protection; documented informed discussion of options

Complexity/step‑down: use lowest complexity that achieves dosimetric goals; document 77412 qualifiers

When lower complexity planning (Level 1) achieves equivalent dosimetric goals, higher complexity levels (Level 2/3) are not medically necessary; IMRT/Level 3 (77412) requires explicit documentation of qualifying complexity factors or risk of downcoding exists.

• If Level 1 achieves equivalent goals, higher complexity is not necessary
• 77412 requires explicit documentation of qualifying factor (e.g., "Multiple isocenters utilized" or "Active motion management (Gating/SGRT) employed")

Maryland: mandatory step therapy override for stage IV cancer per NCCN

In Maryland, step therapy override must be granted for stage IV cancer patients when the prescribed radiation therapy is indicated by NCCN Category 1 or 2A guidelines; denials must include specific clinical rationale beyond non‑NCCN compliance.

• Maryland Insurance Code § 15‑142 mandates step therapy overrides for stage IV cancer per NCCN guidance
• Utilization management staff must recognize NCCN Category 1/2A as mandatory grounds for override

Step therapy prohibitions for advanced/metastatic cancer — state law considerations

Several states in Curative's footprint prohibit step therapy for stage IV/metastatic cancer or require acceptance of NCCN‑recommended treatments (examples: TX, GA, IN, MD); applying step therapy where prohibited risks regulatory noncompliance and denial.

• Texas, Georgia, Indiana, and Maryland include statutory or regulatory prohibitions or mandates related to step therapy for stage IV/metastatic cancer
• Providers should document NCCN‑based indications to support overrides where state law requires

Regulatory references for prior authorization and step therapy

State statutes, regulatory bulletins, and PA reform materials cited in the policy (e.g., Texas TDI, GA OCI Bulletin, DC Law 25‑100, Indiana HB 1114, Maryland Ins. Code) inform prior authorization and step therapy obligations and timelines for providers.

• Policy references multiple state laws and regulatory materials that affect PA timelines and step therapy (see Revision History and Section 7)

Required clinical documentation for prior authorization

All radiation therapy requests must include: confirmed diagnosis, documented performance status (KPS or ECOG), clinical staging with supporting imaging, and a complete physician‑signed radiation prescription meeting the Universal Prerequisites.

• Radiation prescription must include diagnosis with ICD‑10, clinical stage, treatment intent, target volumes (GTV/CTV/PTV), dose prescription, fractions, and modality
• Supporting imaging should be within 90 days of simulation when applicable

Maintain a complete physician‑signed radiation prescription

Providers must maintain a physician‑signed radiation prescription that includes diagnosis with ICD‑10 code(s), stage, explicit treatment intent, target volumes, modality, boost details, dose prescription (total dose, dose per fraction, total fractions), dosimetry type, special parameters/justifications, physics consultation need, concurrent systemic therapy, and OAR dose constraints.

• Prescription must be physician‑signed and include all elements listed in Universal Prerequisites (Section 4)

IMRT documentation: explicit modality, inverse planning, DVH and signed verification

IMRT claims must have documentation explicitly stating the modality is IMRT and that inverse planning was used; the record must include dose constraints for targets and OARs, radiation oncologist signature on isodose distributions and DVHs with date, beam/arc descriptions, and dosimetric verification signed by both radiation oncologist and medical physicist.

• Explicit statements required: "IMRT" and "Inverse planning used"
• Dosimetric verification and signatures with credentials and dates are required

SBRT documentation: performance status, RO evaluation, re‑irradiation and oligometastatic justification

For SBRT prior authorization and claims, document KPS or ECOG score, radiation oncologist evaluation with clinical and technical aspects, oligometastatic justification when applicable, prior RT records for re‑irradiation, and histologic confirmation or MDT rationale for lung SBRT when biopsy is omitted.

• KPS/ECOG mandatory for SBRT
• Prior RT records (dates, fields, doses) required for re‑irradiation; histology preferred for lung SBRT

PBT documentation: ASTRO Core Criterion, DVH, independent verification, comparative dosimetry when required

Proton beam therapy requests must document which ASTRO Core Criterion (A, B, or C) is met, include the treatment prescription with dose‑volume parameters and signed DVHs, patient setup verification methodology, independent dose calculation or measurement verification, and — for cases outside Group 1 — a direct patient‑specific isodose comparison between the proton and best achievable IMRT plan.

• Identify ASTRO Core Criterion met (A, B, or C)
• Submit signed DVHs, independent dose calculation, and patient‑specific proton vs IMRT isodose comparison for non‑Group 1 cases

Proton therapy denial risk: missing enrollment or comparative dosimetry

Proton beam therapy prior authorization will be denied if required trial/registry enrollment or patient‑specific comparative dosimetry is not submitted for Group 2 indications or for Group 1 exceptions that require dosimetric proof.

• Absence of enrollment or comparative dosimetry is grounds for denial
• Ensure enrollment documentation or comparative DVH/isodose files are included with the PA request

Do not submit deleted codes for DOS on/after 2026‑01‑01 — will be denied

When submitting claims, do not bill deleted CPT/HCPCS codes for dates of service on or after January 1, 2026 (including 77401, 77385/77386, 77014, G6001–G6017); such claims will be denied—use the 2026 replacement codes.

• 77401 → use 77437 or 77438 for SRT delivery
• 77385/77386 → use 77407 or 77412 as appropriate
• 77014 and IGRT G‑codes technical components are bundled into delivery codes; use 77387‑26 for professional component

IMRT downcoding risk if 77412 qualifying language is missing

Lack of explicit qualifying documentation (e.g., "Multiple isocenters utilized" or "Active motion management (Gating/SGRT) employed") risks auditors downcoding a 77412 (Level 3) claim to 77407 (Level 2) or denying higher complexity coding.

• Include explicit qualifying phrases in the clinical record to support 77412
• Absence of these statements is grounds for downcoding

SBRT image guidance bundling — do not bill 77387‑26 with 77373 on same DOS

Separately billing the IGRT professional component (77387‑26) with SBRT delivery code 77373 on the same date of service is a billing error and may be denied; image guidance is bundled into SBRT delivery codes.

• Do not bill 77387‑26 separately with 77373 on same DOS for SBRT
• G0339/G0340 follow same bundling rules for Medicare Advantage/Medicaid billing

SBRT boost billing will be denied — SBRT is a standalone course

SBRT codes billed as a boost in addition to a full conventional RT course (i.e., 77373, G0339/G0340 used as a boost) will be denied as SBRT; SBRT is considered a standalone course.

• Do not bill SBRT delivery codes as a boost following full conventional RT
• SBRT must be a complete standalone course ≤5 fractions

77439 ultrasound add‑on: single per course billing and documentation required

SBRT technical add‑on 77439 (ultrasound guidance) is billed once per course and requires documentation of ultrasound guidance at planning; billing 77439 more than once per course or without the primary SRT delivery code will be denied.

• 77439 billed once per course only and must be accompanied by 77437 or 77438
• Document ultrasound guidance performed at planning

SRT documentation: pathology, measurements, photos, surgical rationale, prescription, and KX modifier

SRT claims must include pathology confirming BCC or cSCC, tumor diameter and depth, baseline clinical photographs, documentation why surgery is not primary (nonsurgical candidacy or informed refusal), full radiation prescription, and KX modifier for 77437 when billing under CMS LCD L40179 where applicable.

• Pathology report with histologic subtype and aggressive features
• Tumor measurements and clinical photos
• Document why surgery is not primary; include radiation prescription elements
• Use KX modifier on 77437 under LCD L40179 when applicable

Re‑irradiation documentation: prior RT records required; include Z92.3

For re‑irradiation requests include prior radiation therapy records (dates, fields, total doses) and the diagnosis code Z92.3 (personal history of irradiation) in the documentation; absence may trigger denial.

• Prior RT records are required and Z92.3 should be used to indicate re‑irradiation context

Proton comparative dosimetry required for non‑Group 1 indications

For proton therapy cases outside Group 1, submit a patient‑specific comparative isodose/dosimetry between the proton plan and the best achievable IMRT plan; absence of this comparative dosimetry is grounds for denial.

• Direct patient‑specific isodose comparison required for all Group 2 cases and non‑Group 1 exceptions
• Population or case‑control comparisons are not sufficient

SBRT for specified primary sites requires documented justification per LCD L35076

When SBRT is used as primary treatment for certain specified primary sites (bone, breast, uterine, ovarian), provide documented justification referencing CMS LCD L35076 or individualized clinical rationale; lacking this justification risks denial.

• Provide site‑specific documented justification per LCD L35076 when SBRT used for primary bone, breast, uterine, or ovarian tumors

Electronic brachytherapy not supported — do not bill under SRT codes

Electronic brachytherapy billed under SRT codes is not supported by the policy; document device and modality and do not bill electronic brachytherapy under SRT codes.

• Electronic brachytherapy (Xoft/Axxent) is not medically necessary and must not be billed under SRT codes

Radiation prescription must include all Universal Prerequisite elements and be physician‑signed

The radiation prescription must include the complete set of elements enumerated in Universal Prerequisites (diagnosis ICD‑10, stage, intent, target volumes, modality, boost details, total dose, dose per fraction, total fractions, dosimetry type, OAR constraints) and be signed by the physician.

• Prescription elements a–j per Universal Prerequisites must be present and physician‑signed

Align documentation to CMS LCD standards — failure may prompt denial

If required CMS LCD clinical documentation standards (referenced LCDs: L39553, L35076, L36658, L40179) are not met, Curative may deny the request or request additional information; providers should align documentation to these LCD standards.

• Curative adopts CMS LCD documentation standards as benchmarks; failure to meet them may prompt denial or requests for additional documentation

Coverage is subject to member benefit plan limits

Coverage determinations in this policy reflect medical necessity only and remain subject to the member's specific benefit plan terms, limitations, and exclusions.