Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.31
    OpenPayerPolicy UpdatesRadiation OncologyRegence Breast Cancer IMRT Prior Auth | OpenPayer
    Ask Trek AI about this page
    CurrentRegencePolicy M-MED166

    Intensity Modulated Radiotherapy (IMRT) for Breast Cancer

    Customize your policy alerts

    Sign up for regence Policy M-MED166 alerts

    Get alerted when Policy M-MED166 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Medicare Advantage coverage and prior authorization review for breast cancer IMRT when medical necessity and applicable documentation requirements are met.

    Policy Summary
    PayerRegence
    PolicyIntensity Modulated Radiotherapy (IMRT) for Breast Cancer
    Policy CodePolicy M-MED166
    Change TypeNo material change
    Effective DateJanuary 1, 2026
    Last ReviewDec 1, 2025
    Next Review DateSeptember 1, 2026
    Key ActionSubmit all IMRT requests for review with the required clinical documentation.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Medical necessityCoverage standard
    APBI or prior radiationNo-DVH scenarios
    Color DVHComparative evidence
    Planning and treatmentDenial scope
    6 codesListed codes

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Medical Necessity and Breast Cancer Indications

    General Coverage Requirement

    IMRT is covered only when it is medically necessary.

    IMRT is medically necessary for the member's condition and treatment plan.

    Breast Indications Without DVH Analysis

    For IMRT for Breast Cancer under Medicine Policy No. 166, no dose/volume histogram analysis is required when the policy criteria are met and the treatment involves one of the following indications:

    ALL of the following

    • The service is Intensity Modulated Radiotherapy (IMRT) for Breast Cancer under Medicine Policy No. 166.

    • ONE of the following breast indications

      • Accelerated partial breast irradiation (APBI).
      • Prior radiation to the planned target volume.
    • Physical/chart notes, relevant imaging, tumor type, and tumor location are provided for review.

      When policy criteria are met, the applicable policy may receive auto-approval in the electronic authorization tool.

    Cases Requiring Comparative DVH Analysis

    When the Table 1 policy criteria are not met, submit a color dose/volume histogram and summary analysis to support prior authorization for medically necessary IMRT.

    ALL of the following

    • The applicable criteria from Table 1 are not met.

    • The applicable policy is one of the following

      • Intensity Modulated Radiotherapy (IMRT) for Breast Cancer, Medicine, Policy No. 166.
      • Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk, Medicine, Policy No. 167.
    • A dose/volume histogram is submitted in color with a summary analysis, as described in Section 4 of the IMRT form.

    If a procedure or device lacks scientific evidence regarding safety and efficacy because it is investigational or experimental, the service is noncovered as not reasonable and necessary to treat illness or injury. According to Title XVIII of the Social Security Act, §1862(a)(1)(A), only medically reasonable and necessary services are covered by Medicare. In the absence of a national coverage determination (NCD), local coverage determination (LCD), or other coverage guideline, CMS guidelines allow a Medicare Advantage Organization (MAO) to make coverage determinations using an objective, evidence-based process based on authoritative evidence. The Medicare Advantage Medical Policy—Medicine Policy No. M-MED149—provides further details regarding the plan's evidence-assessment process.

    If IMRT does not meet medical necessity requirements, coverage is denied for the IMRT planning phase as well as the actual treatment.

    Applicable Procedure and Service Codes

    CPT CodesCPT
    77301Intensity modulated radiotherapy plan, including dose volume histograms for target and critical structure partial tolerance specification.
    77338Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan.
    77385Intensity modulated treatment delivery, including guidance and tracking if performed; simple (Not valid for Medicare purposes for physician claims) (Deleted 01/01/2026).
    77386Intensity modulated treatment delivery, including guidance and tracking if performed; complex (Not valid for Medicare purposes for physician claims) (Deleted 01/01/2026).
    HCPCS CodesHCPCS
    G6015Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session (Deleted 01/01/2026).
    G6016Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session (Deleted 01/01/2026).
    Image fusion and treatment planningCPT
    77399Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services.

    Prior Authorization and Documentation Requirements

    Prior Authorization

    Prior Authorization Required for IMRT

    Prior authorization is required for all IMRT requests. Submit each request for review with the required clinical documentation before treatment is provided.

    • Submit all IMRT requests for review.
    • Include the required clinical records, diagnosis coding, radiation history, and any applicable DVH materials.
    Documentation Required

    Clinical History and Tumor Details

    Submit chart notes and medical records describing the member’s clinical history, including the condition, tumor type, and tumor location.

    • Include records sufficient to establish the clinical history and tumor details.

    Clinical Context

    Intensity modulated radiotherapy (IMRT) is a radiation therapy technique that conforms closely to the targeted tumor shape. It can deliver higher radiation doses while minimizing toxicity to surrounding healthy tissue.

    Key Terms

    Intensity modulated radiotherapy (IMRT)
    TechniqueA form of radiation therapy that conforms closely to the targeted tumor shape.
    Clinical purposeAllows higher doses of radiation to be delivered while minimizing toxicity to surrounding healthy tissues.
    Accelerated partial breast irradiation (APBI)
    Full termAccelerated partial breast irradiation.
    Use in this policyA breast cancer IMRT circumstance for which dose/volume histogram analysis is not required when policy criteria are met.
    Dose/volume histogram (DVH)
    Policy Summary
    PayerRegence
    PolicyIntensity Modulated Radiotherapy (IMRT) for Breast Cancer
    Policy CodePolicy M-MED166
    Change TypeNo material change
    Effective DateJanuary 1, 2026
    Last ReviewDec 1, 2025
    Next Review DateSeptember 1, 2026
    Key ActionSubmit all IMRT requests for review with the required clinical documentation.
    SourceLink
    On This Page
    Medical Necessity and Breast Cancer IndicationsApplicable Procedure and Service CodesPrior Authorization and Documentation RequirementsClinical ContextKey Terms
    The summary analysis identifies the organ(s) at risk, dose constraint, source of the constraint, 3D result, IMRT result, and whether the constraint can be met only with IMRT.

    A summary analysis template is available at https://beonbrand.getbynder.com/m/6f8680fbdb40e052/

    Documentation Required

    Specific Diagnosis Coding

    Provide the applicable ICD-10 diagnosis code or codes at the highest level of specificity supported by the clinical documentation.

    • Providers are responsible for reviewing the clinical documentation and coding to the highest level of specificity.
    Documentation Required

    Document Prior Conventional Radiation

    When applicable, document whether the member has already received the maximum amount of radiation delivered by conventional means.

    • State whether the maximum conventional radiation amount has been received.
    • If not applicable, identify that conventional-radiation history is not applicable.
    Documentation Required

    Documentation for Table 1 Breast Indications

    For breast-cancer requests meeting the applicable Table 1 indications, provide physical or chart notes, relevant imaging, tumor type, and tumor location for review. A DVH analysis is not required for these indications.

    • Accelerated partial breast irradiation (APBI).
    • Prior radiation to the planned target volume.
    • Include relevant physical or chart notes and imaging.
    Prior Authorization

    Comparative DVH and Summary Analysis Required

    When Table 1 criteria are not met, submit a color comparative 3D-versus-IMRT dose/volume histogram and a completed summary analysis. The submission should demonstrate that IMRT is needed to meet dose constraints that cannot be achieved through 3D planning.

    • Submit the color DVH and completed summary analysis with the prior authorization request.
    • When possible, render both planning lines on the same graph to facilitate comparison.
    • Use the applicable summary-analysis template when available.
    Documentation Required

    Required DVH Analysis Elements

    The DVH summary analysis must identify each organ at risk, the applicable dose constraint and its source, the 3D result, the IMRT result, and whether the constraint can be met only with IMRT.

    • Organ(s) at risk.
    • Dose constraint.
    • Source of the dose constraint, such as an applicable guideline or publication.
    • Comparative 3D planning result.
    • Comparative IMRT result.
    • Whether the constraint can be met only with IMRT.
    Denial Risk

    Failure to Establish Medical Necessity

    IMRT is covered only when medically necessary. If the request does not establish medical necessity, the denial applies to both the IMRT planning phase and the actual IMRT treatment.

    • Medical necessity must be established before planning and treatment are covered.
    Denial Risk

    Missing Comparative DVH Evidence

    Failure to submit the required color comparative DVH and completed summary analysis may result in denial when Table 1 criteria are not met.

    • The histogram must compare 3D and IMRT planning.
    • The summary analysis must be complete and address the required organs-at-risk and dose-constraint elements.
    Denial Risk

    Incomplete Documentation

    Missing clinical records, diagnosis coding, documentation of prior conventional radiation, or other requested materials may affect the review and the determination.

    • Submit all required documentation with the IMRT request.
    • Incomplete submissions may affect the review outcome.
    Denial Risk

    Investigational or Experimental Service

    Services that lack scientific evidence regarding safety and efficacy because they are investigational or experimental are noncovered as not reasonable and necessary to treat illness or injury.

    • Investigational or experimental services are noncovered.
    Definition
    A graphical comparison of dose and irradiated volume for 3D planning and IMRT planning.
    Clinical useUsed to evaluate whether dose constraints for organs at risk can be achieved.