Currentsierra health and lifePolicy 2026T0613L

Radiation Therapy: Fractionation, Image-Guidance, and Special Services – Commercial and Individual Exchange Medical Policy

Defines medical necessity criteria for fractionation limits, image-guided radiation therapy (IGRT), and special services/dosimetry for external beam radiation therapy (EBRT) across specified disease sites (bone metastases, breast cancer, lung cancer, prostate cancer) for UnitedHealthcare Commercial and Individual Exchange plans. Includes coding clarifications and guidance on when special CPT codes may be used.

Policy Summary

Payersierra health and life

PolicyRadiation Therapy: Fractionation, Image-Guidance, and Special Services – Commercial and Individual Exchange Medical Policy

Policy CodePolicy 2026T0613L

Change TypeCoding clarifications and fractionation updates (material changes)

Effective Date03/01/2026

Next Review DateN/A

Key ActionWhen reporting CPT 77412, document clinical circumstances that justify Level 3 delivery versus Level 2.

SourceLink

POLICY UPDATE CHANGES

Added criterion requiring delivery of up to 10 fractions for accelerated partial-breast irradiation with 3D technique.

Replaced connective tissue disorder wording to specify 'systemic lupus erythematosus or scleroderma' for delivery of up to 33 fractions (inclusive of boost).

Added instruction to refer to coding clarifications in the Applicable Codes section for Image-Guided Radiation Therapy.

Removed language indicating IGRT is not medically necessary for superficial treatment of skin cancer including superficial radiation therapy or electronic brachytherapy when listed criteria are not met.

Updated notation clarifying reporting of radiation treatment delivery levels (CPT 77402/77407/77412) and inclusion of IGRT technical component in those codes; professional IGRT reported as 77387-26.

Updated notation that megavoltage planning/imaging/treatment delivery codes (77436-77439) should not be reported during superficial/surface/orthovoltage therapy; those codes should be used for superficial/surface/orthovoltage RT per policy.

Updated notation regarding special dosimetry (CPT 77331).

Notation added that radiation treatment delivery should be reported using appropriate level of complexity (77402, 77407, 77412) with documentation required when 77412 is used.

When IGRT is used with 2D, 3D, IMRT techniques, the technical component is included under 77402, 77407, and 77412 and should not be reported separately; professional component reported as 77387-26.

Updated notation regarding megavoltage planning, imaging, and treatment delivery codes and their reporting during superficial, surface, or orthovoltage radiation therapy (addresses CPT 77436-77439).

Clarified CPT 77331 use for special dosimetry, including devices used and that 1-6 measurements are typical.

Archived previous policy version 2026T0613K.

4Site-specific fractionation sections included (bone, breast, lung, prostate)

20+CPT codes referenced

ConditionalIGRT coverage depends on criteria

03/01/2026Effective Revision Date

1-6Typical special dosimetry measurements

3Delivery complexity levels (77402/77407/77412)

Coverage Summary

Overview: This policy (Policy Number 2026T0613L, effective 03/01/2026) defines medical necessity criteria and coding guidance for external beam radiation therapy fractionation, image-guided radiation therapy (IGRT), and special services/dosimetry for UnitedHealthcare Commercial and Individual Exchange plans. Coverage stance is mixed/conditional depending on site- and technique-specific criteria.

Scope and disease sites: The policy addresses fractionation limits and IGRT/special services for palliative and definitive EBRT across specified disease sites including bone metastases, breast cancer (including APBI/PBI and whole-breast/chest wall regimens), locally advanced non-small cell lung cancer, and prostate adenocarcinoma.

Key thresholds & quick-reference

Hypofractionation definition>200 cGy per fraction; defined as 240–340 cGy per fraction

Typical hypofractionation examplesASTRO/CHHiP/PROstate trials reference moderate regimens (e.g., 3 Gy x20; 240–340 cGy range)

APBI fraction size (IMRT)Up to 5 fractions for accelerated partial-breast irradiation with IMRT

APBI fraction size (3D technique)Up to 10 fractions for accelerated partial-breast irradiation with 3D technique

Typical special dosimetry measurements1–6 measurements typical for CPT 77331; >6 requires justification/documentation

Delivery complexity reportingReport Level 1/2/3 using CPT 77402 / 77407 / 77412 respectively; 77412 requires documentation to justify Level 3

Effective revision dateEffective 03/01/2026

Medical-Necessity Criteria (by disease site and service)

Bone Metastases - Fractionation

When providing palliative external beam radiation therapy (EBRT) or definitive/locoregional EBRT for the conditions below, the following fractionation rules apply.

When providing palliative EBRT for bone metastases: Delivery of up to 10 fractions of radiation therapy is medically necessary.

Delivery of greater than 10 fractions for the treatment of a site that has previously received radiation therapy (reirradiation) is medically necessary.

Breast Adenocarcinoma - Fractionation

When providing EBRT for breast adenocarcinoma, the following fractionation constructs are medically necessary when documented appropriately.

Accelerated partial-breast irradiation (APBI) options: Delivery of up to 5 fractions when using intensity-modulated radiation therapy (IMRT); or delivery of up to 10 fractions when using a 3D technique.

Applicable CPT Codes and Coding Clarifications

Delivery Complexity Codes (report one based on complexity)CPTCovered

77402	Level 1 radiation treatment delivery: conventional single electron field, multiple-electron fields, or 2D photons
77407	Level 2 radiation treatment delivery: standard single-isocenter 3D or IMRT/VMAT
77412	Level 3 radiation treatment delivery: multiple isocenters, single-isocenter with active motion management, total-skin electrons, or mixed electron/photon fields; documentation required to justify Level 3

IGRT Professional ComponentCPTCovered

77387-26

Image-guided radiation therapy, professional component

Megavoltage/Superficial Treatment CodesCPTCovered

77436	Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting
77437	Surface radiation therapy; superficial, delivery, 150 kV, per fraction (e.g., electronic brachytherapy)
77438	Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction
77439	Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for cutaneous tumors, per course of treatment

Special Dosimetry and Planning CodesCPTCovered

77331	Special dosimetry: measurement of radiation dose at a specific point using specialized devices; typically 1-6 measurements; beyond requires justification
77301	IMRT planning (includes special dosimetry)

Radiation treatment delivery / Image guidance / Special services (referenced descriptions)CPT

77280	Simple simulation (verification of applicator position for brachytherapy)
77370	Special medical radiation physics consultation
77399	Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services
77402	Radiation treatment delivery; Level 1, including imaging guidance when performed
77407	Radiation treatment delivery; Level 2, single-isocenter, including imaging guidance when performed
77412	Radiation treatment delivery; Level 3, multiple isocenters or active motion-management, including imaging guidance when performed
77436	Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting
77437	Surface radiation therapy; superficial, delivery, 150 kV, per fraction
77438	Surface radiation therapy; orthovoltage, delivery, >150-500 kV, per fraction
77439	Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for cutaneous tumors

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IGRT and delivery-level coding: When IGRT is used with 2D, 3D, or IMRT techniques, the technical component is included in CPT codes 77402, 77407, and 77412 and must NOT be reported separately; the IGRT professional component is reported as 77387-26.

Mapping of technique to delivery levels: Report radiation delivery complexity as 77402 (Level 1) for conventional single-electron/multiple-electron or 2D photon fields; 77407 (Level 2) for standard single-isocenter 3D or IMRT/VMAT; and 77412 (Level 3) only for multiple isocenters, single-isocenter with active motion-management, total-skin electrons, or mixed electron/photon fields — documentation is required to justify use of 77412 versus Level 2.

Megavoltage/superficial reporting rules: Megavoltage planning/imaging/treatment delivery codes (77436–77439) should not be reported during megavoltage therapy for superficial/surface/orthovoltage treatments; instead, CPT codes 77436, 77437, 77438, 77439 apply specifically for superficial/surface/orthovoltage therapy per the policy notation.

Special dosimetry (CPT 77331): IMRT planning (77301) includes special dosimetry. Typical number of 77331 measurements is 1–6; requests for more than six measurements require supporting documentation and case-by-case review.

Provider Actions, Documentation & Billing Rules

Documentation Required

Document justification for Level 3 delivery (CPT 77412)

When reporting Level 3 radiation delivery (CPT 77412), document the specific technical factors that distinguish the service from Level 2 (CPT 77407). The medical record must clearly describe why multiple isocenters with photon therapy, single‑isocenter treatment with active motion‑management techniques, total‑skin electrons, or mixed electron/photon fields were required and how these needs could not be met by Level 2 delivery.

Affected code: CPT 77412
Required documentation: explicit description of circumstances justifying Level 3 vs Level 2 (e.g., number of isocenters, motion‑management technique details, complexity of mixed fields)

Billing Rule

IGRT technical vs professional components

The technical component of image‑guided radiation therapy (IGRT) is included in the megavoltage delivery codes (77402, 77407, 77412) and should not be reported separately. When the professional component of IGRT interpretation is billed, report 77387 with modifier -26 for the professional component. Ensure claims and documentation reflect whether the provider is billing the technical or professional component.

Background, Evidence and Guideline Summary

Background summary: The policy defines core radiation therapy delivery concepts and team roles: radiation treatment is delivered as a prescribed total dose divided into fractions, with the care team led by a radiation oncologist supported by medical physicists, dosimetrists, therapists, nurses, and ancillary staff responsible for planning, dosimetry, device build, delivery, and follow-up.

Fractionation concepts and modalities: Fractionated delivery divides dose into multiple sessions; hypofractionation uses fewer, larger doses (policy defines hypofractionation as 240–340 cGy per fraction), hyperfractionation uses smaller doses given more than once daily, and accelerated fractionation shortens overall treatment time by delivering moderate to large doses twice daily. External beam radiation therapy modalities include 3D conformal RT, IMRT, and proton beam therapy.

Purpose: The policy provides site-specific medical necessity criteria for fractionation limits, IGRT indications, and conditions for special services/dosimetry and clarifies coding/reporting rules to align clinical practice and billing.

Source	Key finding
AHRQ systematic review (Skelly et al., 2023)
Compared dose-fractionation schemes for metastatic bone disease: single- and multiple-fraction EBRT likely have similar overall pain response for initial and reirradiation; single-fraction associated with higher reirradiation rates.
ASTRO guideline (Alcorn et al., 2024)
Strong recommendation for conventional palliative bone RT regimens (e.g., 8 Gy x1, 20 Gy/5, 24 Gy/6, 30 Gy/10) and reirradiation options; supports fractionation limits used in coverage criteria.
NSABP B-39 / RTOG 0413 (Vicini et al., 2019)
Large randomized trial (n≈4,216): APBI did not meet equivalence to WBI for local recurrence (IBTR 4.6% APBI vs 3.9% WBI at median 10.2 years); techniques/subgroups not established for equivalence.
APBI‑IMRT Florence trial (Meattini et al., 2020)
External-beam APBI (30 Gy in 5 once-daily fractions with IMRT) produced low 10‑year IBTR (similar to WBI) with less acute/late toxicity and better cosmesis in selected patients, supporting up-to‑5 fraction APBI with IMRT.
RAPID / Whelan APBI trials (Whelan et al., 2019; RAPID 2019)
External-beam APBI using 38.5 Gy in 10 fractions (twice daily) was noninferior for IBTR at 8 years but had higher late moderate toxicity and worse cosmetic outcomes, implicating fractionation/schedule effects.
START and HF‑WBI trials (Haviland et al., 2013; Whelan et al., 2010)
Hypofractionated whole-breast irradiation (e.g., 40 Gy/15 fx or 42.56 Gy/16 fx) demonstrated noninferiority to conventional 50 Gy/25 fx with comparable long-term outcomes and often lower acute toxicity; supports HF‑WBI regimens cited in policy.
RTOG 0617 (Bradley et al., 2015)
High-dose RT (74 Gy) with concurrent chemotherapy was not superior and was potentially harmful versus 60 Gy for locally advanced NSCLC; supports limits on dose escalation and fractionation guidance.
Murthy et al. (POP-RT/whole pelvic RT) (2021)
Prophylactic whole pelvic radiotherapy improved 5‑year biochemical failure–free survival vs prostate-only RT (95.0% vs 81.2%) in high‑risk prostate cancer; informs exceptions for extended fractionation when pelvic nodes treated.
Prostate hypofractionation RCTs (CHHiP, Catton, Dearnaley, HYPRO summarized)
Moderate hypofractionation (e.g., 60 Gy/20 fx) is noninferior to conventional schedules for many prostate patients (CHHiP, Catton, Dearnaley); some regimens (HYPRO 19x3.4 Gy) had higher acute GU/GI toxicity—guidelines recommend moderate hypofractionation with daily IGRT.
Wang et al. IGRT meta-analysis (2022)
IGRT in prostate cancer reduced acute GU (RR 0.78) and GI toxicity (RR 0.49) and improved biochemical control with daily IGRT versus less frequent imaging; supports IGRT coverage criteria and daily imaging recommendations.
Kilburn et al., RTOG‑0630 and additional IGRT evidence (lung, extremity sarcoma, brachytherapy reviews)
Studies show daily CBCT/IGRT improves local control in locally advanced lung cancer and reduces late toxicities in preoperative extremity sarcoma and supports IGRT when motion/adjacent OARs or tight margins are present; underpins IGRT indications in policy.

Definitions

Definitive Treatment: Radiation treatments for cancer with curative intent (definition updated in policy; full updated wording truncated in the brief).

Limited Metastatic Disease: For prostate cancer only — absence of visceral metastasis or fewer than four bone metastases, with no metastasis outside the vertebral bodies or pelvis.

Hypofractionated radiotherapy: External beam RT with fraction size between 240 cGy and 340 cGy (policy also notes hypofractionation described as fewer and larger doses >200 cGy).

APBI / PBI: Accelerated or partial-breast irradiation — radiotherapy limited to the tumor bed rather than whole-breast irradiation, delivered in fewer fractions.

HF-WBI: Hypofractionated whole-breast irradiation (example schedules include 40 Gy in 15 fractions or 42.5 Gy in 16 fractions).

IGRT: Image-guided radiation therapy — imaging during treatment for accurate target localization and decreased margins.

Special dosimetry: Measurement of radiation dose at a specific point within a treatment area using specialized devices (e.g., TLDs, diodes) when doses fall outside standard planning/equipment calibration; typical measurements are 1–6 and greater numbers require justification.

Thresholds (label/value pairs)

Hypofractionation fraction size

Evidence Notes (select highlights)

Key evidence implications for clinical decisions:

Breast cancer — APBI vs WBI: Large randomized trials show APBI does not consistently meet equivalence to WBI for local recurrence (NSABP B-39: IBTR 4.6% APBI vs 3.9% WBI at median 10.2 years), and some APBI regimens (e.g., twice-daily 38.5 Gy/10 fx) had higher late toxicity and worse cosmetic outcomes; however, selected external-beam APBI regimens (e.g., 30 Gy/5 fx IMRT or 26 Gy/5 fx) have shown noninferiority in specific trials and guideline-supported regimens exist — balance efficacy, toxicity, and cosmesis when selecting APBI.

Breast cancer — hypofractionation: Multiple trials (START, Whelan, FAST-Forward) demonstrate HF-WBI schedules (e.g., 40 Gy/15 fx or 42.56 Gy/16 fx) are noninferior with lower acute toxicity and acceptable long-term outcomes, supporting HF-WBI as a preferred option per guidelines.

Lung cancer — dose escalation harms: RTOG 0617 showed higher-dose radiotherapy (74 Gy) with concurrent chemotherapy was not superior and was potentially harmful versus 60 Gy; avoid routine dose escalation above guideline-recommended ranges for locally advanced NSCLC.

Prostate cancer — hypofractionation noninferiority: Multiple randomized trials and guideline syntheses (CHHiP, Catton, Dearnaley, meta-analyses) support moderate hypofractionation (e.g., 60 Gy/20 fx) as noninferior to conventional regimens for localized disease; guideline recommendations endorse moderate hypofractionation for many patients and daily IGRT for localization.

IGRT benefits: Systematic reviews and cohort data show IGRT (especially daily IGRT) reduces acute GU/GI toxicity and improves biochemical control for prostate cancer and can improve local control and reduce margins in lung and other sites; IGRT may reduce late toxicities in selected settings (e.g., extremity sarcoma) and supports tighter margins/motion management when appropriately documented.

Policy Changes & Revision Notes (effective 03/01/2026)

2026-03-01addedLatest

Added criterion requiring delivery of up to 10 fractions for accelerated partial-breast irradiation with 3D technique.

2026-03-01revisedLatest

Replaced connective tissue disorder wording to specify 'systemic lupus erythematosus or scleroderma' for delivery of up to 33 fractions (inclusive of boost).

2026-03-01added

Policy Summary

Payersierra health and life

PolicyRadiation Therapy: Fractionation, Image-Guidance, and Special Services – Commercial and Individual Exchange Medical Policy

Policy CodePolicy 2026T0613L

Change TypeCoding clarifications and fractionation updates (material changes)

Effective Date03/01/2026

Next Review DateN/A

Key ActionWhen reporting CPT 77412, document clinical circumstances that justify Level 3 delivery versus Level 2.

SourceLink

On This Page

Delivery of up to 21 fractions (inclusive of a boost to the tumor bed) is medically necessary.

Delivery of up to 33 fractions (inclusive of a boost to the tumor bed) is medically necessary when ANY of the following are met: treatment of supraclavicular and/or internal mammary lymph nodes; or postmastectomy radiation therapy; or prior thoracic radiation therapy; or connective tissue disorder such as systemic lupus erythematosus or scleroderma.

Delivery of greater than 33 fractions (inclusive of a boost to the tumor bed) is not medically necessary for breast cancer.

Locally Advanced Non-Small Cell Lung Cancer - Fractionation

When providing EBRT, with or without chemotherapy, for locally advanced non-small cell lung cancer:

Delivery of up to 35 fractions is medically necessary.

Delivery of greater than 35 fractions is not medically necessary.

Prostate Adenocarcinoma - Fractionation

When providing EBRT for prostate adenocarcinoma, fractionation allowances vary by treatment intent and clinical context.

Definitive Treatment in an individual with Limited Metastatic Disease: Delivery of up to 20 fractions is medically necessary.

Localized prostate cancer: Delivery of up to 28 fractions is medically necessary.

Delivery of up to 45 fractions for localized prostate cancer is medically necessary when ANY of the following are met: individual with high-risk prostate cancer is undergoing radiation treatment to pelvic lymph nodes; or radiation therapy is delivered post-prostatectomy; or individual has a history of inflammatory bowel disease (e.g., ulcerative colitis or Crohn disease); or individual has received previous pelvic radiation therapy.

For localized prostate cancer, delivery of greater than 45 fractions is not medically necessary.

Image-Guided Radiation Therapy (IGRT) - Medical Necessity

Image-guided radiation therapy (IGRT) is medically necessary when any of the listed indications are present. When these criteria are not met, IGRT is not medically necessary. Operational notes give examples of acceptable alternatives or clarification for documentation and billing.

ANY of the following

When used with intensity-modulated radiation therapy (IMRT) (e.g., prostate cancer).
When used with proton beam radiation therapy (PBRT).
When the target has received prior radiation therapy or abuts a previously irradiated area.
When implanted fiducial markers are being used for target localization.
During Definitive Treatment using 3D conformal radiation therapy (3D-CRT)
- Breast cancer when any of the following apply: accelerated partial-breast irradiation; breast boost with photons; hypofractionated therapy delivered up to 5 fractions to the whole breast or chest wall; patient treated in prone position; left breast with deep inspiration breath-hold technique.
- During boost treatment of rectal and bladder cancer.
- Esophageal cancer.
- Gastric cancer.
- Head and neck cancer.
- Hepatobiliary cancer.
- Lung cancer.
- Pancreatic cancer.
- Soft tissue sarcoma.
IGRT with 3D-CRT may be medically necessary with documentation showing one or more of the following
- Clinically significant difference in normal tissue sparing between deep inspiration breath-hold and free breathing, documented by comparison plans and dose-volume histogram (DVH).
- Member unable to tolerate immobilization during CT simulation.
- Significant target motion documented by imaging.
- Smaller clinical target volume (CTV) margins are required than traditionally used for 3D-CRT.
When the above criteria are not met, IGRT is not medically necessary, including but not limited to aligning bony landmarks without implanted fiducials (e.g., during palliative radiation therapy).
Operational example: simple portal or kV imaging to align bony anatomy without fiducials for palliative setups is not sufficient to justify separate IGRT billing.

Special Services / CPT Use - Medical Necessity Conditions

Special services and CPT-specific rules: the primary radiation procedure must be medically necessary and documented. The CPT usages below describe when separate reporting may be appropriate and operational limits.

CPT 77331 (Special dosimetry): Use to document measurement of radiation dose at a specific point within a treatment area using specialized devices (e.g., TLDs, OSLDs, diode probes, film, implanted markers). Typical number of measurements is 1–6 depending on clinical need; requests beyond this range require supporting documentation and are reviewed case-by-case. Note: IMRT planning (CPT 77301) includes special dosimetry; do not duplicate billing.

Documentation must justify why measurements fall outside standard planning system parameters or equipment calibration.

CPT 77370 (Special medical radiation physics consultation): Report once when a QMP provides specialized consultation for complex clinical or technical circumstances (e.g., complex photon/electron interrelationships, brachytherapy, SRS/SBRT planning, customized beam modifications, fetal dose computation, specialized brachytherapy equipment, fusion of 3D image sets by QMP).

Report once per course when criteria met; include QMP documentation describing the complexity that necessitated the consultation.

CPT 77470 (Special treatment procedure): Report once for circumstances such as pediatric patients requiring daily anesthesia; total body or hemibody irradiation; very difficult setup; combination external beam and brachytherapy; concurrent cytotoxic chemotherapy/targeted therapy requiring extra effort; radioimmunotherapy with external beam; hyperthermia; yttrium microsphere radiotherapy. Routine contouring for 3D-CRT or IMRT, or routine use for SBRT/SRS, is not an appropriate reason to report 77470 without supporting documentation of extra time/effort.

There is no situation where 77470 may be routinely used without documentation.

CPT 77399 (Unlisted procedure, medical radiation physics/dosimetry/treatment devices/special services): Use only if no other code appropriately describes the procedure or service provided. Provide full documentation to support medical necessity and why an established code is not appropriate.

Unlisted code requires submission of operative/technical details for review.

Megavoltage planning, imaging, and treatment delivery codes should not be reported during superficial, surface, or orthovoltage therapy; instead report CPT codes 77436, 77437, 77438, or 77439 as appropriate.

Regardless of number of treatment sites, do not report megavoltage planning/imaging/treatment delivery codes with orthovoltage/surface treatments (ASTRO Coding Resource).

General requirement: the primary radiation procedure must be proven and medically necessary in the medical record before special services (77331, 77370, 77470, 77399) will be considered for separate payment.

Include rationale, measurements/reports, QMP notes, and justification for additional resources or time as applicable.

Evidence and Guideline-Based Recommendations (Summary)

Evidence and guideline-based recommendations summary used to inform the above criteria.

Recommendations and thresholds in this section are based on guideline syntheses and coding resources (e.g., ASTRO Coding Resource, AMA/CMS coding guidance, and National Comprehensive Cancer Network recommendations) and reflect evidence- and consensus-based practice for fractionation, IGRT use, and special services.

When documentation demonstrates deviation from standard fractionation, IGRT, or special service usage, supporting clinical rationale and peer-reviewed evidence or authoritative guideline citations should be provided in the medical record for review.

Image-Guided Radiation Therapy (IGRT) - Billing

Billing clarifications for IGRT and related services to guide correct coding and avoid inappropriate separate reporting.

Image-guided radiation therapy codes should not be reported separately for stereotactic body radiation therapy (SBRT) or stereotactic radiosurgery (SRS).

When IGRT is used with 2D, 3D, IMRT techniques, the technical component of image guidance is included in CPT codes 77402, 77407, and 77412 and should not be billed separately; the professional component may be reported with 77387-26 when appropriate.

IGRT codes should not be used for imaging performed during brachytherapy; applicator position verification should be reported using simple simulation CPT code 77280.

Operational note: Examples of non-billable IGRT-level activities include aligning bony landmarks using port films or kV imaging without implanted fiducials during palliative setups; such alignment should be documented but not billed as IGRT.

Megavoltage Planning, Imaging, and Treatment Delivery Codes for Superficial/Surface/Orthovoltage Therapy

Megavoltage planning, imaging, and treatment delivery codes do not apply to superficial/surface/orthovoltage therapy; use the codes below when applicable.

Do not report megavoltage planning, imaging, or treatment delivery CPT codes when delivering superficial, surface, or orthovoltage radiation therapy.

Report CPT codes 77436, 77437, 77438, or 77439 for superficial, surface, or orthovoltage radiation therapy as appropriate.

Affected codes (technical included): CPT 77402, 77407, 77412
Professional IGRT: CPT 77387-26 (report when professional interpretation is provided separately)

Billing Rule

Do not use IGRT codes for brachytherapy imaging

Do not use image‑guidance CPT codes to report imaging performed during brachytherapy. Verification of applicator or implant position for brachytherapy should be reported using simple simulation code CPT 77280 or other appropriate brachytherapy reporting per guidance, not IGRT codes.

Do not bill IGRT codes during brachytherapy; use CPT 77280 for applicator position verification when appropriate
Related codes noted in policy: CPT 77387 (IGRT professional component) should not be used for brachytherapy imaging

Documentation Required

Special services only when primary procedure is medically necessary

Special services (e.g., special dosimetry, specialized physics consults, special treatment procedures, and unlisted special services) are covered only when the primary radiation therapy procedure is medically necessary and documented as such. The medical record must demonstrate that the primary radiation treatment is indicated and that the special service was required to accomplish safe or effective delivery.

Affected codes: CPT 77331, 77370, 77470, 77399
Requirement: primary radiation procedure must be proven medically necessary in the record before special services are considered

Billing Rule

Limit special dosimetry measurements

Limit the number of special dosimetry measurements reported under CPT 77331 to the typical clinical range (one to six measurements). Any request to report more than six measurements must have contemporaneous justification in the chart explaining why additional measurements were clinically necessary; include who performed the measurements, devices used, and clinical rationale.

Typical number of measurements: 1–6
If >6 measurements are performed: document justification, clinical need, and equipment/method details; will be reviewed case‑by‑case
Note: IMRT planning (CPT 77301) includes special dosimetry

Billing Rule

Select appropriate delivery complexity code

Select and report the appropriate treatment delivery complexity level. Use CPT 77402 for conventional electron/surface or 2D photon techniques (Level 1), CPT 77407 for standard single‑isocenter 3D or IMRT/VMAT treatments (Level 2), and CPT 77412 for Level 3 delivery only when the documented complexity meets Level 3 criteria. When billing CPT 77412, ensure supporting documentation is present (see "Document justification for Level 3 delivery").

Delivery complexity codes: CPT 77402 (Level 1), CPT 77407 (Level 2), CPT 77412 (Level 3)
Document reason for Level 3 when using CPT 77412

Documentation Required

Use guideline-recommended fractionation regimens

When using hypofractionated regimens or accelerated partial‑breast irradiation (APBI) per guideline recommendations (ASTRO, NCCN, NICE), document the indication, technique (e.g., IMRT vs 3D), total number of fractions and dose per fraction, and the clinical rationale for selecting the regimen (e.g., patient factors, tumor characteristics, guideline citation). Include counseling and shared decision‑making notes when nonstandard fractionation is used.

Document: indication, technique, fractions/dose, rationale referencing guideline when applicable
When APBI or hypofractionation is used outside standard indications, document justification

Documentation Required

Image guidance frequency

Document the frequency of image guidance used during treatment. For example, daily IGRT for prostate localization is recommended when delivering hypofractionated radiation therapy; the chart should contain the imaging frequency, the localization method (e.g., fiducials, CBCT), and the clinical rationale for the chosen imaging schedule.

Example: daily IGRT documented for hypofractionated prostate RT with method (fiducials, CBCT) and rationale
Support IGRT with clinical documentation when used outside listed policy indications

Documentation Required

Counseling and shared decision-making for APBI/hypofractionation

Discuss and document counseling about technique selection, anticipated toxicities, and trade‑offs (including cosmetic outcomes for APBI or hypofractionation). Shared decision‑making should be recorded, including alternatives presented and patient preferences influencing the treatment selection.

Document counseling on expected toxicities and cosmetic trade‑offs for APBI/hypofractionation
Record shared decision‑making and patient preference

>200 cGy per fraction; defined as 240–340 cGy (policy definition)

APBI tumor size exclusionTumors >3 cm excluded in Whelan trial (APBI eligibility <=3 cm)

Isolated tumor cells / micrometastases eligibilityEligibility in Whelan trial allowed isolated tumor cells/micrometastases <=2 mm

Special dosimetry measurementsTypical number of CPT 77331 measurements: 1–6; requests beyond require documentation

APBI fraction limits (technique-specific)IMRT: up to 5 fractions; 3D technique: up to 10 fractions

Added instruction to refer to coding clarifications in the Applicable Codes section for Image-Guided Radiation Therapy.

2026-03-01removedLatest

2026-03-01revisedLatest

Updated notation clarifying reporting of radiation treatment delivery levels (CPT 77402/77407/77412) and inclusion of IGRT technical component in those codes; professional IGRT reported as 77387-26.

2026-03-01clarifiedLatest

Updated notation regarding special dosimetry (CPT 77331).

2026-03-01addedLatest

Notation added that radiation treatment delivery should be reported using appropriate level of complexity (77402, 77407, 77412) with documentation required when 77412 is used.

2026-03-01revisedLatest

When IGRT is used with 2D, 3D, IMRT techniques, the technical component is included under 77402, 77407, and 77412 and should not be reported separately; professional component reported as 77387-26.

2026-03-01revisedLatest

Updated notation regarding megavoltage planning, imaging, and treatment delivery codes and their reporting during superficial, surface, or orthovoltage radiation therapy (addresses CPT 77436-77439).