CurrentUnitedHealthcarePolicy CS179KS.01

Radiation Therapy: Fractionation, Image-Guidance, and Special Services (for Kansas Only)

UnitedHealthcare Medical Policy CS179KS.01 (effective June 1, 2025) governs medical necessity criteria for external beam radiation therapy (EBRT) fractionation limits, use of image-guided radiation therapy (IGRT), and certain special services for members in the state of Kansas. It specifies allowable fractions for select disease sites, circumstances when IGRT is medically necessary or not necessary, coding clarifications, and definitions.

Policy Summary

PayerUnitedHealthcare

PolicyRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for Kansas Only)

Policy CodePolicy CS179KS.01

Change TypeNew Medical Policy

Effective DateJun 1, 2025

Next Review Date

Key ActionWhen IGRT with 3D-CRT is requested for a condition not explicitly listed, provide documentation showing one or more supporting items (e.g., clinically significant DVH comparison, inability to tolerate immobilization during CT simulation, imaging evidence of significant target motion, or need for smaller CTV margins).

POLICY UPDATE CHANGES

New Medical Policy

5Primary disease sites with explicit fractionation rules

ManyReferenced CPT/HCPCS codes

non-inferiorBreast outcomes (HF-WBI)

non-inferiorProstate hypofractionation outcome

reduced toxicityIGRT benefit

multipleEvidence & guidelines cited

Coverage Summary

UnitedHealthcare Medical Policy CS179KS.01 (effective June 1, 2025) applies only to the state of Kansas and governs medical necessity criteria for external beam radiation therapy (EBRT) fractionation limits, use of image-guided radiation therapy (IGRT), and certain special services and coding clarifications. The policy specifies allowable fractionation by disease site (examples include bone metastases, breast adenocarcinoma, locally advanced non-small cell lung cancer, and prostate adenocarcinoma), circumstances when IGRT is medically necessary or not medically necessary, definitions for key terms (e.g., Definitive Treatment, Limited Metastatic Disease, and Hypofractionation), and rules for reporting special physics and dosimetry services and select CPT/HCPCS codes.

In scope, the policy: (1) sets fractionation limits for selected indications (for example, up to 10 fractions for palliative EBRT to bone metastases, defined multi-tier fractions for breast cancer, up to 35 fractions for locally advanced NSCLC, and defined limits for prostate cancer including up to 28 or up to 45 fractions in specific circumstances); (2) details when IGRT is medically necessary (e.g., with IMRT, proton therapy, prior irradiation, fiducials, or certain 3D-CRT definitive treatments for specified sites) and when IGRT is not medically necessary (e.g., superficial skin therapy or alignment to bony landmarks without fiducials); and (3) clarifies special services and coding (e.g., use of CPT 77280 for brachytherapy applicator verification, guidance on CPT 77331, 77370, 77470, and restrictions on reporting IGRT with SBRT/SRS).

Thresholds & Quick Facts

Hypofractionation fraction size>200 cGy; defined here as fraction size between 240 cGy and 340 cGy

Median tumor motion (study example)4.4 mm (median from 4D-CT study)

Example margin reductions with 4D-IGMedian reduction ~5.1 mm (range up to 5.2 mm); overall 37%-47% reduction in treatment field margins with 4D-CT + daily IG

Intrafraction prostate motion lower-limit margin2 mm lower-limit margin for intrafraction prostate motion (fiducial-based study)

Policy fraction caps — quick factsBone metastases: up to 10 fractions (re-irradiation may justify >10); Breast APBI: up to 5 fractions; Breast WBI: up to 21 or up to 33 when specific criteria met; Prostate: up to 20 fractions (limited metastatic), up to 28 fractions (localized), up to 45 when select criteria met

Medical-Necessity Criteria

Bone Metastases — Palliative EBRT

When providing palliative external beam radiation therapy (EBRT) for the treatment of a bone metastasis the following are medically necessary:

ALL of the following

Delivery of up to 10 fractions of radiation therapy
Delivery of greater than 10 fractions for the treatment of a site that has previously received radiation therapy
Re-irradiation at previously treated site may justify >10 fractions

Breast Adenocarcinoma — EBRT fractionation

When providing EBRT for breast adenocarcinoma the following are medically necessary:

Options

Clinical Indications, Rationale, and Evidence

Clinical Indications and Rationale

Use of IGRT and respiratory motion management is supported/ recommended in the following clinical scenarios per cited evidence and professional guidelines:

ONE of

Targets located within or near critical structures or organs at risk where high precision is required (ACR/ASTRO, ASTRO coding resource).
Targets subject to daily internal motion (e.g., lung, liver, pancreas) where motion management and daily image guidance reduce margins and toxicity (Korreman et al., ASTRO guidelines).
Highly conformal techniques (e.g., IMRT, 3D-CRT, SABR/SBRT, proton therapy) with steep dose gradients or planned dose escalation (ACR/ASTRO, NCCN, ASTRO).
Patients receiving dose-escalated or hypofractionated RT for liver primary tumors, oligometastatic NSCLC, or pancreatic cancer — respiratory motion management and daily IGRT recommended/strongly recommended (ASTRO guidelines cited).

Coding and Billing

Referenced CPT / HCPCS codes (for reference only)mixed

77280	Simple simulation CPT code — verification of applicator position for brachytherapy
77301	IMRT planning
77331	Special dosimetry (e.g., TLD, microdosimetry)
77370	Special medical radiation physics consultation
77470	Special treatment procedure
77399	Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services
77401	Radiation treatment delivery, superficial and/or ortho voltage, per day
77402	Radiation treatment delivery, >=1 MeV; simple
77407	Radiation treatment delivery, >=1 MeV; intermediate
77412	Radiation treatment delivery, >=1 MeV; complex

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Coding and billing language in the policy is presented for billing guidance only; it does not replace payer-specific billing rules or contractual coverage determinations. The Applicable Codes and Coding Clarifications sections note that listed CPT/HCPCS codes are provided for reference and that inclusion of a code does not guarantee coverage or reimbursement.

Provider actions in the policy include billing-related restrictions and documentation expectations (examples: IGRT cannot be reported separately with SBRT/SRS and IGRT codes should not be used for imaging during brachytherapy — use 77280 for applicator verification; special dosimetry 77331, special physics consultation 77370, and special treatment procedure 77470 have single-reporting criteria; certain megavoltage delivery codes must not be reported with 77401). Clinicians should follow payer-specific billing rules and the policy's listed billing restrictions when submitting claims.

Provider Actions and Billing Rules

Documentation Required

Document justification for IGRT when used with 3D‑CRT for conditions not listed

Document justification when IGRT is used with 3D‑CRT for clinical indications not explicitly listed in policy. Briefly state why IGRT is required for the individual patient and attach supporting evidence.

Dose‑volume histogram (DVH) comparison between techniques (e.g., DIBH vs free breathing) showing clinically significant normal tissue sparing
Documentation that the member is unable to tolerate immobilization devices during CT simulation
Imaging evidence demonstrating significant target motion
Rationale that smaller clinical target volume (CTV) margins are required compared with traditional 3D‑CRT margins

Billing Rule

IGRT reporting restrictions

IGRT reporting restrictions and special cases.

Evidence Summary

AHRQ/Skelly et al. 2023Systematic review: single vs multiple fraction EBRT have similar pain response; SBRT may have slightly higher pain response

ASTRO 2024Guideline recommendations for palliative RT dose-fractionation for bone mets (supports single and multifraction options)

Brunt et al. 2020 (FAST‑Forward)5‑fraction adjuvant breast RT (26 Gy in 5) non‑inferior to 40 Gy in 15 at 5 years; supports 1‑week schedules with verification imaging

START trials (Haviland et al. 2013)10‑year breast local‑regional relapse: hypofractionation (e.g., 40 Gy/15 fx) non‑inferior to 50 Gy/25 fx

Bradley et al. 2015 (NSCLC)Dose escalation to 74 Gy with concurrent chemo not superior and worse OS vs 60 Gy; supports standard ~60 Gy

Murthy et al. 2021 (Prostate POP‑RT)WPRT improved 5‑year biochemical failure‑free and DFS vs prostate‑only RT; no OS difference

Revision History

2025-06-01material changeLatest

New Medical Policy

Policy Summary

PayerUnitedHealthcare

PolicyRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for Kansas Only)

Policy CodePolicy CS179KS.01

Change TypeNew Medical Policy

Effective DateJun 1, 2025

Next Review Date

On This Page

Delivery of up to 5 fractions for accelerated partial breast irradiation (APBI)

Delivery of up to 21 fractions (inclusive of a boost to the tumor bed)

ALL of the following

Treatment of supraclavicular and/or internal mammary lymph nodes
Post-mastectomy radiation therapy
Individual has received previous thoracic radiation therapy
Individual has a connective tissue disorder such as lupus or scleroderma

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

Image-Guided Radiation Therapy (IGRT) — Medically Necessary Indications

Image guidance for radiation therapy is medically necessary under any of the following circumstances:

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 previously irradiated area
When implanted fiducial markers are being used for target localization
ANY of the following
- Breast cancer subgroup
  - Accelerated partial breast irradiation
  - Breast boost with the use of photons
  - Hypofractionated radiation therapy delivered up to five fractions to the whole breast or chest wall
  - Individual is being treated in prone position
  - Left breast cancer and deep inspiration breath hold (DIBH) technique is being used
- 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
- ALL of the following
  - Clinically significant difference in normal tissue sparing between DIBH and free breathing as documented by comparison plans and dose-volume histogram (DVH) (e.g., right-sided breast cancer)
  - Member unable to tolerate immobilization during computed tomography (CT) simulation
  - Significant target motion as documented by imaging
  - Smaller clinical target volume (CTV) margins are required than what is traditionally used for 3D-CRT

Image-Guided Radiation Therapy (IGRT) — Not Medically Necessary

When the above criteria are not met, IGRT is not medically necessary including, but not limited to, any of the following circumstances:

ANY of the following

Superficial treatment of skin cancer including superficial radiation therapy or electronic brachytherapy
To align bony landmarks without implanted fiducials (e.g., during palliative radiation therapy)

Re-irradiation cases or previously irradiated adjacent areas where abutting fields must be precise (ACR/ASTRO).

Scenarios requiring narrow PTV margins to protect adjacent structures (ACR/ASTRO; AAPM recommends geometric accuracy and daily QC).

The policy provides definitions and cites professional societies and evidence supporting dose-fractionation recommendations: key definitions include Definitive Treatment (curative intent), Limited Metastatic Disease (prostate-specific definition), Hypofractionated radiotherapy (fraction size defined here as between 240 cGy and 340 cGy and generally > 200 cGy), HF-WBI, IGRT, 4D-CT, and PTV.

Professional society guidance and systematic reviews cited in the policy include ASTRO, ACR, NCCN, and ESTRO recommendations and multiple evidence syntheses and randomized controlled trials. Examples: AHRQ/Skelly et al. 2023 and ASTRO 2024 support palliative bone metastasis fractionation choices (single 8 Gy or multifraction options); START and FAST-Forward trials and ASTRO/NCCN guidance support hypofractionated whole-breast regimens (e.g., 40 Gy/15 fractions and validated 5-fraction APBI schedules); randomized trials and systematic reviews (CHHiP, Catton, HYPRO, Cochrane) underpin prostate hypofractionation recommendations; and RTOG 0617 and ASTRO guidance inform NSCLC definitive fractionation (60 Gy in 2 Gy fractions commonly preferred). The policy references multiple RCTs, systematic reviews/meta-analyses, and professional guideline statements as the evidentiary basis for its fractionation guidance.

Surface Definitions

Definitive TreatmentRadiation treatments with curative intent

Limited Metastatic DiseaseNo visceral mets or <4 bone mets with none outside vertebrae/pelvis (prostate-only applicability)

HypofractionationFewer, larger doses (>200 cGy); defined as 240–340 cGy per fraction

HF-WBIHypofractionated whole-breast irradiation — shorter course with larger fraction sizes (e.g., 40 Gy in 15 fractions)

IGRTUse of imaging before or during radiation to improve targeting (daily CBCT, kV/MV imaging)

WPRTWhole-pelvic radiotherapy (includes pelvic lymph nodes)

4D-CTFour-dimensional CT that accounts for respiratory motion during imaging

PTVPlanning target volume — accounts for internal motion and setup variation to ensure prescribed dose covers the clinical target

Evidence	Key finding
AHRQ/Skelly et al. 2023
Single and multiple fraction EBRT likely have similar overall pain response for initial/re-irradiation; SBRT may have slightly higher pain response
Hartsell et al. (2005)
8 Gy single fraction non-inferior to 30 Gy/10 for pain relief at 3 months; single fraction had higher retreatment rate but less acute toxicity
Brunt et al. (2020)
Five-fraction adjuvant whole-breast RT (26 Gy in 5) non-inferior to 40 Gy in 15 fractions for local control; 26 Gy/5 safe up to 5 years
Shaitelman et al. (2015)
Hypofractionated whole-breast irradiation (HF-WBI) had significantly lower acute grade ≥2 toxicity and less fatigue vs conventional fractionation
START trials (Haviland et al. 2013)
Long-term (10-year) data support 40 Gy in 15 fractions as safe and effective versus 50 Gy in 25 fractions

IGRT cannot be reported separately with stereotactic body radiation therapy (SBRT) or stereotactic radiosurgery (SRS)
For brachytherapy, use CPT 77280 to report verification of applicator position rather than IGRT codes

Billing Rule

Superficial radiation therapy coding restriction

Superficial radiation therapy (77401) coding restriction: megavoltage treatment delivery and listed codes should not be reported when 77401 is provided.

Affected codes: 77261, 77262, 77263, 77332, 77333, 77334, 77306, 77307, 77316, 77317, 77318, 77336, 77370, 77371, 77372, 77373, 77402, 77407, 77412, 77417, 0394T, 0395T, 77427, 77431, 77432, 77435, 77469, 77470, 77499

Billing Rule

Use of special dosimetry CPT 77331

Use CPT 77331 for special dosimetry measurements outside normal planning system/calibration parameters. Note that IMRT planning (77301) includes special dosimetry.

Codes: 77331, 77301

Billing Rule

Use of CPT 77370 and 77470

Report CPT 77370 (special medical radiation physics consultation) and CPT 77470 (special treatment procedure) once when the specified complex circumstances are met and documented.

Codes: 77370, 77470
Report once when criteria (e.g., complex photon/electron interactions, pediatric daily anesthesia, total/hemibody irradiation, combination EBRT and brachytherapy, fusion of 3D image sets by a QMP) are met and documented

Documentation Required

Communicate HF‑WBI benefits to patients

Communicate benefits, tradeoffs, and expectations of hypofractionated whole‑breast irradiation (HF‑WBI) to patients prior to treatment. Document that shared decision making occurred and that the patient received counseling about expected outcomes and potential toxicities.

Documentation Required

Use of IGRT and imaging frequency; motion management; BMI tailoring

Document use of IGRT and the imaging frequency for each treatment course. Follow professional‑society recommended motion management and IGRT techniques when indicated (e.g., respiratory gating, DIBH, implanted fiducials, intrafraction tracking). Tailor imaging frequency for patients with high body mass index (BMI) receiving pelvic radiotherapy and document rationale when increased imaging or modified setup is used.

Document the specific IGRT modality and frequency (e.g., daily kV imaging, cone‑beam CT frequency)
Use and document professional‑society recommended motion management or tracking when indicated (e.g., respiratory gating, DIBH, fiducials)
For obese patients receiving pelvic RT, document any tailoring of imaging frequency or setup to account for reproducibility concerns

Documentation Required

Consider pelvic nodal RT for high‑risk prostate cancer

Consider and document the rationale for treating pelvic lymph nodes for individuals with high‑risk prostate cancer. Include risk stratification and indication for elective nodal irradiation when pelvic nodal RT is being used.

Documentation Required

Quality assurance program requirement

Document that the department has and follows a formal quality assurance (QA) program for imaging, motion management, and IGRT processes. Include evidence of routine QA activities and procedures.

Documentation Required

PSA thresholds and documentation

Document prostate‑specific antigen (PSA) thresholds and related clinical rationale when relevant to treatment decisions (e.g., salvage therapy post‑prostatectomy).

Cochrane hypofractionation (Hickey et al.)Moderate hypofractionation: little to no difference in cancer‑specific survival and late GU toxicity vs conventional; uncertain GI toxicity

Catton et al. 2017Prostate 60 Gy/20 fx non‑inferior to 78 Gy/39 fx for 5‑yr biochemical‑clinical failure; similar late toxicity

HYPRO trialHypofractionation (19×3.4 Gy) not superior for 5‑yr relapse‑free survival; higher acute GU/GI toxicity reported

Wang et al. IGRT meta‑analysis 2022IGRT reduced acute GU (RR 0.78) and GI (RR 0.49) toxicity and improved 3‑yr biochemical outcomes with daily IGRT

Korreman et al. (4D‑CT/4D‑IG)Respiration‑correlated imaging + daily IG can reduce margins ~37%–47%; median tumor motion 4.4 mm; median margin reduction with 4D‑IG ~5.1 mm

Kotte et al. (Prostate intrafraction motion)In 11,426 fractions, 66% had motion >2 mm; supports a 2 mm lower‑limit margin for intrafraction motion