CurrentUnitedHealthcarePolicy RADIOLOGY 044.5

Radiation Therapy: Fractionation, Image-Guidance, and Special Services

Defines medical necessity criteria for external beam radiation therapy (EBRT) fractionation limits for specific disease sites (bone metastases, breast adenocarcinoma, locally advanced NSCLC, prostate adenocarcinoma), indications and limitations for image-guided radiation therapy (IGRT), coding clarifications, documentation expectations, and descriptions of services. This part contains coverage rationale, definitions, applicable codes list header, coding clarifications, and evidence summaries for listed disease sites.

Policy Summary

PayerUnitedHealthcare

PolicyRadiation Therapy: Fractionation, Image-Guidance, and Special Services

Policy CodePolicy RADIOLOGY 044.5

Change TypeCoverage criteria and coding clarifications (material and non-material changes)

Effective DateFebruary 1, 2025

Next Review Date

Key ActionMedical records documentation may be required to assess whether the member meets the clinical criteria for coverage; documentation does not guarantee coverage and benefits are determined by the member-specific benefit plan and applicable laws.

POLICY UPDATE CHANGES

Revised list of medically necessary services when providing EBRT for breast adenocarcinoma; added delivery of up to 5 fractions for APBI.

Added language indicating IGRT may be medically necessary during Definitive Treatment when used with 3D-CRT for a condition not listed as medically necessary if documentation shows one or more specific criteria.

Updated Medical Records Documentation Used for Reviews to add and replace multiple fields (e.g., diagnosis replaced with diagnosis and stage; proposed radiation prescription replaced with proposed treatment plan).

Coding clarifications: note added that megavoltage treatment delivery codes should not be reported with CPT 77401 and statement that CPT 77470 may not be routinely used.

Supporting Information updated to reflect the most current Description of Services, Clinical Evidence, and References.

up to 10 / >10Bone metastases fractionation

up to 21/33; APBI 5Breast fractionation (including APBI)

up to 35NSCLC fractionation limit

up to 28; up to 45Prostate fractionation

2025-02-01Policy revisions on

Coverage Summary

Quick-reference thresholds and limits

Hypofractionation fraction size240–340 cGy per fraction

PSA threshold for offering salvage RT after prostatectomyOffer when PSA < 0.5 ng/mL; consider at ≥ 0.2 ng/mL for high-risk patients

Breast APBI fraction limitUp to 5 fractions for accelerated partial breast irradiation (APBI)

Breast whole-breast / boost fraction limitsUp to 21 fractions (inclusive of boost); up to 33 fractions in specified circumstances; >33 not medically necessary

Prostate fractionation limitsUp to 28 fractions for localized disease; up to 20 fractions for definitive treatment with limited metastatic disease; up to 45 fractions when specified criteria met

Bone metastases palliative fractionsUp to 10 fractions (or >10 if site previously irradiated)

Locally advanced NSCLC limitUp to 35 fractions; >35 not medically necessary

Medical-Necessity Criteria

Medically necessary when ANY of the following are met:

ANY of the following

Bone Metastases - EBRT Fractionation
- Delivery of greater than 10 fractions for the treatment of a site that has previously received radiation therapy.
- Delivery of up to 10 fractions of radiation therapy.

Breast Adenocarcinoma - Not Medically Necessary

Delivery of greater than 33 fractions (inclusive of a boost to the tumor bed) for breast cancer.

Locally Advanced Non-Small Cell Lung Cancer - EBRT Fractionation

Dose-Fractionation & Evidence Summary

This policy (RADIOLOGY 044.5) is effective February 1, 2025 and is CURRENT. It defines the scope for medical necessity of external beam radiation therapy (EBRT) fractionation limits by tumor site (bone metastases, breast adenocarcinoma, locally advanced NSCLC, and prostate adenocarcinoma), specifies indications and limitations for image-guided radiation therapy (IGRT), clarifies coding and reporting rules (including explicit guidance about CPT 77401 and that CPT 77470 is not routinely used), and describes documentation expectations and special services (e.g., special treatment procedure, medical physics consultation). The high-level thrust: site-specific EBRT fractionation ceilings and exceptions are stated, IGRT is allowed for listed indications and limited otherwise (with added criteria allowing IGRT with 3D-CRT for non-listed definitive treatments when specific documentation is provided), and coding clarifications and documentation requirements are emphasized.

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IGRT Use, Documentation & Prior Authorization

Documentation Required

Required medical records for radiation therapy reviews

The following medical records are commonly requested when reviewing radiation therapy and IGRT requests. Submission of complete documentation helps determine if criteria are met but does not guarantee coverage.

Radiation oncologist consultation and progress notes detailing indication and intent of therapy (definitive, adjuvant, palliative).
Relevant surgical history and operative reports (if applicable).
Pathology, diagnosis, and cancer stage (imaging reports, biopsy results).
Proposed treatment plan including prescription (dose, fractionation, target volumes, organs at risk) and image-guidance approach/frequency.

Prior Authorization

Documentation to support IGRT when used for non-listed definitive treatment

Applicable Codes & Coding Rules

Referenced CPT / HCPCS codes (for reference only)mixed

77014	Computed tomography guidance for placement of radiation therapy fields
77301	IMRT planning (see coding clarification)
77331	Special dosimetry (TLD, microdosimetry) (see coding clarification)
77370	Special medical radiation physics consultation (see coding clarification)
77385	IMRT delivery; simple (includes guidance and tracking when performed)
77386	IMRT delivery; complex (includes guidance and tracking when performed)
77387	Guidance for localization of target volume; includes intrafraction tracking
77399	Unlisted procedure, medical radiation physics/dosimetry/special services
77401	Radiation treatment delivery, superficial and/or ortho voltage, per day
77402	Radiation treatment delivery, >=1 MeV; simple

1–10 of 34

1/4

Coding clarifications / Not to report with 77401CPTNot Covered

77401	Superficial radiation therapy (note: megavoltage treatment delivery codes should not be reported when 77401 is provided)
77261	(listed in policy as a megavoltage treatment delivery code not to report with 77401)
77316	(listed in policy as a megavoltage treatment delivery code not to report with 77401)
77317	(listed in policy as a megavoltage treatment delivery code not to report with 77401)
77435	(listed in policy as a megavoltage treatment delivery code not to report with 77401)
77469	(listed in policy as a megavoltage treatment delivery code not to report with 77401)
77470	(listed in policy as a megavoltage treatment delivery code not to report with 77401)
77499	(listed in policy as a megavoltage treatment delivery code not to report with 77401)

Code explicitly not routinely usedCPT

77470

External beam therapeutic radiation; contoured target/other? (policy states there is no situation in which CPT code 77470 may be routinely used)

Billing Rule

IGRT coding exclusions and megavoltage/77470 guidance

Actionable billing guidance about IGRT and related treatment delivery codes: certain megavoltage delivery codes should not be reported with CPT 77401, and CPT 77470 should not be reported routinely. Providers should follow the coding clarifications in the policy when billing.

Do not report megavoltage treatment delivery codes (e.g., 77261, 77316, 77317, 77435, 77469, 77470, 77499) with superficial radiation therapy CPT 77401
CPT 77470 is not routinely used and should only be reported in specified complex circumstances with documentation

Billing Rule

Special services reporting frequency and when to report 77370/77331

Summarizes frequency and reporting guidance for special services codes: CPT 77370 (special medical radiation physics consultation) should be reported once in specified complex circumstances; CPT 77331 (special dosimetry) frequency varies (typically 1–6 measurements) and is considered only when the primary radiation procedure is proven and medically necessary.

Definitions

Term	Definition
Definitive Treatment
Radiation treatments for cancer with a curative intent (Landsteiner et al., 2023).
Limited Metastatic Disease (prostate)
Absence of visceral metastasis or less than four bone metastases with no metastasis outside the vertebral bodies or pelvis (Parker et al., 2018).
Hypofractionated radiotherapy
Delivery of fewer and larger (>200 cGy) doses of radiation; defined here as EBRT with a fraction size between 240 cGy and 340 cGy.
HF-WBI
Hypofractionated whole-breast irradiation (shortened fractionation schedules such as 40 Gy/15 fractions).
APBI/PBI
Accelerated/partial breast irradiation - targeted radiation to tumor bed over shorter schedules (e.g., 30 Gy in 5 fractions).
IGRT
Image-guided radiation therapy using imaging (CBCT, MV, kV) to improve target localization and reduce margins.
Definitive Treatment (duplicate entry noted)
Definition added to policy (exact definition text not included in this part).

Revision History

2025-02-01revisedLatest

Revised list of medically necessary services when providing EBRT for breast adenocarcinoma; added delivery of up to 5 fractions for APBI. Coverage Rationale updated to permit up to 5 fractions for APBI; other breast fractionation rules clarified (up to 21, up to 33 with specific criteria).

2025-02-01added

Added IGRT documentation criteria: three example documentation items (DVH comparison showing DIBH benefit, inability to tolerate immobilization during CT simulation, or significant target motion documented by imaging) that may make IGRT medically necessary when used with 3D-CRT for conditions not otherwise listed.

2025-02-01

Policy Summary

PayerUnitedHealthcare

PolicyRadiation Therapy: Fractionation, Image-Guidance, and Special Services

Policy CodePolicy RADIOLOGY 044.5

Change TypeCoverage criteria and coding clarifications (material and non-material changes)

Effective DateFebruary 1, 2025

Next Review Date

On This Page

Delivery of up to 35 fractions for locally advanced non-small cell lung cancer when delivered with or without chemotherapy.

Locally Advanced Non-Small Cell Lung Cancer - Not Medically Necessary

Delivery of greater than 35 fractions for locally advanced non-small cell lung cancer.

Prostate Adenocarcinoma - EBRT Fractionation

Delivery of up to 28 fractions for localized prostate cancer.
Delivery of up to 20 fractions for definitive treatment in an individual with limited metastatic disease.
Delivery of up to 45 fractions for localized prostate cancer when any of the following criteria are met:
ANY of the following
- Radiation therapy is delivered post-prostatectomy.
- Individual with high-risk prostate cancer is undergoing radiation treatment to pelvic lymph nodes.
- Individual has a history of inflammatory bowel disease such as ulcerative colitis or Crohn's disease.
- Individual has received previous pelvic radiation therapy.

Prostate Adenocarcinoma - Not Medically Necessary

Delivery of greater than 45 fractions for localized prostate cancer.

Image-Guided Radiation Therapy (IGRT) - Medical Necessity

IGRT when used with intensity modulated radiation therapy (IMRT) (e.g., prostate cancer).
IGRT when used with proton beam radiation therapy (PBRT).
IGRT when implanted fiducial markers are used for target localization.
IGRT when the target has received prior radiation therapy or abuts a previously irradiated area.
During Definitive Treatment using three-dimensional conformal radiation therapy (3D-CRT)
- Accelerated partial breast irradiation.
- Breast cancer with any of the following: breast boost with the use of photons; individual being treated in prone position; hypofractionated radiation therapy delivered up to five fractions to the whole breast or chest wall; left breast cancer and deep inspiration breath hold (DIBH) technique is being used.
- Esophageal cancer.
- During boost treatment of rectal and bladder cancer.
- Gastric cancer.
- Head and neck cancer.
- Lung cancer.
- Hepatobiliary cancer.
- Pancreatic cancer.
- Soft tissue sarcoma.
- 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).
IGRT when used with 3D-CRT may be medically necessary for a condition not listed above when documentation shows one or more of the following: member unable to tolerate immobilization during CT simulation; smaller clinical target volume (CTV) margins are required than traditionally used for 3D-CRT; significant target motion as documented by imaging.
Policy revision summary: Medically Necessary Use of IGRT during Definitive Treatment — clarified and expanded indications for IGRT with 3D-CRT, IMRT, PBRT, implanted fiducials, prior RT, and specific definitive treatment scenarios; documentation requirements emphasized for non-listed conditions.

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

IGRT when the above criteria are not met, including but not limited to: aligning bony landmarks without implanted fiducials (e.g., during palliative radiation therapy).
IGRT for superficial treatment of skin cancer including superficial radiation therapy or electronic brachytherapy.
Refer to Coding Clarification section for services and use of IGRT with brachytherapy, SRS, and SBRT.

When IGRT is requested for a non-listed definitive 3D-CRT condition, provide documentation demonstrating clinical necessity. One of the following items should be supplied to support coverage of IGRT in these cases.

Comparison plans and dose-volume histogram (DVH) demonstrating a clinically significant difference in normal tissue sparing between DIBH and free-breathing (e.g., for right-sided breast cancer).
Documentation that the member is unable to tolerate immobilization during CT simulation such that image guidance is required to ensure accurate daily set-up.
Imaging (simulation/4D CT/fluoroscopic) documenting significant target motion that cannot be managed with standard margins.

Documentation Required

Use of IGRT and imaging frequency

Recommended IGRT modality and imaging frequency depend on disease site and treatment technique. These represent commonly accepted practice patterns to ensure accurate targeting and may be requested in documentation or prior authorization reviews.

Daily CBCT for prostate and lung definitive treatments when using IMRT/VMAT or proton therapy.
Daily image guidance for left-sided whole-breast treatment in the prone position when DIBH is used.
Weekly imaging may be acceptable for right-sided prone whole-breast treatment when motion and setup are stable and documented.

Documentation Required

Medical records documentation may be required

Medical records documentation may be required to determine whether services meet clinical criteria. Submission of documentation does not guarantee coverage — benefits are member- and plan-specific and adjudication follows the applicable benefit plan and laws.

Dose/fractionation selection should follow the policy clinical guidelines and referenced sources; provide the planned dose and number of fractions.
Do not report megavoltage treatment delivery codes in conjunction with CPT 77401 (superficial radiation therapy) — these codes should not be billed together.
CPT 77470 (special treatment procedure) is not routinely used and should only be reported with supporting documentation for the exceptional circumstances described in coding guidance; there is no situation where 77470 may be used routinely.

Report CPT 77370 once only for specified complex scenarios (e.g., complex photon/electron interactions, specialized brachytherapy, pediatric anesthesia, dose-to-fetus calculations, fusion of multiple 3D image sets by a QMP) with supporting documentation
CPT 77331 (special dosimetry) is used for measurements outside normal planning/calibration parameters; frequency typically varies from one to six measurements and is evaluated case-by-case
Codes 77331, 77301, 77370, 77470, and 77399 are considered only when the primary radiation procedure is proven and medically necessary

Updated Medical Records Documentation Used for Reviews to add radiation oncologist notes, history of prior surgical treatment, replaced diagnosis with diagnosis and stage, and replaced proposed radiation prescription with proposed treatment plan including radiation prescription; additional IGRT-specific documentation items listed.

2025-02-01clarified

Coding clarifications added: megavoltage treatment delivery codes should not be reported with CPT 77401 and statement that CPT 77470 may not be routinely used; guidance on special dosimetry and 77370 reporting frequency clarified.

2025-02-01revised

Supporting Information updated and previous policy version (RADIOLOGY 044.4) archived.