Radiation and Oncologic Procedures

Coverage Summary

UnitedHealthcare Medicare Advantage policy MMP077.14 provides coverage guidance and applicable procedure codes for a range of radiation and oncologic procedures, including high‑dose rate electronic brachytherapy, implantable beta‑emitting microspheres/TARE/SIRT, transarterial liver therapies (TAE/TACE), image guided radiation therapy (IGRT), standard radiation therapy (2D/3D), proton beam therapy (PBT), intensity modulated radiation therapy (IMRT), stereotactic radiosurgery/stereotactic body radiation therapy (SRS/SBRT), and intraoperative radiation treatment (IORT). This policy aligns with and requires compliance with existing Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) where they apply; where Medicare NCDs/LCDs/LCAs do not exist for a specific modality or procedure, the policy references specified UnitedHealthcare commercial medical policies or InterQual criteria to supplement Medicare guidance.

Key policy metadata and stats

Policy numberMMP077.14

Effective dateJuly 1, 2025

Last review / Committee approvalJune 11, 2025

StatusCURRENT

Medicare NCD referencedNCD 20.28 (Therapeutic Embolization)

Procedural/HCPCS/CPT codes referenced10+ codes (e.g., 0394T, 0395T, 37243, 77373, 77520)

Modalities covered/referencedMultiple (PBT, IMRT, SRS/SBRT, IORT, IGRT, TARE/SIRT, TAE/TACE)

Medical-Necessity Criteria by Modality

High-Dose Rate Electronic Brachytherapy

Medicare and contractor guidance:

ALL of the following

Medicare NCD/LCD status: Medicare does not have a National Coverage Determination (NCD) for high dose electronic brachytherapy.
LCDs/LCAs: Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) exist and compliance with these policies is required where applicable.
Refer to contractor-specific LCD/LCA tables.
Where to find guidance: For specific LCDs/LCAs and applicable coverage guidelines, refer to the table for High Dose Electronic Brachytherapy.

Codes Referenced

High-Dose Rate Electronic Brachytherapy (reference)CPT

0394T	High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed.
0395T	High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed.

Implantable Beta-Emitting Microspheres / TARE/SIRTmixed

37243	Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction.
79445	Radiopharmaceutical therapy, by intra-arterial particulate administration.

Transarterial Therapy of the LiverCPT

37243

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction.

Image Guided Radiation Therapy (IGRT)mixed

77014	Computed tomography guidance for placement of radiation therapy fields.
77387	Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed.
G6001	Ultrasonic guidance for placement of radiation therapy fields.
G6002	Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy.
G6017	Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy, each fraction of treatment.

Special/Associated ServicesCPT

77331	Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician.
77370	Special medical radiation physics consultation.
77399	Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services.
77470	Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral or endocavitary irradiation).

Standard Radiation Therapy (2D/3D)mixed

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.
G6003	Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5 mev.
G6004	Radiation treatment delivery, single treatment area...: 6-10 mev.
G6005	Radiation treatment delivery...: 11-19 mev.
G6006	Radiation treatment delivery...: 20 mev or greater.
G6007	Radiation treatment delivery, two separate treatment areas...: up to 5 mev.
G6008	Radiation treatment delivery...: 6-10 mev.

1–10 of 16

1/2

Proton Beam Therapy (PBT)mixed

77520	Proton treatment delivery; simple, without compensation.
77522	Proton treatment delivery; simple, with compensation.
77523	Proton treatment delivery; intermediate.
77525	Proton treatment delivery; complex.

Intensity Modulated Radiation Therapy (IMRT)mixed

77385	Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple.
77386	Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex.
G6015	Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session.
G6016	Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high resolution compensator, per treatment session.

SRS/SBRTmixed

77371	Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based.
77372	Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based.
77373	Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions.
G0339	Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment.
G0340	Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, per session, second through fifth sessions.

Intraoperative Radiation Treatment (IORT)CPT

77424	Intraoperative radiation treatment delivery, x-ray, single treatment session.
77425	Intraoperative radiation treatment delivery, electrons, single treatment session.
77469	Intraoperative radiation treatment management.

Provider Actions & Requirements

Documentation Required

Follow applicable NCDs/LCDs/LCAs and referenced policies

Follow applicable Medicare NCDs, LCDs, and LCAs where they exist. When LCDs/LCAs do not exist for a therapy, follow the specific UnitedHealthcare Commercial Medical Policy or InterQual criteria referenced in this policy for that modality (e.g., Omnibus Codes, Transarterial Radioembolization/TARE-SIRT policy, InterQual CP for TAE/TACE, Radiation Therapy: Fractionation, Image-Guidance, and Special Services). This ensures coverage determinations align with CMS guidance when available and with UnitedHealthcare supplemental criteria when CMS determinations are absent.

Prior Authorization

Delegate-managed prior authorization

If a delegate manages utilization management and prior authorization for the member, providers must comply with the delegate’s utilization management and prior authorization requirements for services under this policy.

Medicare NCDs / LCDs / LCAs Referenced

Name	Number	Type
Therapeutic Embolization	20.28	NCD
High-Dose Rate Electronic Brachytherapy	L35490	LCD
Proton Beam Therapy	L36658	LCD
Stereotactic Radiation Therapy: SRS and SBRT	L35076	LCD
Intraoperative Radiation Therapy	L37779	LCD

Background & Rationale

This policy clarifies Medicare alignment and the use of supplemental criteria: where Medicare provides a specific NCD/LCD/LCA, compliance with that Medicare determination is required; where Medicare has only a general NCD or no specific NCD/LCD/LCA, UnitedHealthcare supplements Medicare guidance with its Commercial Medical Policies or InterQual criteria. For example, Medicare has a general NCD for Therapeutic Embolization (NCD 20.28) but no specific NCD for implantable beta‑emitting microspheres (TARE/SIRT) or for transarterial bland embolization (TAE) and transarterial chemoembolization (TACE). In those situations, UnitedHealthcare refers to its Transarterial Radioembolization (TARE)/SIRT commercial policy and to InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver, respectively, and uses those criteria to determine when the services are reasonable and necessary. The intent of using UnitedHealthcare commercial policies and InterQual is to guide consistent coverage decisions for radiation and transarterial oncologic procedures, balancing clinical benefits (reducing inappropriate denials and approvals) against potential harms (risk of inappropriate denial and consequent morbidity or mortality).

Revision History

07/01/2025revisedLatest

Coverage Rationale for Transarterial Therapy of the Liver modified: replaced language to state Medicare has a general NCD for therapeutic embolization (NCD 20.28) but not a specific NCD for TAE or TACE; changed guidance to refer to InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver in addition to the general NCD.

07/01/2025addedLatest

Added language that UnitedHealthcare uses InterQual criteria to supplement the Medicare NCD (20.28) for TAE/TACE, to ensure consistency in coverage determinations and described potential clinical benefits and harms of applying these criteria.

Special/Associated Services; Standard Radiation Therapy (2D/3D); PBT; IMRT; SRS/SBRT; IORT

General instruction for each modality:

Per-modality rules

Special/Associated Services: Medicare does not have an NCD; LCDs/LCAs do not exist; refer to UnitedHealthcare Commercial Medical Policy titled Radiation Therapy: Fractionation, Image-Guidance, and Special Services for coverage guidelines.
Applicable codes: 77331, 77370, 77399, 77470.
Standard Radiation Therapy (2D/3D): Medicare does not have an NCD; LCDs/LCAs do not exist; refer to UnitedHealthcare Commercial Medical Policy titled Radiation Therapy: Fractionation, Image-Guidance, and Special Services.
Applicable codes: 77401, 77402, 77407, 77412, plus G6003-G6014.
Proton Beam Therapy (PBT): Medicare does not have an NCD. LCDs/LCAs exist and compliance with those LCDs/LCAs is required where applicable; for states/territories with no LCDs/LCAs, refer to UnitedHealthcare Commercial Medical Policy titled Proton Beam Radiation Therapy.
Applicable codes: 77520, 77522, 77523, 77525.
Intensity Modulated Radiation Therapy (IMRT): Medicare does not have an NCD. LCDs/LCAs exist and compliance with those LCDs/LCAs is required where applicable; for states/territories with no LCDs/LCAs, refer to UnitedHealthcare Commercial Medical Policy titled Intensity-Modulated Radiation Therapy.
Applicable codes: 77385, 77386, G6015, G6016.
Combined PBT and IMRT: Combined use of PBT and IMRT: Medicare does not have an NCD or LCDs/LCAs; refer to UnitedHealthcare Commercial Medical Policies titled Proton Beam Radiation Therapy and Intensity-Modulated Radiation Therapy.
SRS/SBRT: Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT): Medicare does not have an NCD. LCDs/LCAs exist and compliance is required where applicable; for states/territories with no LCDs/LCAs, refer to UnitedHealthcare Commercial Medical Policy titled Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery.
Applicable codes: 77371-77373, G0339, G0340.
Intraoperative Radiation Treatment (IORT): Medicare does not have an NCD. LCDs/LCAs exist and compliance is required where applicable; for states/territories with no LCDs/LCAs, refer to UnitedHealthcare Commercial Medical Policy titled Omnibus Codes.
Applicable codes: 77424, 77425, 77469.