Fractionation, Image-Guidance, and Special Services
Defines medically necessary fractionation limits, image-guidance indications, and coding/technical clarifications for external beam radiation therapy (EBRT) and related special services for UnitedHealthcare Commercial and Individual Exchange plans.
Policy Summary
PayerUnitedHealthcare
PolicyFractionation, Image-Guidance, and Special Services
Policy CodePolicy 2026T0613L
Change TypeMaterial revisions to fractionation and coding guidance
Effective DateMar 1, 2026
Next Review DateN/A
Key ActionWhen requesting authorization, document the planned fractionation regimen, IGRT use, and clinical rationale to support delivery level and coding.
Added criterion requiring delivery of up to 10 fractions for accelerated partial-breast irradiation with 3D technique.
Replaced language specifying connective tissue disorders to name systemic lupus erythematosus or scleroderma when allowing delivery of up to 33 fractions (inclusive of a boost to the tumor bed).
Updated notations clarifying which CPT delivery codes (77402, 77407, 77412) correspond to levels of complexity and when 77412 is appropriate, and that IGRT technical component is included with those delivery codes while 77387-26 reports the professional component.
Updated notation that megavoltage planning/imaging/delivery codes should not be reported during superficial/surface/orthovoltage radiation therapy and that 77436–77439 should be reported for those therapies.
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.
Added instruction to refer to coding clarifications in the Applicable Codes section for Image-Guided Radiation Therapy.
Clarified use of CPT code 77331 (special dosimetry): used to document point dose measurements with specialized devices when standard planning/equipment calibration parameters are insufficient; typical number of measurements is one to six.
Noted that IMRT planning (CPT code 77301) includes special dosimetry.
Updated Description of Services, Clinical Evidence, and References sections to reflect current information and archived previous policy version 2026T0613K.
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up to 10palliative bone fractions
up to 33breast (inclusive boost)
up to 35locally advanced NSCLC
up to 45localized prostate
240-340 cGyhypofractionation size
77402/77407/77412key delivery codes
Coverage Criteria and Medical Necessity Rules
inv-01: Bone Metastases — Covered when ALL of the following are met
Covered when ALL of the following are met
Bone metastases EBRT: Delivery of up to 10 fractions of external beam radiation therapy (EBRT) for palliative treatment of bone metastases is medically necessary; delivery of greater than 10 fractions is medically necessary only for treatment of a site that has previously received radiation therapy.<=10 fractions unless previously irradiated
Based on AHRQ evidence summary and ASTRO guideline; see documentation of prior RT for reirradiation decision-making
inv-02: Breast Adenocarcinoma — Covered when ALL of the following are met
Covered when ALL of the following are met
Breast adenocarcinoma EBRT: For accelerated partial‑breast irradiation (APBI) with IMRT: delivery of up to 5 fractions is medically necessary; for APBI with a 3D technique: delivery of up to 10 fractions is medically necessary. Whole‑breast/chest wall EBRT is medically necessary up to 21 fractions inclusive of a boost. Delivery up to 33 fractions inclusive of a boost is medically necessary when any of the following apply: treatment of supraclavicular and/or internal mammary lymph nodes; postmastectomy radiation therapy; prior thoracic radiation therapy; or presence of a connective tissue disorder such as systemic lupus erythematosus or scleroderma. Delivery greater than 33 fractions (inclusive of boost) is not medically necessary.<=33 fractions unless specified criteria met
Revised to explicitly allow APBI‑3D up to 10 fractions and to name specific connective tissue disorders for the 33‑fraction allowance
inv-03: Locally Advanced Non-Small Cell Lung Cancer — Covered when ALL of the following are met
Covered when ALL of the following are met
Locally advanced NSCLC EBRT: 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 greater than 35 fractions is not medically necessary.<=35 fractions
inv-04: Prostate Adenocarcinoma and IGRT Indications — Covered when ALL of the following are met
Covered when ALL of the following are met
Prostate adenocarcinoma EBRT fractionation: Definitive treatment in an individual with limited metastatic disease: delivery up to 20 fractions is medically necessary. For localized prostate cancer: delivery up to 28 fractions is medically necessary. Delivery up to 45 fractions is medically necessary when any of the following criteria are met: radiation to pelvic lymph nodes for high‑risk disease; post‑prostatectomy radiation; history of inflammatory bowel disease (e.g., ulcerative colitis or Crohn disease); or prior pelvic radiation therapy. Delivery greater than 45 fractions is not medically necessary.<=45 fractions unless specified criteria met
Follow NCCN/ASTRO guidance for fractionation selection
IGRT medically necessary circumstances: Image‑guided radiation therapy (IGRT) is medically necessary when used with IMRT or proton beam RT; when the target has received prior RT or abuts a previously irradiated area; when implanted fiducial markers are used for localization; during definitive treatment with 3D‑CRT for indications listed (including APBI, breast boost, hypofractionated whole‑breast RT up to 5 fractions, prone positioning, left breast with DIBH), during boost treatments of rectal or bladder cancer, and for tumor types and situations where guidelines recommend IGRT. IGRT with 3D‑CRT may be necessary for other conditions when documentation shows clinically significant normal tissue sparing, inability to tolerate immobilization, significant target motion, or need for smaller CTV margins. When these criteria are not met, IGRT is not medically necessary (e.g., sole use to align bony landmarks without fiducials).
inv-05: Palliative radiotherapy for bone metastases — Covered when treatment is for symptomatic bone metastases and selection of regimen considers prognosis, prior RT, normal tissue risks, QoL, and expected benefit
Covered when treatment is for symptomatic bone metastases and selection of regimen considers prognosis, prior RT, normal tissue risks, QoL, and patient goals (per sources):
Conventional palliative regimens: One of the following conventional palliative regimens is medically necessary for symptomatic bone metastases: 8 Gy in 1 fraction; 20 Gy in 5 fractions (2000 cGy); 24 Gy in 6 fractions (2400 cGy); or 30 Gy in 10 fractions (3000 cGy). For spinal cord/cauda equina compression in nonsurgical candidates, recommended options include 8 Gy ×1, 16 Gy in 2 fractions, 20 Gy in 5 fractions, or 30 Gy in 10 fractions.
ASTRO/ESTRO/AHRQ evidence and guideline recommendations
Reirradiation options: For reirradiation of the spine: recommended conventional regimens include 8 Gy ×1, 20 Gy in 5 fractions, 24 Gy in 6 fractions, or 20 Gy in 8 fractions. For non‑spine symptomatic sites, options include 8 Gy ×1 or multifraction regimens such as 20 Gy in 5 fractions or 24 Gy in 6 fractions.
ASTRO guidance based on AHRQ evidence
SBRT considerations: Stereotactic body radiation therapy (SBRT), delivered in single or multiple fractions, may offer a slightly greater likelihood of overall pain response versus multiple‑fraction EBRT in some studies; selection between SBRT and conventional EBRT should consider limited comparative evidence, patient and tumor factors, and prognosis.
inv-06: Partial‑breast irradiation / hypofractionation in early breast cancer — Covered when patient selection matches trial/inclusion criteria
Covered when patient selection matches trial/inclusion criteria
Patient selection for PBI/APBI: APBI/PBI is medically necessary when patient selection matches trial/inclusion criteria for early‑stage disease (typically tumor ≤ 3 cm, minimal or no nodal involvement) and when modality‑specific protocols and dose‑volume constraints are followed.tumor ≤3 cm; minimal/no nodal involvement (per trial criteria)
Based on AHRQ systematic review and trial eligibility in RCTs
Efficacy and regimen evidence: Evidence comparing PBI with whole‑breast irradiation (WBI) shows no significant differences in ipsilateral breast recurrence or overall survival at 5–10 years for selected patients and modalities; specific APBI regimens with favorable long‑term outcomes include IMRT 30 Gy in five nonconsecutive daily fractions (Meattini) and other trial‑supported schedules. Verification imaging is required for certain 5‑fraction whole‑breast regimens.
Brunt et al., Meattini et al., NSABP B‑39/RTOG 0413 context
APBI caution:
inv-07: Coverage with criteria — guideline-concordant RT
Covered when consistent with guideline-recommended dose-fractionation and patient selection
Guideline-concordant RT: Radiation therapy is covered when the selected regimen and technique align with evidence‑based guideline recommendations (ASTRO, NCCN, START), including appropriate dose‑fractionation for whole‑breast or partial‑breast irradiation and use of image verification and motion‑management techniques as indicated.
Examples: HF‑WBI 40 Gy in 15 fractions; NCCN‑preferred APBI 30 Gy in 5 fractions; ASTRO PBI options
inv-08: Coverage with criteria — Coverage aligned with major trials and society guidelines
Covered with criteria — guideline-aligned regimens and documentation expectations
Moderate hypofractionation for prostate: Moderate hypofractionated regimens for localized prostate cancer are covered when evidence‑based schedules are selected (examples: 60 Gy in 20 fractions) and when appropriate image guidance and advanced planning (IMRT or 3D‑CRT with daily IGRT) are documented.fraction size approximately 2.4–3.4 Gy per fraction
Supported by RCTs and ASTRO/NCCN guidance; document regimen and IGRT frequency
Regimens requiring caution: Certain hypofractionation schedules (e.g., 3.4 Gy ×19 as in the HYPRO trial) showed higher acute GI/GU toxicity and are not uniformly accepted as standard; coverage of these regimens may require explicit justification or selection of alternate regimens.3.4 Gy per fraction
HYPRO trial evidence
Use of IGRT:
inv-09: Guideline-supported indications and clinical evidence — IGRT is supported/recommended in guidelines and studies when specific conditions are met
IGRT is supported/recommended in clinical practice guidelines and studies when specific conditions are met
General guideline indications for IGRT: IGRT is recommended when targets are near or within critical structures, when narrow PTV margins are required, when targets are subject to daily internal or respiratory motion, when prior irradiation necessitates precise abutting fields, or when dose escalation is planned beyond usual doses.
Derived from AAPM, ACR‑ASTRO, ASTRO, and NCCN guidance
Tumor/site‑specific recommendations: Strong or required recommendations for daily IGRT include: preoperative RT for extremity/truncal/retroperitoneal soft tissue sarcoma; dose‑escalated hypofractionated RT for hepatocellular/intrahepatic cholangiocarcinoma; highly conformal or SABR treatments for oligometastatic NSCLC; conventionally fractionated pancreatic RT; and head and neck cases where anatomical change may require replanning. NCCN similarly lists IGRT recommendations across biliary, hepatocellular, NSCLC, and soft tissue sarcoma guidelines.
Multiple guideline citations (ASTRO, NCCN, AAPM)
Motion and margin rationale:
inv-10: Breast radiation fractionation — Revised coverage criteria and coding guidance (including APBI fractions and connective tissue allowance)
Revised coverage criteria and coding guidance
Breast radiation fractionation and coding revisions: Accelerated partial‑breast irradiation with 3D technique: delivery up to 10 fractions is medically necessary. Individuals with systemic lupus erythematosus or scleroderma may receive up to 33 fractions inclusive of a boost. Coding clarifications: treatment delivery level should be reported using appropriate CPT delivery codes (77402, 77407, 77412) with documentation to justify Level 3 (77412) when used; IGRT technical component is included in delivery codes and the professional component is reported as 77387‑26. Megavoltage planning/imaging/delivery codes should not be reported for superficial/orthovoltage therapy (use 77436–77439).see Applicable Codes for fraction and code guidance
Material changes: added APBI‑3D 10‑fraction allowance and specified connective tissue disorder naming; see Applicable Codes for coding/reporting details
The policy defines explicit fractionation ceilings beyond which treatment is considered not medically necessary unless a specific exception applies. For example, delivery of greater than 33 fractions (inclusive of any boost to the tumor bed) for breast EBRT, greater than 35 fractions for locally advanced non–small cell lung cancer EBRT, and greater than 45 fractions for localized prostate cancer are not medically necessary. Exceptions that permit higher fraction counts (e.g., up to 33 fractions for breast when specified criteria are met, or higher prostate fractions when pelvic nodes or postprostatectomy treatment are indicated) are described within each indication and must be documented.
Image-guided radiation therapy (IGRT) is considered medically necessary only when used in the listed clinically appropriate circumstances (for example, with IMRT or proton therapy, when implanted fiducials are used, when the target abuts previously irradiated tissue, or for specific disease sites/techniques). IGRT used solely to align bony landmarks without implanted fiducials (such as during palliative treatment) is not medically necessary. Documentation should support any deviation from the listed fractionation limits or IGRT criteria.
The large NSABP B‑39/RTOG 0413 randomized equivalence trial comparing accelerated partial‑breast irradiation (APBI) with whole‑breast irradiation (WBI) enrolled >4,200 participants and found that APBI did not meet prespecified equivalence criteria for local control overall at median follow-up (~10 years). This outcome means APBI cannot be considered universally equivalent to WBI across broad, unselected patient populations and highlights the importance of patient selection and technique when offering APBI.
Smaller or technique‑specific trials and analyses show variable results for APBI (including differences in acute vs late toxicity and cosmesis), so APBI should be applied consistent with trial inclusion criteria and guideline-recommended patient selection rather than as a general substitute for WBI.
APBI coverage is contingent on treatment plans meeting protocol dose‑volume and patient‑selection constraints. The policy specifies technique‑dependent fraction limits (for example, APBI with IMRT: up to 5 fractions; APBI with 3D technique: up to 10 fractions) and requires that plans conform to dose‑volume requirements used in supporting trials and guidelines. Plans that fail to meet protocol DVH constraints or are applied to tumors excluded from trial criteria (for example, lobular histology, tumors >3 cm, or multicentric/multiquadrant disease) may be considered inappropriate for APBI coverage.
When APBI is considered, documentation should demonstrate that the selected APBI modality and dose‑fractionation match the evidence-based or guideline-recommended regimens and that dose‑volume constraints and reproducibility requirements are met.
Some hypofractionated prostate regimens have been associated with higher acute genitourinary and gastrointestinal toxicity in randomized trials. Specifically, the HYPRO trial's hypofractionation schedule of 3.4 Gy × 19 fractions showed increased acute GU/GI toxicity compared with conventional fractionation, and the investigators concluded that this regimen cannot be regarded as the new standard of care for intermediate‑ or high‑risk patients without further efficacy data.
Because of these trial findings, hypofractionated schedules with evidence of greater acute toxicity require careful selection, explicit clinical justification, and documentation when used instead of established moderate hypofractionated regimens supported by noninferiority trials.
ASTRO guidance notes that IGRT is generally not indicated for superficial skin treatments and should not be used solely to align bony landmarks in the absence of implanted fiducials. For superficial or orthovoltage surface therapy, IGRT is not routinely required — the guideline lists superficial skin cancer treatment and bony‑landmark alignment without fiducials as contexts in which IGRT is not indicated.
When superficial modalities (for example, electronic brachytherapy or orthovoltage) are used, appropriate surface‑therapy planning and delivery codes should be applied rather than routine IGRT billing.
The policy's revision removed prior language that explicitly stated IGRT was not medically necessary for superficial skin therapy or electronic brachytherapy. That removal means the previous categorical exclusion for IGRT in superficial treatments was eliminated from the policy text; current guidance instead refers readers to coding clarifications and to apply clinical judgment and documentation expectations.
Practically, providers should follow the updated coding and documentation instructions in the Applicable Codes section and ensure that any use of image guidance in superficial treatments is supported by clinical rationale and appropriate billing codes.
Examples of clinically implausible or coverage‑exceeding fractionation scenarios include: delivery of breast EBRT exceeding 33 fractions inclusive of boost without an allowed exception; locally advanced NSCLC EBRT exceeding 35 fractions; localized prostate EBRT exceeding 45 fractions when none of the listed criteria (pelvic nodes, postprostatectomy, prior pelvic RT, inflammatory bowel disease) apply; and routine use of IGRT solely to align bony landmarks without fiducials. These scenarios would typically be identified as not medically necessary unless documentation demonstrates a specific, evidence‑based justification or a listed exception.
Providers should document the clinical indication, prior radiation history, targeted volumes (including nodal treatment), and any factors that justify deviation from standard fractionation limits to avoid claim denials.
Comparative‑effectiveness evidence across fractionation strategies and techniques is heterogeneous and limited in some areas. For palliative bone metastases, the AHRQ evidence review included 53 RCTs and found modest differences between single‑ and multiple‑fraction regimens for short‑term pain response but little difference at later follow‑up; overall evidence for comparative effectiveness is sparse. For breast and prostate indications, high‑quality randomized trials support some hypofractionated regimens (e.g., UK FAST‑Forward 5‑fraction whole‑breast schedule; multiple prostate hypofractionation noninferiority trials), but other schedules (for example, HYPRO) showed increased acute toxicity.
As a result, the policy aligns coverage with regimens supported by randomized data and guideline endorsement, and requires that deviations from these established regimens be explicitly justified with documentation of clinical rationale and anticipated benefit vs risk.
APBI versus WBI trial evidence is mixed: the NSABP B‑39/RTOG 0413 large equivalence trial did not demonstrate equivalence of APBI to WBI for the overall study population at long‑term follow‑up, while other randomized trials and pooled analyses have shown similar local control in selected patient subgroups or with specific APBI techniques. Differences in trial designs, APBI modalities, fractionation schedules, and patient selection limit broad generalizability.
Accordingly, APBI may be appropriate for selected early‑stage patients when treatment conforms to trial or guideline inclusion criteria (tumor size, histology, margins, nodal status) and when planning and dose‑volume constraints are met; outside those conditions, WBI remains the standard approach.
The policy cautions against routine adoption of hypofractionation schedules that lack consistent trial support as the new standard of care for higher‑risk patients. For prostate cancer, although several noninferiority trials support moderate hypofractionation (for example, 60 Gy in 20 fractions), the HYPRO regimen of 3.4 Gy × 19 fractions was associated with greater acute GU/GI toxicity and was not shown to be superior; thus, its routine use in intermediate or high‑risk patients is not endorsed without explicit justification.
Providers should preferentially use hypofractionated regimens that are supported by randomized evidence and guideline recommendations, and document rationale when selecting alternative or investigational fractionation schedules.
ASTRO guidance reiterates scenarios where IGRT is not indicated (for example, superficial skin treatments and alignment to bony landmarks without fiducials) and outlines clinical contexts that commonly warrant IGRT, such as targets near critical structures, narrow margin requirements, and targets subject to daily internal motion. The policy refers readers to these ASTRO coding and practice statements when considering IGRT applicability.
When an IGRT indication is not explicitly met, documentation must demonstrate why IGRT was necessary for safe or effective delivery of therapy to avoid denials tied to inappropriate use.
Coding guidance clarifies that the technical component of IGRT is included in radiation treatment delivery CPT codes (for example, 77402, 77407, and 77412) and should not be reported separately; the professional component of IGRT should be reported as 77387-26. When reporting Level 3 delivery (77412), documentation must explicitly justify Level 3 complexity (multiple isocenters, active motion management, total‑skin electrons, mixed fields) rather than Level 2.
For superficial or orthovoltage treatments, megavoltage planning/imaging/delivery codes should not be reported; instead, use the surface therapy codes 77436–77439. Special dosimetry (77331) has specific documentation expectations (clinical need, devices used, and number of measurements typically one to six).
Applicable Codes and Billing Clarifications
Referenced CPT/HCPCS Radiation Therapy Codesmixed
77331
Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician.
77370
Special medical radiation physics consultation.
77387
Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed.
77399
Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services.
77402
Radiation treatment delivery; Level 1 (e.g., single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed.
77407
Radiation treatment delivery; Level 2, single-isocenter (e.g., 3D or IMRT), photons, including imaging guidance, when performed.
77412
Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (e.g., 2D, 3D, or IMRT) or a single-isocenter photon therapy (e.g., 3D or IMRT) with active motion management, or total skin electrons, or mixed-electron/photon field(s), including imaging guidance, when performed.
77436
Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting.
Surface radiation therapy; orthovoltage, delivery, > 150-500 kV, per fraction.
1–10 of 16
1/2
Referenced dosing/regimens (no billing codes in excerpt)mixed
No codes listed
FDA product codes (informational)mixed
LHN
FDA product code referenced for proton beam radiation therapy accelerators and delivery systems (informational)
FDA product codes (informational)mixed
MUJ
FDA product code referenced for devices used in IMRT/SBRT/SRS (informational)
IYE
FDA product code referenced for devices used in IMRT/SBRT/SRS (informational)
Coding clarifications and delivery/planning codesCPT
77402
Radiation treatment delivery — Level 1: conventional single electron field, multiple electron fields, or 2D photons
77407
Radiation treatment delivery — Level 2: standard single-isocenter 3D or IMRT/VMAT treatments
77412
Radiation treatment delivery — Level 3: multiple isocenters with photon therapy, single-isocenter with active motion-management, total-skin electrons, or mixed electron/photon fields; requires documentation justifying Level 3
77387
Image-guided radiotherapy (IGRT) professional component (report as 77387-26 for professional component)
77436
Superficial, surface, or orthovoltage radiation therapy (planning/imaging/delivery codes for these therapies)
77437
Superficial, surface, or orthovoltage radiation therapy
77438
Superficial, surface, or orthovoltage radiation therapy
77439
Superficial, surface, or orthovoltage radiation therapy
77331
Special dosimetry — measurement of radiation dose at a specific point using specialized devices when outside standard planning/calibration parameters (typically 1–6 measurements)
77301
IMRT planning; notation updated to indicate IMRT planning includes special dosimetry
DefinitionHypofractionation = external beam radiation therapy with a fraction size between 240 cGy and 340 cGy.
Dose threshold rationaleHypofractionated radiotherapy delivers fewer, larger (>200 cGy) doses per fraction as described in the policy's Description of Services.
Clinical guidance sourceDefinition cited to Morgan et al., Smith et al., and ASTRO guidance within the policy Description of Services.
inv-29: Hypofractionation fraction size — restated (240–340 cGy per fraction)
Restated definitionHypofractionation: 240–340 cGy per fraction (external beam radiation therapy).
Authorization, Documentation, and Operational Guidance
Prior Authorization
Prior authorization — document dose-fractionation and technique
Authorization: Prior authorization requests should document the planned dose-fractionation and the treatment delivery technique (e.g., 3D-CRT, IMRT/VMAT, proton). Include the selected fractionation schedule (total dose, per-fraction dose, number of fractions) and clinical rationale when requesting approval.
Document dose-fractionation (total dose, dose per fraction, number of fractions) and the specific delivery technique.
If reporting a Level 3 delivery (CPT 77412), include documentation that justifies Level 3 complexity vs Level 2 (multiple isocenters, active motion management, mixed electron/photon fields, total-skin electrons).
Prior Authorization
Authorization — specify fractionation, IGRT, and risk grouping
Specify in authorization requests the planned fractionation regimen, the intended image-guidance strategy (frequency and modality of IGRT), and the clinical risk grouping when relevant (e.g., prostate low/intermediate/high risk; breast APBI vs WBI). This information supports clinical review and ensures appropriate resources and QA are in place.
Background and Evidence Summary
Radiation therapy may be delivered as single or multiple fractions and includes hypofractionation (fewer, larger fractions), hyperfractionation, and accelerated fractionation approaches. Hypofractionation for policy purposes is defined as fraction sizes between 240 and 340 cGy per fraction. EBRT delivery techniques covered by the policy include 3D conformal RT, intensity‑modulated RT (IMRT), volumetric arc therapy, stereotactic techniques, and proton beam therapy; IGRT uses imaging (often volumetric) to localize the target and reduce margins, which can reduce toxicity when documented and performed according to QA standards.
Key Definitions
inv-59: Definitive Treatment — definition of definitive intent
DefinitionDefinitive Treatment = radiation treatments for cancer with a curative intent.
Source definitionsDefinition attributed to NCCN and National Cancer Institute descriptions cited in the policy Definitions section.
Clinical implicationUsed to distinguish curative-intent regimens (definitive) from palliative or adjuvant treatments in coverage determinations.
Prostate limited metastatic diseaseLimited Metastatic Disease (prostate only) = absence of visceral metastasis or fewer than four bone metastases, with no metastasis outside the vertebral bodies or pelvis.
Treatment implications
Policy Revision History
2026-03-01policy_revisionLatest
Revised coverage criteria for breast adenocarcinoma to add up to 10 fractions for accelerated partial‑breast irradiation with 3D technique and specified connective tissue disorders (systemic lupus erythematosus or scleroderma); updated definition of 'Definitive Treatment'; clarified IGRT and coding guidance including notations for CPT 77402/77407/77412 and inclusion of IGRT technical component in delivery codes; removed prior language stating IGRT not medically necessary for superficial skin treatments under certain conditions.
Policy Summary
PayerUnitedHealthcare
PolicyFractionation, Image-Guidance, and Special Services
Policy CodePolicy 2026T0613L
Change TypeMaterial revisions to fractionation and coding guidance
Effective DateMar 1, 2026
Next Review DateN/A
Key ActionWhen requesting authorization, document the planned fractionation regimen, IGRT use, and clinical rationale to support delivery level and coding.
clinical documentation required when not explicitly listed
Refer to coding clarifications for IGRT reporting and to evidence supporting daily IGRT for prostate (reduced acute GU/GI toxicity and improved biochemical control)
AHRQ evidence: low‑moderate strength of evidence for some SBRT comparisons
APBI did not meet equivalence to WBI in the NSABP B‑39/RTOG 0413 trial overall; APBI techniques and plans must meet protocol dose‑volume requirements and patient selection to be appropriate for coverage.
NSABP B‑39/RTOG 0413 trial findings and exclusions
IGRT (preferably daily volumetric imaging) is expected and should be documented for prostate treatments because evidence indicates reduced acute GU/GI toxicity and improved biochemical control; omission of IGRT requires justification in the record.
daily preferred
Meta‑analysis shows IGRT reduced acute GU/GI toxicity and improved 3‑year BFFS with daily imaging
Respiration‑correlated imaging (4D‑CT), 4D image guidance, and beam gating can reduce required treatment margins (median tumor motion ~4.4 mm; 4D‑IG median margin reduction ~5.1 mm), enabling tighter PTVs and potential toxicity reduction.
Korreman et al. and margin calculations per van Herk
Prostate intrafraction motion evidence: Intrafraction prostate motion occurs frequently over 5–7 minutes; studies indicate a lower‑limit margin of ~2 mm to account for intrafraction motion, supporting daily IGRT and fiducial use to reduce margins.~2 mm lower‑limit margin
Kotte et al. intrafraction motion data
QA and program requirements: CT‑based IGRT systems require daily quality control, geometric accuracy assessment, documented SOPs, and team‑based QA processes when PTV margins are tightened; these program elements should be documented.
AAPM and ACR‑ASTRO practice parameters
Comparison noteHypofractionation involves fewer fractions with larger per‑fraction dose (>200 cGy) compared with conventional fractionation.
Source contextPolicy Description of Services defines the fraction‑size range and references Morgan et al. and Smith et al.
inv-30: Accelerated partial-breast irradiation fractions — up to 10 fractions for 3D technique
Allowed fraction count for EBRT 3D APBIAccelerated partial‑breast irradiation (APBI) delivered with a 3D technique: up to 10 fractions are allowed as added in the revised coverage criteria.
Alternative APBI regimensASTRO recommends external beam PBI options including 3,000 cGy in 5 fractions or 4,005 cGy in 15 fractions; NCCN prefers 30 Gy in 5 fractions for APBI.
Trial contextNSABP B‑39/RTOG 0413 used EBRT APBI delivered as 38.5 Gy in 10 fractions over 5 treatment days in some arms; the trial informed APBI policy considerations.
inv-31: Connective tissue disorder fraction allowance — up to 33 fractions inclusive of boost for systemic lupus erythematosus or scleroderma
Connective tissue disorder allowanceWhen the individual has systemic lupus erythematosus or scleroderma, delivery of up to 33 fractions (inclusive of a boost to the tumor bed) is allowed.
Policy revision noteThe policy replaced nonspecific 'lupus' language with explicit 'systemic lupus erythematosus' in the revised coverage criteria.
Context in breast criteriaThe up-to-33-fraction allowance applies in specified scenarios (e.g., regional node treatment, postmastectomy, prior thoracic RT, or connective tissue disorder) per the breast adenocarcinoma coverage criteria.
State the planned regimen (example: prostate 60 Gy in 20 fractions or NCCN-preferred 3 Gy x 20).
Identify IGRT plan: daily vs weekly, imaging modality (kV/MV planar, CBCT, fiducial-based localization) and frequency.
Indicate tumor/risk grouping when relevant (e.g., prostate risk group, breast APBI candidate vs WBI).
Documentation Required
Prior authorization: coding and documentation expectations
Coding and documentation expectations for prior authorization and claims: report the appropriate delivery complexity code and support higher-complexity codes with contemporaneous documentation. Ensure IGRT billing follows coding rules (technical component included in delivery codes; professional IGRT billed as 77387-26 when applicable).
Report delivery complexity using CPT 77402 (Level 1), 77407 (Level 2), or 77412 (Level 3) with documentation justifying Level 3 when used.
Do not report IGRT technical component separately with 77402/77407/77412; professional IGRT may be reported as 77387-26 when appropriate.
For superficial/surface/orthovoltage therapy, do not report megavoltage planning/imaging/delivery codes — use CPT 77436–77439 instead.
Step Therapy
Step therapy / sequencing — not specified
None specified in this excerpt for step therapy or mandatory sequencing; clinical choice of fractionation and technique should be guided by evidence-based regimens, patient factors, and guideline recommendations.
No step therapy requirements stated in this policy.
When sequencing decisions are clinically complex, document rationale in the prior authorization request.
Documentation Required
Documentation: special procedures and medical physics consultations
When treatment complexity warrants, document special procedures and medical physics consultations (e.g., CPT 77370) and special dosimetry (CPT 77331) with clinical justification and the number of measurements performed. These are billable when the complexity meets the coding definitions.
Report CPT 77370 for special medical physics consultation when a written analysis by a qualified medical physicist is required (complex planning, brachytherapy, SRS/SBRT, custom devices, fetal dose calculations).
Report CPT 77331 for special dosimetry when measurements fall outside standard planning/system calibration; document devices used and number of measurements (typically 1–6).
IMRT planning (77301) includes routine special dosimetry and should not duplicate 77331 unless additional measurements are clinically required.
Billing Rule
Billing rule — coding mismatch risk for superficial/orthovoltage therapy
Coding mismatch risk: do not report megavoltage planning, imaging, or delivery codes for superficial, surface, or orthovoltage radiation therapy. Use the specific superficial/orthovoltage codes (CPT 77436–77439) to avoid denials.
Megavoltage planning/imaging/delivery codes (e.g., 77402/77407/77412) must not be reported for superficial treatments.
Use CPT 77436, 77437, 77438, or 77439 for superficial/surface/orthovoltage therapy depending on service specifics.
Documentation Required
Operational and QA documentation — when high-precision treatment planned
Operational/QA documentation expectations: include IGRT frequency and modality, immobilization and localization methods, and evidence of QA programs and SOPs when daily high-precision techniques or tighter PTV margins are planned.
Document daily QA procedures, geometric accuracy assessments, and the program used to assure safe IGRT implementation.
For prostate and other sites where daily localization is essential, document daily prostate localization technique and frequency.
For APBI and other regimens where imaging frequency affects setup verification, document imaging schedule (NCCN recommends minimum weekly imaging; more frequent as indicated).
Definition used to qualify definitive treatment allowances for limited metastatic prostate cancer (e.g., fractionation limits for definitive intent).
Source referencesDefinition cited to Parker et al. (2018) and aligned with NCCN guidance for prostate cancer.
DefinitionHypofractionation = external beam radiation therapy with fraction sizes in the range approximately 240–340 cGy (2.4–3.4 Gy per fraction).
Example regimensExamples of moderate hypofractionation cited include 3 Gy × 20 fractions (60 Gy) and other NCCN‑listed schedules (2.5–3.0 Gy schedules).
Clinical noteASTRO and NCCN support moderate hypofractionation for many prostate cancer patients, with counseling about small increased acute GI toxicity in some trials.
inv-62: Special medical physics consultation — definition and when required
Definition and purposeSpecial medical physics consultation = a written analysis required when treatment plan complexity necessitates the expertise of a qualified medical physicist.
When requiredUsed when treatment complexity warrants additional physician/physics effort (e.g., complex planning, motion management, or special dosimetry situations).
Documentation notePolicy states such consultations and special treatment procedure codes should be documented to justify coverage; see coding clarifications for examples (e.g., CPT 77370).
inv-63: APBI / PBI — definition of accelerated/partial-breast irradiation
DefinitionAPBI/PBI = accelerated/partial‑breast irradiation delivering radiation confined to the lumpectomy cavity or partial breast over a shorter overall treatment time than whole‑breast irradiation; may be delivered via brachytherapy or external beam techniques.
Typical regimensASTRO recommends external beam PBI regimens such as 3,000 cGy in 5 fractions or 4,005 cGy in 15 fractions; NCCN prefers 30 Gy in 5 fractions for APBI.
Trial considerationsLarge trials (e.g., NSABP B‑39/RTOG 0413) inform APBI outcomes and patient selection; APBI techniques and dose‑volume constraints must be met for appropriate coverage.
Definition and exampleHF‑WBI = hypofractionated whole‑breast irradiation delivering a larger dose per fraction over fewer total fractions (example: 40 Gy in 15 fractions).
Guideline supportASTRO and NCCN endorse HF‑WBI (40–42.5 Gy in 15–16 fractions) as preferred whole‑breast dosing when dose homogeneity goals are achievable.
Boost considerationsIn the presence of strong risk factors for local recurrence, a tumor‑bed boost may be used with specified boost dosing per ASTRO/NCCN guidance.
inv-65: Moderate hypofractionation — example regimens and fraction-size range
DefinitionModerate hypofractionation = EBRT regimens with fraction sizes in the approximate range 2.4–3.4 Gy per fraction.
Example regimensExamples include 3 Gy × 20 fractions (60 Gy) and other NCCN‑listed schedules such as 2.7 Gy × 26 or 2.5 Gy × 28 fractions; Catton et al. and Dearnaley et al. trials support noninferiority for many patients.
Clinical considerationsPatients should be counseled about a small increase in acute GI toxicity seen in some trials; regimen choice depends on risk group and nodal treatment plans.
inv-66: Daily IGRT — definition and clinical benefits (prostate localization)
DefinitionDaily IGRT = daily image‑guidance using volumetric imaging (e.g., cone‑beam CT) to localize the prostate and reduce planning target volume (PTV) margins.
Clinical benefitsMeta-analysis in the policy reported reductions in acute GU and GI toxicity and improved biochemical control measures (e.g., 3‑year PSA relapse‑free survival and BFFS) with daily IGRT compared with nondaily or no IGRT.
QA implicationCT‑based IGRT requires daily quality control and geometric accuracy assessment; tighter PTV margins demand robust QA and documented SOPs per AAPM guidance.
inv-67: PTV (planning target volume) — definition and relation to geometric uncertainties
DefinitionPTV (planning target volume) = a target volume margin constructed to account for geometric uncertainties during planning and delivery.
Relation to uncertaintiesTighter PTV margins require higher geometric accuracy from IGRT systems and daily QC; AAPM emphasizes geometric accuracy as important as dosimetric accuracy when margins are reduced.
Margin reduction exampleRespiration‑correlated imaging and 4D‑IG strategies can reduce required margins (Korreman et al. showed median margin reduction with 4D‑IG ~5.1 mm in lung cancer studies).
Definition4D‑CT / 4D‑IG = respiration‑correlated imaging and image‑guidance strategies that account for tumor motion during the breathing cycle to reduce treatment margins.
Effect on marginsKorreman et al. demonstrated that 4D‑CT and 4D‑IG can reduce required treatment field margins substantially (median tumor motion 4.4 mm; median margin reduction with 4D‑IG ~5.1 mm).
Clinical useUsed for lung tumors and other thoracic/abdominal targets where respiratory motion affects target position; enables tighter PTVs with appropriate QA.
inv-69: Definitive Treatment — updated definition placeholder (exact revised wording in full doc)
Revised definitive treatment definition (placeholder)Definition of 'Definitive Treatment' was updated in the policy; exact revised wording is included in the full policy document and referenced in the Policy History/Revision Information.
Reference to full textSee the policy Definitions section for the complete updated wording of 'Definitive Treatment'.
Revision dateUpdated as part of the 03/01/2026 policy revision (Policy History/Revision Information).