Intensity‑Modulated Radiation Therapy (for Kentucky Only)
This policy governs coverage and medical necessity criteria for IMRT for adults (19 years and older) in Kentucky and applies to UnitedHealthcare members and providers delivering radiation oncology services in that state.
Revised list of conditions for which IMRT for definitive therapy for the primary site is proven and medically necessary and adjusted phrasing for breast cancer criteria.
Added new covered indications including unresectable hepatocellular carcinoma, Hodgkin lymphoma, unresectable intrahepatic cholangiocarcinoma, rectal cancer involving inguinal nodes, limited-stage small cell lung cancer, retroperitoneal/intra-abdominal soft tissue sarcoma, and stage I-II NSCLC undergoing hypofractionated RT up to 10 fractions.
Replaced language describing hippocampal-avoidance whole brain RT of up to 10 fractions from 'proven and medically necessary when all criteria are met' to 'considered proven and medically necessary when all criteria are met.'
Removed language indicating compensator-based beam modulation is proven and medically necessary when done with IMRT indications listed as proven.
Revised general policy language to state IMRT 'may be considered medically necessary' for conditions not defined as proven in the policy, instead of 'may be covered'.
Updated medical records documentation requirements to state that documentation may be required to assess criteria and must fully support medical necessity; records must be available upon request.
Added CPT codes 77407 and 77412 to applicable codes and removed CPT/HCPCS codes 77385, 77386, G6015, G6016, and G6017.
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