ModifiedUnitedHealthcarePolicy CS064TN.R

Intensity-Modulated Radiation Therapy (for Tennessee Only)

This Tennessee Medicaid/CoverKids medical policy governs coverage and medical necessity criteria for IMRT for individuals 19 years and older (and notes coverage for those under 19), applicable to Medicaid and CoverKids in Tennessee.

Policy Summary

PayerUnitedHealthcare

PolicyIntensity-Modulated Radiation Therapy (for Tennessee Only)

Policy CodePolicy CS064TN.R

Change TypeRevised indications and definitions

Effective DateJun 1, 2025

Next Review Date

Key ActionWhen requesting IMRT for indications not listed, provide comparison treatment plans (IMRT vs non-IMRT) to justify clinical necessity.

SourceLink

POLICY UPDATE CHANGES

Revised list of conditions for which IMRT for Definitive Therapy for the primary site is proven and medically necessary, including adding 'vulvar cancer' and replacing 'anal cancer' with 'anus /anal canal cancer'.

Updated definition of 'Definitive Therapy'.

Updated Description of Services, Clinical Evidence, and References sections to reflect the most current information.

19+applies to individuals aged

≤2ECOG threshold (HA-WBRT)

≥70Karnofsky threshold (HA-WBRT)

4 months

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minimum prognosis (HA-WBRT)

2025-06-01policy revision date

Coverage and Medical Necessity Criteria

Proven Indications - Definitive Therapy

Covered when ALL of the following are met for definitive therapy at the primary site:

Primary site indications: IMRT is proven and medically necessary for definitive therapy of specified primary sites (anus/anal canal; breast when treating left-sided internal mammary nodes or for accelerated partial-breast irradiation up to 5 fractions; central nervous system tumors including brain, brainstem, and spinal cord; cervical cancer; endometrial cancer; esophageal cancer; head and neck cancers as specified; mediastinal tumors including thymomas and lymphomas; stage III non-small cell lung cancer undergoing chemoradiation; pancreatic cancer; prostate cancer; vulvar cancer).

See policy chunk 4 for full site list and breast-specific conditions.

Technique-Specific Coverage

Covered with criteria for specific techniques and scenarios:

Compensator-based and hippocampal-avoidance treatments: Compensator-based beam modulation is proven when used in combination with a listed IMRT indication. Hippocampal-avoidance whole-brain radiotherapy (HA-WBRT) of up to 10 fractions is covered for brain metastasis when performance status and other criteria are met.10 fractions

Performance status (ECOG ≤2 or KPS ≥70), prognosis ≥4 months, and absence of leptomeningeal disease are required for HA-WBRT per policy chunk 5.

Case-by-Case Approval Criteria

Exceptions / case-by-case coverage:

Case-by-case criteria: IMRT may be covered for conditions not listed when at least one of the following is present: (1) use of a non‑IMRT technique would increase the probability of clinically meaningful normal‑tissue toxicity as demonstrated by a comparison of IMRT and non‑IMRT treatment plans (e.g., 3‑D conformal plan), or (2) the same or immediately adjacent area has been previously irradiated and sculpting of dose is required to avoid exceeding cumulative normal‑tissue tolerance. Requests will be evaluated on a case‑by‑case basis.

Requires clinically appropriate radiation dose and supporting comparison plans.

Not Medically Necessary

Not medically necessary: IMRT used in conjunction with proton beam radiation therapy is unproven and not medically necessary due to insufficient evidence of efficacy.

Covered with criteria — disease-site evidence summaries

Coverage supported by clinical studies and guideline recommendations when IMRT/VMAT is used to reduce dose to normal structures and/or when target conformity is required

Anal cancer - supportive evidence: Retrospective NCDB analyses and prospective/phase II studies report IMRT or dose‑painted IMRT is associated with reduced acute toxicity and, in matched analyses, improved overall survival (e.g., 5‑year OS 74.6% vs 70.5%) and guideline groups (ACR, ESMO, NCCN) cite IMRT/VMAT as usually appropriate or preferred for anal carcinoma.

RTOG 0529 showed reductions in several acute toxicities though primary endpoint not met; real‑time QA emphasized.

Breast cancer - supportive evidence: Randomized trials (APBI‑IMRT versus whole‑breast irradiation) demonstrate comparable tumor control with reduced treatment volumes/toxicity for selected patients (APBI‑IMRT 30 Gy in 5 fractions); IMRT and compensator/respiratory control techniques can improve dose homogeneity and spare cardiac structures when treating left‑sided disease.

APBI‑IMRT trial N=520 with median follow‑up 10.7 years showed low ipsilateral breast tumor recurrence and favorable cosmesis.

CNS tumors - supportive evidence: Case series and guideline evidence support IMRT for complex skull‑base meningiomas and diffuse gliomas, demonstrating high local control and reduced toxicity; ASTRO strongly recommends IMRT/VMAT to reduce acute and late toxicity for selected diffuse gliomas.

Evidence synthesis by disease site

Summarized clinical and guideline positions by disease site

CNS tumors (meningioma, diffuse glioma): Case series and guideline evidence support IMRT for complex‑shaped skull base meningiomas with high local control (e.g., LC ~93.6%) and for IDH‑mutant WHO grade 2–3 diffuse glioma where ASTRO strongly recommends IMRT/VMAT to reduce acute and late toxicity.

Cervical cancer: Meta‑analyses, trials, and guidelines indicate IMRT reduces acute and chronic GI/GU and hematologic toxicity compared with 3D‑CRT, with similar oncologic outcomes; ASTRO strongly recommends postoperative IMRT and conditionally recommends IMRT for definitive treatment; NCCN prefers IMRT and routine IGRT.

Endometrial cancer: Randomized and nonrandomized evidence and ASTRO guidance support pelvic IMRT to reduce acute and late toxicity in the adjuvant setting with recommended daily IGRT for verification.

Esophageal cancer: RCT and meta‑analytic data show that IMRT reduces irradiated lung and heart volumes compared with 3D‑CRT and may be associated with improved overall survival in pooled analyses, though dose escalation beyond standard (50.4 Gy) did not improve local control or survival in RCTs.

Evidence-supported indications and benefits

Guideline and trial-based indications and demonstrated benefits

NCCN-preferred instances: IMRT or proton beam RT may be used when reduction in dose to critical organs at risk cannot be achieved by 3‑D techniques; IMRT is standardly applied in preoperative, definitive, and postoperative esophageal cancer and is preferred in multiple head and neck sites to spare salivary glands, optic structures, cochlea, and other critical OARs.

Guideline‑based preferred use (NCCN).

Trial-demonstrated benefits: Randomized and comparative studies have demonstrated dosimetric and clinical benefits with IMRT including reduced parotid‑sparing xerostomia, improved swallowing with dysphagia‑optimized IMRT, reduced heart and lung dose in esophageal cancer, and cognitive preservation with HA‑WBRT plus memantine (NRG CC001).

Study‑level outcomes summarized in policy.

HA-WBRT plus memantine (coverage conditions)

HA-WBRT plus memantine: covered when ALL of the following are met

HA-WBRT plus memantine coverage criteria: 1) Patient is receiving whole‑brain radiotherapy for brain metastases; 2) No metastases within the hippocampal‑avoidance region (no metastases within 5 mm of the hippocampus) and no leptomeningeal disease; 3) Expected survival/prognosis of at least 4 months or ECOG performance status ≤2 or KPS ≥70; 4) Memantine is administered concurrently or per guideline recommendations (e.g., as in NRG CC001).

Based on RCT evidence (NRG CC001) and ASCO/SNO/ASTRO and NCCN guidance.

IMRT / advanced RT technologies (coverage considerations)

Use of IMRT/advanced RT technologies: covered when ALL of the following considerations apply

Advanced RT technique coverage considerations: 1) Clinical indication where sparing specific OARs is important (e.g., head and neck sites to spare salivary glands, cochlea, optic structures; mediastinal lymphoma to reduce heart/esophagus dose; thymoma to minimize heart dose; pancreatic cancer to reduce stomach/duodenum dose; stage III NSCLC to reduce lung and heart toxicity); 2) Treatment planning demonstrates improved OAR sparing or clinically meaningful reduction in expected toxicity without compromising PTV coverage; 3) Technique selection is consistent with guideline recommendations and treating physician rationale (NCCN/ASTRO/ACR), and documentation supports selection.

NCCN and ASTRO guidance note IMRT/VMAT/DIBH/IGRT as appropriate when they reduce clinically relevant OAR dose.

Guideline-aligned coverage criteria by cancer type

Coverage supported when treatment indication aligns with guideline recommendations and evidence of benefit in toxicity or target coverage:

Pancreatic cancer: IMRT/VMAT is recommended for localized pancreatic cancer to improve PTV coverage and reduce dose to OARs; evidence shows reduced GI toxicity versus 3D‑CRT and guideline support from ASTRO and NCCN for modulated techniques.

ASTRO strongly recommends modulated techniques for localized pancreatic cancer.

Prostate cancer: IMRT is the current standard external‑beam RT technique for prostate cancer; dose‑escalated or moderately hypofractionated IMRT with daily IGRT yields acceptable control and low long‑term grade ≥3 GU/GI toxicity. IMRT is strongly recommended when treating pelvic lymph nodes (45–52 Gy).

AUA/ASTRO and NCCN guidelines endorse IMRT for prostate cancer.

Vulvar cancer: Adjuvant and definitive IMRT (often with IGRT and daily verification) is recommended to maximize target dose while minimizing normal‑tissue dose; guideline groups (ESGO, NCCN) endorse IMRT techniques for vulvar cancer.

Sources: ESGO 2023 and NCCN guidance.

IMRT used in conjunction with proton beam radiation therapy is considered unproven and not medically necessary due to insufficient evidence of efficacy.

No explicit procedural or diagnosis exclusions are stated in the cited sections of the policy. Guidance and exclusions described elsewhere are disease- or technique-specific (for example, recommendations about use of IGRT with pelvic IMRT or trial-based fractionation approaches) rather than blanket procedural exclusions.

IMRT should not be used as a routine alternative to brachytherapy for treatment of central disease in individuals with an intact cervix; brachytherapy remains the standard for central disease and IMRT is reserved for indications where brachytherapy is not appropriate or feasible.

There are no broad coverage exclusion statements in the provided excerpts. Certain advanced techniques and alternative fractionation schedules (for example SMART boost) are noted as experimental or best used within clinical trials when phase III data are lacking, and technique selection is advised to be individualized according to patient- and disease-specific factors.

Patients with metastases within the hippocampal-avoidance region (within 5 mm of the hippocampus) or with leptomeningeal disease are not candidates for hippocampal-avoidance WBRT. In addition, guideline statements indicate patients with poor performance status or very limited expected survival (e.g., KPS thresholds cited in guidance) may not derive benefit and are therefore excluded from HA‑WBRT candidacy.

No clinical evidence was identified supporting the combined use of IMRT and proton beam radiation therapy within a single treatment plan. The policy notes this combined approach is unsupported and, consequently, not considered an evidence-based technique.

This Medical Policy is informational and does not override federal, state, or contractual benefit plan terms. In the event of a conflict, the applicable federal, state, or contractual requirements for benefit plan coverage govern; providers should check those terms and plan-specific tools when making coverage determinations.

Billing and Coding

Applicable CPT/HCPCS Codesmixed

77301	Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications.
77338	Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan.
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.
77387	Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed.
77520	Proton treatment delivery; simple, without compensation.
77522	Proton treatment delivery; simple, with compensation.
77523	Proton treatment delivery; intermediate.
77525	Proton treatment delivery; complex.
G6015	Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session.

1–10 of 11

1/2

Additional HCPCS CodeHCPCS

G6017

Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment.

No explicit CPT/HCPCS/ICD-10 codes in this excerptmixed

No codes listed

FDA product codes mentionedmixed

MUJ	FDA product code referenced for IMRT devices
IYE	FDA product code referenced for IMRT devices

Prognosis — HA‑WBRT threshold

Prognosis threshold>= 4 months

Context of useMinimum expected survival required for HA-WBRT eligibility for brain metastases

Related requirementAbsence of leptomeningeal disease also required for HA-WBRT

ECOG performance status — eligibility

ECOG performance status threshold<= 2

Applies toEligibility for HA‑WBRT (hippocampal‑avoidance WBRT) and consideration for memantine co‑administration

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Guideline-based indication (no explicit PA listed)

Guideline-based indications: Follow specialty guidelines (NCCN, ASTRO, ACR, ASCO/SNO) when determining IMRT/VMAT appropriateness. Many guidelines state IMRT/VMAT is preferred or usually appropriate for specific sites (e.g., anal, breast in selected settings, CNS, cervical, endometrial, esophageal, head & neck, prostate, pancreatic, thymic, Hodgkin lymphoma, T‑cell lymphomas) and should guide prior authorization decisions when no explicit PA rule is listed.

Prior authorization decisions should align with guideline-recommended indications and documented clinical rationale.

Prior Authorization

Prior authorization considerations for IGRT‑guided IMRT

When IMRT/VMAT is requested for pelvic or adjuvant endometrial/cervical therapy, documentation of image-guided radiation therapy (IGRT) use (orthogonal imaging and/or volumetric imaging such as CBCT) and daily verification is expected. For other sites where IGRT is standard per guideline, expect IGRT-related planning and delivery documentation.

Include verification imaging frequency and modality (e.g., daily CBCT, orthogonal imaging).

Background and Rationale

External beam radiation therapy (EBRT) delivers targeted high-energy beams to treat cancer. IMRT is an advanced EBRT technique that modulates beam intensity to improve dose conformity to the target while sparing adjacent normal tissues (organs at risk). IMRT is commonly delivered with image guidance (IGRT) to ensure accurate daily localization and reproducible treatment delivery; these capabilities enable dose sculpting, simultaneous integrated boosts, and techniques such as hippocampal-avoidance WBRT.

Definitions and Abbreviations

Definitive Therapy — definition

DefinitionRadiation treatments for cancer with curative intent

Scope noteTerm used to distinguish definitive (curative) RT from palliative or symptom‑directed EBRT

Updated in policyDefinition modified in the 06/01/2025 revision

DP‑IMRT / IMRT / VMAT — definitions

DP‑IMRT / IMRT / VMATConformal radiotherapy techniques that modulate beam intensity and/or use arc delivery to spare normal tissues and allow simultaneous integrated boosts or dose painting

Typical usesUsed to reduce dose to organs at risk and improve target conformity across multiple tumor sites (e.g., anal, breast, head and neck)

Policy Summary

PayerUnitedHealthcare

PolicyIntensity-Modulated Radiation Therapy (for Tennessee Only)

Policy CodePolicy CS064TN.R

Change TypeRevised indications and definitions

Effective DateJun 1, 2025

Next Review Date

Key ActionWhen requesting IMRT for indications not listed, provide comparison treatment plans (IMRT vs non-IMRT) to justify clinical necessity.

SourceLink

On This Page

When IMRT/VMAT unavailable, 3‑D CRT is an alternative per ASTRO.

Related requirementKarnofsky performance status alternative threshold of >= 70 may be used

Karnofsky performance status — eligibility

Karnofsky performance status threshold (KPS)>= 70

Applies toEligibility for HA‑WBRT (hippocampal‑avoidance WBRT) as alternative to ECOG criterion

Related requirementAlso requires prognosis >= 4 months and absence of leptomeningeal disease

Dose‑volume comparisons — Lung V20 and Heart V50

Pooled dosimetric findingIMRT produced lower irradiated lung volume at >= 20 Gy (Lung V20) compared with 3D‑CRT in pooled analysis

Cardiac dosimetryIMRT produced lower irradiated heart volume at ~50 Gy (Heart V50) compared with 3D‑CRT in pooled analysis

Clinical implicationReduced lung and heart dose volumes with IMRT may contribute to reduced cardiopulmonary toxicity

If IGRT-guided IMRT is proposed, provide IGRT protocols and justification in the PA or chart note.

Prior Authorization

Preferred techniques requiring clinical justification

Preferred or advanced techniques (e.g., HA‑WBRT + memantine, IMRT/VMAT over 3D‑CRT for OAR sparing, use of compensator-based modulation) require clinical justification linking the technique to expected reduction in clinically meaningful toxicity or improved normal-tissue sparing that cannot be achieved with simpler techniques.

For hippocampal avoidance WBRT, document absence of metastases within 5 mm of hippocampus, expected survival ≥ 4 months, and memantine plan when applicable.
If requesting IMRT instead of brachytherapy (e.g., central cervical disease), provide rationale — IMRT is not a routine alternative to brachytherapy.

Documentation Required

Quality assurance implication

Quality assurance (QA) and treatment planning documentation are critical for IMRT authorization. Trial experience (e.g., RTOG) emphasizes real‑time radiation QA; providers should supply QA processes, plan review notes, and dosimetric comparisons when requested.

Provide IMRT plan(s) including dose–volume histograms and OAR constraints (e.g., RTOG/QUANTEC references).
Include QA records, physics checks, and any real‑time QA procedures used during trial or clinical delivery.

Prior Authorization

Treatment planning comparison

When IMRT is requested for an indication not listed as proven, supply a comparison of IMRT versus non‑IMRT plans showing that a non‑IMRT technique would increase the probability of clinically meaningful normal‑tissue toxicity or that prior irradiation requires sculpting to respect cumulative normal‑tissue tolerances.

Include both IMRT and comparable 3‑D CRT (or other non‑IMRT) treatment plans with dose statistics for targets and OARs.
Document prior radiation fields/doses when reirradiation is the rationale.

Billing Rule

Coding documentation

Coding and billing documentation should accompany authorization and claim submission. Include procedure codes for IMRT planning and delivery, MLC/compensator codes, IGRT guidance codes, and applicable G‑codes for intensity‑modulated delivery.

Relevant CPT/HCPCS/G‑codes to include: 77301, 77338, 77385, 77386, 77387, G6015, G6016; proton delivery codes (77520–77525) when applicable.
Ensure documentation supports billed codes (complexity, guidance/tracking, compensator use).

Documentation Required

Required treatment and QA documentation

Required treatment and planning details: provide prescribed dose and fractionation, target volumes, OAR constraints, planning technique, and delivery reproducibility measures. For IMRT trials and many guideline-recommended uses, document prescribed dose by stage and any special planning volumes (e.g., vaginal ITV for endometrial adjuvant EBRT).

Dose/fractionation by indication and stage.
Target and OAR contours, planning target volume margins, and any motion‑management or respiratory control techniques (e.g., DIBH).

Documentation Required

Careful attention to detail and reproducibility

Careful attention to detail and reproducibility is required for proper IMRT delivery. Documentation should describe immobilization, setup reproducibility, motion management, and verification imaging protocols.

Describe immobilization devices, setup checks, and reproducibility thresholds.
State how motion (respiratory, organ motion) is managed (4DCT, gating, breath‑hold).

Note

No step therapy stated

No step therapy or sequencing mandates are specified in this excerpt; guidelines generally prefer IMRT/VMAT where clinically indicated and do not require trials of other techniques before IMRT authorization.

If plan‑specific payer rules exist, verify contract/federal/state requirements — this policy excerpt does not impose step therapy.

Prior Authorization

Memantine with HA‑WBRT

Memantine with hippocampal avoidance WBRT: when HA‑WBRT is requested, document that patient meets criteria (no hippocampal lesions within 5 mm, expected survival ≥ 4 months or KPS/ECOG thresholds) and whether memantine will be offered.

Document hippocampal imaging review and memantine prescription plan when applicable.

Prior Authorization

Preference for IMRT over 3D‑CRT where supported

Preference for IMRT over 3D‑CRT where supported: where clinical evidence shows reduced GI/GU or other toxicities with IMRT (e.g., pancreatic, prostate, anal cancers), provide site‑specific outcome rationale and supporting literature when requested for PA.

Cite comparative trials or systematic reviews demonstrating toxicity reduction if used to justify IMRT over 3‑D CRT.

Note

Prior authorization not specified in this excerpt

No explicit prior authorization codes or plan‑level PA workflow are specified in this excerpt. Providers must check plan‑specific prior authorization requirements and submit documentation per payer/contract requirements.

Verify and follow federal, state, and contractual benefit plan terms for exact PA codes and submission processes.

Denial Risk

Unsupported combined IMRT + proton therapy

Unsupported combined IMRT + proton therapy: the evidence base does not support combining IMRT and proton beam therapy in a single treatment plan; such requests will require strong rationale and will be evaluated as experimental/unsupported.

If proposing sequential or mixed‑modality approaches, clearly state timing and rationale; expect case‑by‑case review.

Note

Device approval informational

Device approvals: FDA device clearance information is informational only and not a basis for coverage decisions; include device details in documentation if relevant.

Reference FDA product codes MUJ and IYE for informational purposes only.

Documentation Required

Documentation and decision context

Documentation and decision context: Coverage determinations must follow federal, state, or contractual benefit plan requirements. In the event of conflict, contract/federal/state terms govern. UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist in administration.

Include plan identifiers and applicable contract terms when submitting requests.
Be aware that policy is informational and may be modified; check current plan terms.

Guideline supportGuidelines (NCCN, ACR, ASTRO) recommend or prefer these techniques when OAR sparing or dose painting is clinically important

OAR — Organs at risk

DefinitionNormal structures adjacent to the target volume for which dose constraints are important to reduce toxicity

ExamplesSalivary glands, cochlea, optic structures, heart, lungs, hippocampi

Role in planningOAR dose constraints guide selection of advanced techniques (IMRT/VMAT) to spare critical tissues

IGRT (image‑guided radiotherapy) — definition & role

DefinitionUse of imaging (orthogonal or volumetric such as cone beam CT) during planning and delivery to ensure accurate target localization and reproducible daily treatment

Role with IMRTIGRT is often used with IMRT to account for anatomic changes, verify setup, and maximize normal tissue sparing

RecommendationDaily IGRT is recommended for verification in several disease sites (e.g., endometrial, pelvic treatments)

HA‑WBRT — hippocampal‑avoidance whole‑brain radiotherapy

DefinitionWhole‑brain radiotherapy planned with IMRT techniques that spare the hippocampal neurogenic niche to reduce cognitive decline

Typical deliveryAdministered with memantine in trials and commonly delivered as 30 Gy in 10 fractions when indicated

Eligibility considerationsRequires no metastases within 5 mm of hippocampus, absence of leptomeningeal disease, and adequate prognosis/performance status

DO‑IMRT — dysphagia‑optimized IMRT

DefinitionIMRT planning approach that reduces dose to dysphagia‑ and aspiration‑related structures to improve swallowing outcomes

EvidencePhase 3 RCT demonstrated improved patient‑reported swallowing (MDADI) with DO‑IMRT versus standard IMRT

Clinical useApplied in oropharyngeal and hypopharyngeal cancers to spare pharyngeal constrictors and related OARs

HA‑WBRT — (duplicate definition)

Definition (duplicate)WBRT planned with IMRT to spare the hippocampi (hippocampal‑avoidance) to reduce cognitive decline

Concurrent therapyTypically given with memantine per RCTs and guidelines for eligible patients

EligibilityNo metastases within 5 mm of hippocampus; adequate prognosis and performance status required

IMRT — Intensity‑Modulated Radiation Therapy

DefinitionAdvanced radiotherapy technique that shapes dose distributions via modulation of beam intensity to better spare normal tissues while delivering therapeutic dose to targets

Clinical advantageEnables improved OAR sparing (e.g., parotid glands, heart) and dose conformity compared with conventional techniques

Typical accompanimentOften delivered with IGRT for setup verification and reproducibility

Modulated treatment techniques — IMRT and VMAT

DefinitionTreatment planning and delivery methods (e.g., IMRT, VMAT) that modulate beam intensity or arc delivery to improve conformity and spare normal tissues in both conventionally fractionated and hypofractionated RT

Recommended usesRecommended by guidelines (ASTRO, NCCN) for multiple disease sites when OAR sparing or dose conformity is clinically important

ExamplesVMAT (volumetric modulated arc therapy) delivers modulated dose via rotating gantry arcs to shorten treatment time and improve conformity

Image‑guided IMRT (IGRT) — definition & recommended use

DefinitionIMRT delivered with image guidance (IGRT) to account for anatomic changes and ensure accurate delivery

Recommended scenariosRecommended when treating pelvic nodes, adjuvant endometrial therapy, prostate RT, and other sites where motion/edema may affect dosing

Implementation noteRegular use of orthogonal imaging or volumetric imaging such as cone beam CT is essential for appropriate target coverage and normal tissue sparing

Definitive Therapy — updated definition

Definition (updated)Definitive Therapy: Radiation treatments for cancer with curative intent

Policy changeDefinition updated in the 06/01/2025 policy revision

RelevanceUsed to define coverage group 'Definitive Therapy' for site‑specific IMRT indications