CurrentUnitedHealthcarePolicy MMP077.17

Radiation and Oncologic Procedures

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Medicare Advantage coverage guidance and applicable coding for selected radiation oncology, liver transarterial, embolization, and related radiation treatment services.

Policy Summary

PayerUnitedHealthcare

PolicyRadiation and Oncologic Procedures

Policy CodePolicy MMP077.17

Change TypeAdministrative/reference updateno guideline change

Effective DateSeptember 1, 2026

Next Review DateN/A

Key ActionFollow the applicable Medicare LCD or LCA where one exists; otherwise apply the referenced UnitedHealthcare policy for the procedure.

SourceLink

POLICY UPDATE CHANGES

References to National Government Services (NGS) were replaced with Wellpoint Federal (Wellpoint).

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Radiation Oncology Coverage Criteria

Implantable Beta-Emitting Microspheres

Covered under the applicable Medicare coverage framework and referenced UnitedHealthcare clinical policy.

Applicable coverage framework

Apply the Medicare National Coverage Determination for Therapeutic Embolization (20.28).
Apply the UnitedHealthcare Commercial Medical Policy titled Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver.
Local Coverage Determinations and Local Coverage Articles do not exist for this service in the policy.

Transarterial Bland Embolization or Chemoembolization

Covered under the applicable Medicare coverage framework and InterQual criteria.

Applicable coverage framework

Apply the Medicare National Coverage Determination for Therapeutic Embolization (20.28).
Refer to InterQual CP: Procedures, Ablative or Transarterial Therapy, Liver, for coverage guidelines.
Local Coverage Determinations and Local Coverage Articles do not exist for this service in the policy.

Image Guided Radiation Therapy

Covered when the applicable UnitedHealthcare clinical policy is applied.

Referenced policy: Apply the UnitedHealthcare Commercial Medical Policy titled Radiation Therapy: Fractionation, Image-Guidance, and Special Services.

Medicare does not have a National Coverage Determination for image guided radiation therapy, and Local Coverage Determinations and Local Coverage Articles do not exist.

Radiation Treatment and Associated Services

Covered when the applicable UnitedHealthcare clinical policy is applied.

Referenced policy: Apply the UnitedHealthcare Commercial Medical Policy titled Radiation Therapy: Fractionation, Image-Guidance, and Special Services.

This applies to radiation therapy special or associated services and Level 1, 2, or 3 radiation treatment delivery when reported for 2D/3D. Medicare does not have a National Coverage Determination for these services, and Local Coverage Determinations and Local Coverage Articles do not exist.

Proton Beam Therapy

Covered when the applicable Medicare contractor policy or UnitedHealthcare policy is followed.

Applicable coverage source

Follow the applicable Medicare Local Coverage Determination or Local Coverage Article where one exists.
Compliance is required where applicable.
For states or territories without an applicable Local Coverage Determination or Local Coverage Article, apply the UnitedHealthcare Commercial Medical Policy titled Proton Beam Radiation Therapy.

IMRT-Related Radiation Treatment Delivery

Covered when the applicable Medicare contractor policy or UnitedHealthcare policy is followed.

Applicable coverage source

Follow the applicable Medicare Local Coverage Determination or Local Coverage Article where one exists.
Compliance is required where applicable.
For states or territories without an applicable Local Coverage Determination or Local Coverage Article, apply the UnitedHealthcare Commercial Medical Policy titled Intensity-Modulated Radiation Therapy.

Combined Proton Beam Therapy and IMRT

Covered when both applicable UnitedHealthcare clinical policies are applied.

Referenced policies

Apply the UnitedHealthcare Commercial Medical Policy titled Proton Beam Radiation Therapy.
Apply the UnitedHealthcare Commercial Medical Policy titled Intensity-Modulated Radiation Therapy.

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

Covered when the applicable Medicare contractor policy or UnitedHealthcare policy is followed.

Applicable coverage source

Follow the applicable Medicare Local Coverage Determination or Local Coverage Article where one exists.
Compliance is required where applicable.
For states or territories without an applicable Local Coverage Determination or Local Coverage Article, apply the UnitedHealthcare Commercial Medical Policy titled Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery.

Applicable Procedure and Reference Codes

Implantable Beta-Emitting Microspheres for Treatment of Malignant TumorsCPT

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.
79445	Radiopharmaceutical therapy, by intra-arterial particulate administration.

Image Guided Radiation Therapy (IGRT)CPT

77387

Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed.

Radiation Therapy 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).

Radiation Treatment Delivery; Level 1, 2, 3 (When Reported for 2D/3D)CPT

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.

Proton Beam Therapy (PBT)CPT

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

Radiation Treatment Delivery: Level 2 or 3 [When Reported for Intensity Modulated Radiation Therapy (IMRT)]CPT

77301	Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications.
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.

Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT)CPT

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.

Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT)HCPCS

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, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment.

Applicable HCPCS CodesHCPCSCovered

G0339	Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT) 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, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment

CMS Related Document Identifiersmixed

L36658	Proton Beam Therapy
A55315	Billing and Coding: Proton Beam Therapy
L33937	Proton Beam Radiotherapy
A57669	Billing and Coding: Proton Beam
L35075	Proton Beam Therapy
A56827	Billing and Coding: Proton Beam
A59350	Billing and Coding: Proton Beam Therapy
L39553	Radiation Therapies
A59350	Billing and Coding: Radiation Therapies
L35076	Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

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Provider and Billing Responsibilities

Prior Authorization

Follow Delegate Prior Authorization Requirements

When a delegate manages utilization management and prior authorization for a UnitedHealthcare Medicare Advantage member, follow the delegate’s applicable requirements before providing services.

Confirm whether a delegate manages utilization management or prior authorization.
Follow the delegate’s current submission, review, and authorization requirements.

Documentation Required

Maintain Supporting Documentation

Retain or have access to appropriate documentation and provide it when requested to support coverage, medical necessity, documentation requirements, or Medicare coding and billing requirements. Coverage remains subject to the member-specific benefit plan and applicable laws.

Maintain records supporting the services billed and the applicable coverage criteria.

Policy Scope and Clinical Context

This policy addresses liver-directed transarterial procedures, including TARE/SIRT using implantable beta-emitting microspheres for malignant tumors and transarterial bland embolization or chemoembolization of the liver. It also provides coverage guidance for related radiation oncology services, including image-guided radiation therapy, radiation treatment delivery and associated services, proton beam therapy, IMRT, combined proton beam therapy and IMRT, and stereotactic radiosurgery or stereotactic body radiation therapy.

Coverage is determined using the applicable Medicare NCD, LCD, or LCA when available, together with the UnitedHealthcare policy or criteria identified for the specific service. Where no applicable Medicare coverage document exists, the policy directs reviewers to the referenced UnitedHealthcare medical policy or criteria.