ModifiedUnitedHealthcarePolicy CS179NJ.E

Radiation Therapy: Fractionation, Image-Guidance, and Special Services (for New Jersey Only)

Defines medically necessary fractionation limits, use of image-guided radiation therapy (IGRT), and coding/coverage guidance for external beam radiation therapy services for members in New Jersey.

Policy Summary

PayerUnitedHealthcare

PolicyRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for New Jersey Only)

Policy CodePolicy CS179NJ.E

Change TypeMaterial revisions and coding updates

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionInclude documentation supporting medical necessity for any use of Level 3 delivery (77412) or special dosimetry and report standard single-isocenter 3D/IMRT/VMAT under CPT 77407.

SourceLink

POLICY UPDATE CHANGES

Added criterion requiring delivery of up to 10 fractions for accelerated partial-breast irradiation with 3D technique.

Replaced delivery of up to five fractions for accelerated partial breast irradiation with delivery of up to five fractions for accelerated partial breast irradiation with intensity-modulated radiation therapy.

Clarified connective tissue disorder example to 'systemic lupus erythematosus or scleroderma' for allowing up to 33 fractions inclusive of a boost.

Removed language indicating IGRT is not medically necessary for superficial treatment of skin cancer when listed criteria are not met.

Added language clarifying that medical records documentation may be required and must fully support medical necessity; coverage is determined by federal, state, or contractual requirements.

Added CPT codes 77436, 77437, 77438, and 77439 to the Applicable Codes section.

Added CPT codes 77436-77439 may not be covered by NJ Medicaid (not on State fee schedule).

Standard single-isocenter 3D/IMRT/VMAT should be reported under CPT 77407; 77412 reserved for multiple isocenters or other specified complexities and requires documentation.

When IGRT is used with 2D, 3D, IMRT techniques, the technical component is included under treatment codes and the professional component should be reported as 77387-26.

up to 10

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fractions for palliative EBRT for bone metastases

10fractions allowed for APBI with 3D technique

5fractions allowed for APBI with IMRT

up to 35fractions for locally advanced NSCLC

4new CPT planning/treatment codes added

Coverage Criteria and Clinical Limits

Bone Metastases — Palliative EBRT

Bone Metastases

Bone metastases palliative EBRT medically necessary when up to 10 fractions are delivered, except when treating a previously irradiated site where >10 fractions may be medically necessary.

Breast Adenocarcinoma — EBRT

Breast Adenocarcinoma

Breast EBRT fractionation allowances and upper limits; APBI technique-specific fraction limits

Locally Advanced NSCLC — EBRT

Locally Advanced Non-Small Cell Lung Cancer

Definitive thoracic EBRT fractionation limited to 35 fractions; higher total fractions are considered not medically necessary based on trial evidence showing harm with dose escalation.

Prostate Adenocarcinoma — EBRT

Prostate Adenocarcinoma

Prostate EBRT fractionation guidance including hypofractionation allowances and higher-fraction exceptions for specific clinical scenarios.

Image-Guided Radiation Therapy (IGRT) — Indications and When Medically Necessary

Image-Guided Radiation Therapy (IGRT) — Indications

IGRT indications and documentation requirements; IGRT not necessary for bony-landmark alignment alone without fiducials

Palliative Bone Metastases — Covered Regimens and Evidence

Evidence supports multiple equivalent fractionation options for pain control; single-fraction has higher reirradiation rates but less acute toxicity.

Early-Stage Breast Cancer — PBI, APBI, Hypofractionation

APBI and hypofractionation supported for selected patients; imaging verification expectations for short-course regimens.

Coverage Rationale and Criteria — Trial and Guideline Support

Policy aligns coverage with high-quality evidence; operational expectations for exceptions.

Prostate Cancer — Fractionation and IGRT Evidence

Clinical evidence supports moderate hypofractionation; IGRT expectations and when higher fraction counts are appropriate.

IGRT — Indications & Supporting Evidence

IGRT and Motion-Management — Indications & Evidence

Evidence supports motion-management and IGRT to reduce margins and improve accuracy; frequency of verification imaging should be individualized.

Operational & QA Criteria — IGRT

Quality assurance, SOPs, and staffing expectations; coding and documentation requirements for Level 3 IGRT and short-course regimens.

Radiation Therapy Fractionation — Breast Adenocarcinoma Exceptions

Breast Fractionation Exceptions

Explicit fraction allowances for APBI techniques and imaging expectations for 5-fraction regimens.

Coding and IGRT Reporting Clarifications

Coding and IGRT Reporting — Provider Actions and Clarifications

Billing rules and NJ Medicaid coverage risk; coding justification and documentation expectations.

Denial Risk

Exceeding Fractionation Limits — Provider Action

Exceeding fractionation limits: Deliveries exceeding the fractionation limits listed for disease sites (e.g., >10 for bone metastases, >35 for locally advanced NSCLC, >33 for breast inclusive of boost, >45 for localized prostate) are subject to medical review and may require prior authorization. Providers should submit supporting documentation including rationale, prior treatment records, dosimetry, and expected clinical benefit.

Deliveries beyond listed fractionation limits require documentation and may require prior authorization
Provide medical record support, prior RT records, dosimetry, and justification for exception requests

Documentation Required

Provider Actions — Documentation, Prior Authorization, and Coding Clarifications

Documentation and operational provider actions (consolidated): - Prior authorization: Prior authorization is required for certain RT regimens per payer rules; when in doubt, obtain prior authorization before treatment planning. For treatments exceeding fractionation limits or using nonstandard techniques, obtain prior authorization and include comprehensive documentation. - Documentation required for special/coverage-considered codes: Submit complete medical record documentation that supports medical necessity, including history, physical exam, diagnostic imaging, prior RT records, treatment intent, dose/fractionation plan, DVHs, immobilization method, IGRT/fiducial details, and expected benefit. - Medical record support and coding justification: When billing Level 3 delivery (CPT 77412), IGRT professional component (77387-26), special dosimetry (77331), or megavoltage imaging (77436–77439), include operative notes, motion-management descriptions, number of isocenters, and justification for resource-intensive services. - Verification imaging for 5-fraction breast RT: Verification imaging is required for each fraction with documentation of measured displacements and corrective actions. - IGRT localization recommendation and Level 3 documentation: For prostate and other sites where daily localization is essential, document immobilization, fiducial use, localization method, and daily correction logs. Level 3 procedures must clearly describe complexity (multiple isocenters, active motion management). - Quality assurance and SOP documentation: Maintain and make available SOPs, QA logs, machine calibration, and personnel training records for IGRT services. - IGRT is time- and resource-intensive: Providers should recognize the staffing, technology, and QA resource needs and document team-based processes accordingly. - NJ Medicaid code coverage risk: CPT codes 77436–77439 are not on the NJ Medicaid fee schedule and may not be reimbursed; confirm state-specific coverage prior to billing. - Prior authorization not specified: Where prior authorization is not explicitly required by payer, adequate documentation in the medical record is still necessary to support claims.

Obtain prior authorization for nonstandard regimens or when required by payer

Considerations for Fraction Selection and Prostate RT Sequencing/Field Selection

Considerations for Fraction Selection and Prostate Sequencing

Clinical factors influencing fractionation and field selection; prostate-specific sequencing considerations.

Providers should follow payer-specific prior authorization processes where applicable; absence of step therapy does not alleviate the need for documentation or prior authorization when indicated.

Applicable Procedure Codes and Coding Guidance

Procedure CPT/HCPCS CodesCPT

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
77437	Surface radiation therapy; superficial, delivery, 150 kV, per fraction (e.g., electronic brachytherapy)
77438	Surface radiation therapy; orthovoltage, delivery, > 150-500 kV, per fraction

1–10 of 16

1/2

No explicit codes in these chunksmixed

No codes listed

Procedure and fractionation protocols referenced (informational)mixed

No codes listed

Applicable CPT Codes and Coding GuidanceCPT

77407	Standard single-isocenter 3D or IMRT/VMAT treatment (reported Level 2)
77412	Multiple isocenters, single-isocenter with active motion-management, total-skin electrons, or mixed electron/photon fields (Level 3)
77387-26	Professional component of image-guided radiation therapy
77331	Special dosimetry measurements
77301	IMRT planning (includes special dosimetry)
77436	Surface radiation therapy; superficial or orthovoltage, treatment planning and simulation-aided field setting
77437	Surface radiation therapy; superficial, delivery, 150 kV, per fraction (e.g., electronic brachytherapy)
77438	Surface radiation therapy; orthovoltage, delivery, > 150-500 kV, per fraction
77439	Surface radiation therapy; superficial or orthovoltage, image guidance, ultrasound for placement of radiation therapy fields for treatment of cutaneous tumors, per course of treatment

Removed/Deprecated Codesmixed

77014	Removed from policy code list (historical)
77385	Removed from policy code list (historical)
77386	Removed from policy code list (historical)
77401	Removed from policy code list (historical)
G6001-G6017	Removed from policy code list (historical)

Hypofractionation fraction size — numeric definition

Hypofractionation definitionFraction size between 240 cGy and 340 cGy per fraction (external beam radiotherapy)

Threshold lower bound240 cGy per fraction

Threshold upper bound340 cGy per fraction

Definitive RT dose for locally advanced NSCLC — numeric floor

Definitive RT minimum dose>= 60 Gy total prescribed dose for definitive radiotherapy for locally advanced NSCLC

Typical prescription range

Provider Responsibilities, Documentation, and Prior Authorization

Documentation Required

Documentation required for special/coverage-considered codes

When requesting coverage for special services or high-complexity delivery codes, include clinical documentation that justifies the need for the service and supports medical necessity.

Document why the primary radiation procedure is proven and medically necessary before requesting special dosimetry (77331), medical physics consultation (77370), special treatment procedures (77470), unlisted services (77399), or Level 3 delivery (77412) ([[chunk 11]], [[chunk 12]], [[chunk 13]]).
When billing 77412, documentation must clearly describe circumstances that justify Level 3 rather than Level 2 delivery ([[chunk 11]]).

Note

Guideline-recommended palliative regimens (informational)

Guideline-supported palliative regimens to reference in planning and authorization include single-fraction 8 Gy or multifraction options such as 20 Gy/5 fx, 24 Gy/6 fx, and 30 Gy/10 fx; selection should weigh prognosis, prior RT, toxicity risk, and retreatment likelihood.

ASTRO recommends 800 cGy ×1, 2,000 cGy ×5, 2,400 cGy ×6, or 3,000 cGy ×10 for conventional palliative RT (ASTRO guideline) ([[chunk 26]]).

Background and Evidence Summary

External beam radiation therapy (EBRT) is used for both curative and palliative cancer treatment and may be delivered using conventional fractionation, hypofractionation (defined here as 240–340 cGy per fraction), hyperfractionation, or accelerated schedules. Image-guided radiation therapy (IGRT) is employed to localize and reposition patients or delivery systems to ensure accurate targeting, particularly when using highly conformal techniques or when targets are near critical structures.

Definitions and Terminology

Definitive Treatment — definition entry

DefinitionRadiation treatments for cancer with curative intent

Source examplesDefinition referenced from NCCN and National Cancer Institute descriptions of curative intent

Clinical implicationUsed to distinguish definitive (curative) radiotherapy from palliative or symptom-directed treatments

Limited Metastatic Disease (prostate) — definition entry

Definition (prostate-specific)Limited metastatic disease: absence of visceral metastasis or fewer than four bone metastases, with no metastasis outside the vertebral bodies or pelvis

ApplicabilityDefinition applied specifically to prostate cancer scenarios in this policy

Policy Updates and Material Changes

2026-06-01Revised coverage criteriaLatest

Added allowance of up to 10 fractions for accelerated partial-breast irradiation (3D technique); specified up to 5 fractions for APBI when delivered with IMRT; clarified connective tissue disorders example to 'systemic lupus erythematosus or scleroderma'.

2026-06-01Coding additions

Added CPT codes 77436, 77437, 77438, and 77439 to the Applicable Codes section and noted these codes are not on the New Jersey Medicaid Fee Schedule.

2026-06-01

Policy Summary

PayerUnitedHealthcare

PolicyRadiation Therapy: Fractionation, Image-Guidance, and Special Services (for New Jersey Only)

Policy CodePolicy CS179NJ.E

Change TypeMaterial revisions and coding updates

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionInclude documentation supporting medical necessity for any use of Level 3 delivery (77412) or special dosimetry and report standard single-isocenter 3D/IMRT/VMAT under CPT 77407.

SourceLink

On This Page

Provide complete medical record documentation for coverage-considered codes

Include Level 3 justification when billing CPT 77412

Perform and document verification imaging for each fraction of 5-fraction breast RT

Confirm NJ Medicaid coverage for CPT 77436–77439 before billing

Maintain QA, SOP, and staffing documentation for IGRT services

60–70 Gy delivered over ~6–7 weeks (per NCCN)

Rationale noteDoses of at least 60 Gy should be given to achieve definitive intent; higher doses (e.g., 74 Gy) not preferred based on trial data

Preferred whole-breast hypofractionation — regimen examples

Preferred HF-WBI example40–42.5 Gy in 15–16 fractions (preferred by NCCN/ASTRO/NICE)

Alternate HF-WBI example26 Gy in 5 fractions (1-week schedule) for selected patients (Brunt et al.)

Boost options (when indicated)Typical boost doses 10–16 Gy in 4–8 fractions per ASTRO/NCCN

Preferred APBI per NCCN/ASTRO — regimen examples and schedules

NCCN-preferred APBI regimen30 Gy in 5 fractions (external beam) per NCCN

ASTRO-recommended APBI regimens3,000 cGy in five once-daily fractions or 4,005 cGy in 15 once-daily fractions (external beam) per ASTRO

IMRT APBI example (trial)30 Gy in five nonconsecutive daily fractions (Meattini et al. APBI-IMRT), delivered over ~2 weeks

BMI categories referenced — category thresholds used in considerations

Normal weightBMI < 25 kg/m2

OverweightBMI 25 to < 30 kg/m2

Mild obesityBMI 30 to < 35 kg/m2

Moderate to severe obesityBMI >= 35 kg/m2

Special dosimetry measurements — typical measurement counts and documentation requirement for excess

Typical measurement countOne to six special dosimetry measurements are typical depending on clinical need

Requests beyond typical rangeAny requests beyond one to six measurements must be supported with documentation and will be considered case-by-case

IMRT planning noteIMRT planning (CPT 77301) includes special dosimetry as part of the planning process

Hartsell et al. (8 Gy ×1 vs 30 Gy ×10) found equivalent pain relief with higher retreatment after single fraction (retreatment higher with 8 Gy) ([[chunk 24]]).

NCCN supports single-fraction palliative radiotherapy (8 Gy) for selected patients ([[chunk 29]]).

Prior Authorization

Prior authorization: reflect guideline-concordant fractionation and IGRT use

Prior authorization submissions should state the intended, guideline-concordant fractionation and whether IGRT will be used; include plan details and justification for any deviation from preferred regimens.

Indicate planned fractionation (e.g., HF-WBI 40–42.5 Gy in 15–16 fractions; definitive NSCLC ≥60 Gy) and whether IGRT or motion management will be used to protect OARs ([[chunk 52]]).
Coding clarifications state when 77412 is appropriate and require documentation to justify Level 3 delivery ([[chunk 11]]).
Prior authorization should include plan details and justification for pelvic nodal fields for high-risk prostate when applicable ([[chunk 53]]).

Note

Prior authorization: no administrative trigger specified in excerpt

This excerpt does not specify an administrative prior authorization trigger or explicit prior-authorization-only codes; clinical guideline recommendations are provided but payer prior-auth rules are not defined here.

Policy notes clinical recommendations (preferred hypofractionation schedules) but does not define payer-level prior authorization triggers in these chunks ([[chunk 64]]).
Applicable codes section and policy instructions should be consulted for plan-specific prior authorization processes (policy-level instruction) ([[chunk 98]]).

Note

Prior authorization: none specified in these chunks

No explicit prior authorization codes or requirements are listed in the provided sections; professional guidelines describe indications but do not define payer prior-authorization rules in these chunks.

ASTRO and other guidelines describe clinical indications for IGRT but do not specify payer prior-authorization codes in these sections ([[chunk 79]]).
Operational and QA expectations are described but not tied to specific prior authorization processes in these chunks ([[chunk 80]]).

Prior Authorization

Prior authorization and coding: justify level of delivery and fractionation

Documentation must justify the complexity level and fractionation requested; when billing Level 3 delivery (77412) or special dosimetry (77331), include specific clinical rationale and measurements supporting the higher-level service.

When reporting 77412, include documentation describing circumstances that justify Level 3 rather than Level 2 delivery ([[chunk 11]], [[chunk 95]]).
Special dosimetry (77331) use and any requests beyond the typical 1–6 measurements require supporting documentation and case-by-case review ([[chunk 12]], [[chunk 95]]).

Step Therapy

No step therapy required in this section

The policy does not require step therapy for radiation treatments in the provided sections; no sequential conservative-then-escalation requirement is described.

No step therapy requirements are specified in this section of the document ([[chunk 10]]).

Note

Considerations for selecting single vs multi‑fraction palliative regimens

Choose fractionation based on evidence, patient prognosis, prior radiation, risk of retreatment, and normal-tissue tolerance; single 8-Gy fractions increase retreatment rates and multifraction regimens may have higher acute toxicity.

ASTRO recommends selecting among 800 cGy ×1, 2,000 cGy ×5, 2,400 cGy ×6, or 3,000 cGy ×10 based on prognosis, prior RT, and patient goals ([[chunk 26]]).
Hartsell et al. found similar pain relief between 8 Gy ×1 and 30 Gy ×10 but higher retreatment with the single fraction (retreatment 18% vs 9%) ([[chunk 24]]).

Note

Prostate RT sequencing: use trial evidence to choose WPRT vs prostate-only

For high‑risk prostate cancer, base the decision to include whole‑pelvic radiotherapy versus prostate‑only fields on trial evidence and estimated nodal risk; WPRT improved 5‑year biochemical failure‑free survival in a randomized trial for nodal risk ≥20%.

Murthy et al. showed WPRT (with IMRT/IGRT and ≥2 years ADT) improved 5‑year BFFS versus prostate‑only RT for patients with estimated nodal risk ≥20% ([[chunk 53]]).

Step Therapy

No step therapy described

The document does not describe step therapy requirements for radiation services in this excerpt; clinical decisions are guided by evidence and coverage criteria instead.

ASTRO/AUA/SUO guidance and NCCN recommendations are provided for clinical decision-making, but no step therapy pathway is specified here ([[chunk 61]], [[chunk 62]]).

Documentation Required

Medical record must justify medical necessity and coding

Medical records must fully support medical necessity with relevant history, exam findings, diagnostic test results, and clear justification for the requested radiation plan and billing codes.

Documentation should include relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures; records must be legible and available upon request ([[chunk 8]], [[chunk 93]]).
Records should justify the radiation plan, fractionation, target volumes, and any use of higher-complexity codes (e.g., 77412, 77331) ([[chunk 95]]).

Documentation Required

Verification imaging required for 5‑fraction whole‑breast RT

For 5‑fraction whole‑breast schedules, verification imaging is required each fraction; measured displacements should be corrected per trial recommendations.

Brunt et al. required verification imaging for each fraction of the 5‑fraction schedules with recommendations to correct all measured displacements ([[chunk 32]]).

Documentation Required

Required treatment documentation: dose, fractionation, targets, IGRT use

Document delivered dose and fractionation, target volumes (whole breast, partial breast, pelvic nodes), use of IGRT when OARs are close or when using 3DCRT/IMRT, and any motion‑management techniques (e.g., DIBH).

NCCN recommends documenting dose and constraints to normal tissues and PTVs and use of DIBH with IGRT as appropriate ([[chunk 46]]).
NCCN states IGRT is appropriate when OARs are near high-dose regions and should be documented when used to enable safe delivery ([[chunk 52]]).

Documentation Required

Daily IGRT localization recommended for prostate RT

NCCN and professional guidance recommend daily prostate localization using IGRT to reduce target margins and improve treatment accuracy; include IGRT localization details in the record when used.

NCCN states daily prostate localization using IGRT is essential for target margin reduction and treatment accuracy ([[chunk 64]]).
Document the IGRT method used (fiducials, imaging modality) when daily localization is performed ([[chunk 52]]).

Documentation Required

Require QA programs and SOPs for IGRT delivery

Maintain quality assurance programs and documented SOPs for IGRT, including geometric accuracy assessment and daily QC when tight PTV margins are used; absence of these processes may raise safety concerns.

AAPM recommends daily QC procedures and geometric accuracy assessment as PTV margins tighten ([[chunk 77]]).
ASTRO emphasizes documented SOPs, interdisciplinary staffing, and comprehensive QA for safe IGRT implementation ([[chunk 80]]).

Documentation Required

Medical records must support medical necessity and be available on request

Medical records must fully support medical necessity and may be requested; documentation must be legible, maintained in the record, and available upon request to support coverage decisions.

Benefit coverage is determined by federal, state, or contractual requirements; medical records may be requested to assess clinical criteria ([[chunk 8]], [[chunk 93]]).
Documentation must fully support the medical necessity for requested services and be made available upon request ([[chunk 8]]).

Billing Rule

When billing 77412, document justification for Level 3 complexity

When billing CPT 77412 for Level 3 IGRT delivery, include documentation that describes the specific circumstances justifying Level 3 complexity versus Level 2 (single‑isocenter standard delivery).

Coding clarifications specify 77412 is for multiple isocenters, single‑isocenter with active motion management, total‑skin electrons, or mixed fields and requires documentation to justify Level 3 billing ([[chunk 11]], [[chunk 95]]).

Billing Rule

Special dosimetry (77331): document requests beyond 1–6 measurements

Requests for special dosimetry beyond the typical one to six measurements (CPT 77331) must be supported with documentation; such requests will be reviewed case‑by‑case.

Special dosimetry (77331) is used when dose measurements fall outside standard planning system parameters; typical measurements range from one to six ([[chunk 12]], [[chunk 96]]).
Any requests beyond this range must be supported with documentation and will be considered on a case‑by‑case basis ([[chunk 12]]).

Note

Administrative prior‑authorization triggers: none specified here

No administrative authorization triggers are specified in the provided excerpts; the policy provides clinical guidance but does not define payer administrative trigger rules here.

ASTRO and other guidelines inform clinical decisions, but no administrative prior‑auth triggers are listed in these chunks ([[chunk 26]]).

Denial Risk

Denial risk: not meeting dose or IGRT expectations

Failure to meet recommended minimum definitive doses (e.g., <60 Gy for locally advanced NSCLC) or omission of IGRT when recommended for OAR protection or highly conformal treatments may affect coverage determinations and require justification.

NCCN recommends definitive RT doses of at least 60 Gy for locally advanced NSCLC; doses below recommended minima should be justified ([[chunk 52]]).
Coding clarifications note IGRT technical components are included in treatment codes and IGRT should be documented when used to protect nearby OARs ([[chunk 11]]).

Documentation Required

Resource and SOP expectations for IGRT; lack may impact coverage

IGRT requires documented SOPs, a QA program, and team‑based processes; absence of these documented resources and processes for IGRT implementation may raise safety and coverage concerns.

AAPM and ASTRO recommend comprehensive QA programs, documented SOPs, and interdisciplinary staffing for IGRT safety and effectiveness ([[chunk 77]], [[chunk 80]]).
Lack of documented processes or QA may affect the ability to justify IGRT use for tight margins or dose escalation ([[chunk 80]]).

Denial Risk

Documentation‑related denial risk: insufficient medical record support

Coverage is subject to federal, state, or contractual requirements; lack of required medical record documentation supporting medical necessity may result in denial of the requested services.

Medical records documentation may be required to assess whether the member meets clinical criteria, but documentation does not guarantee coverage ([[chunk 8]]).
Policy emphasizes records must fully support medical necessity and be made available upon request; absence of such documentation risks denial ([[chunk 93]]).

Denial Risk

NJ Medicaid coverage risk for CPT codes 77436–77439

CPT codes 77436–77439 (surface/superficial/orthovoltage planning, delivery, and IGRT) are not on the New Jersey Medicaid fee schedule and therefore may not be covered for NJ Medicaid members; verify Medicaid coverage before billing.

Policy notes CPT codes 77436, 77437, 77438, and 77439 were added and are not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by NJ Medicaid ([[chunk 95]], [[chunk 96]]).
For superficial, surface, or orthovoltage therapy, these CPTs should be used, but check NJ Medicaid reimbursement rules prior to billing ([[chunk 11]], [[chunk 95]]).

Use in coverageSupports eligibility for limited-metastatic definitive fractionation allowances (where specified)

Hypofractionation — fraction size definition

Fraction size definitionHypofractionation: external beam radiotherapy with a fraction size between 240 cGy and 340 cGy

Contextual definitionAlso described as delivery of fewer and larger (>200 cGy) doses compared with conventional fractionation

Example applicationsUsed in prostate moderate hypofractionation regimens and selected breast or other site protocols

Conventional palliative RT regimens — examples of regimens

Single-fraction example800 cGy (8 Gy) in one fraction

Five-fraction example2,000 cGy in five fractions (20 Gy/5 fx)

Six- and ten-fraction examples2,400 cGy in six fractions (24 Gy/6 fx); 3,000 cGy in 10 fractions (30 Gy/10 fx)

Partial-breast irradiation (PBI) — definition and example schedules

PBI definitionRadiation targeting the tumor bed region (e.g., multicatheter brachytherapy, 3D-CRT, IMRT, or EBRT schedules such as 30 Gy in five fractions)

APBI IMRT example30 Gy in five once-daily fractions (external beam IMRT) as an ASTRO-recommended regimen

APBI EBRT/3D example38.5 Gy in 10 fractions (external beam, twice-daily) used in some trials (NSABP B-39/RTOG 0413)

APBI / PBI — accelerated/partial-breast irradiation definition and examples

APBI / PBI definitionAccelerated or partial-breast irradiation: focal breast irradiation delivered over shorter schedules to the tumor bed in selected early-stage patients

NCCN example30 Gy in 5 fractions (preferred APBI per NCCN)

ASTRO examples3,000 cGy in five once-daily fractions or 4,005 cGy in 15 once-daily fractions (ASTRO-recommended external beam PBI regimens)

HF-WBI — hypofractionated whole-breast irradiation definition and examples

HF-WBI definitionHypofractionated whole-breast irradiation: whole-breast radiation delivered in larger fractional doses over fewer fractions

Preferred regimens40–42.5 Gy in 15–16 fractions (preferred by NCCN/ASTRO/NICE)

Alternative 1-week schedule26 Gy in 5 fractions for selected patients (Brunt et al.)

DIBH — deep inspiration breath-hold definition

DIBH definitionDeep inspiration breath-hold: a motion-management technique used to reduce cardiac dose during left-sided breast irradiation

Clinical purposeUsed with IGRT to minimize heart exposure and facilitate meeting dose-volume constraints

Guideline recommendationRecommended in NICE and NCCN guidance for left-sided breast cancer to reduce cardiac dose

Moderate hypofractionation — fractionation range definition

Moderate hypofractionation rangePer-fraction doses approximately 2.4–3.4 Gy (consistent with ASTRO guidance)

Example prostate regimens60 Gy in 20 fractions (3 Gy/fx) or 70 Gy in 28 fractions (2.5 Gy/fx)

Clinical noteRecommended for selected low- and intermediate-risk patients and some high-risk patients when pelvic nodes are not treated

Conventional fractionation — typical daily dose and fraction counts

Typical daily doseApproximately 1.8 to 2.0 Gy per fraction

Typical fraction countsDelivered over ~37 to 45 fractions (conventional course)

ContextUsed as reference comparator for trials of hypofractionation and dose-escalation

Intrafraction motion — definition and examples (prostate motion)

DefinitionIntrafraction motion: target movement that occurs during an individual treatment fraction (e.g., prostate motion over 5–7 minutes)

Observed magnitude (prostate)Motion outside 2 mm occurred in 66% of fractions; 28% exceeded 3 mm (Kotte et al.)

Clinical implicationFiducial-based verification and margins (e.g., ~2 mm lower limit) are used to manage intrafraction motion, but larger margins may be needed for other uncertainties

4D-CT / 4D-IG — respiration-correlated imaging definition

Definition4D-CT / 4D-IG: respiration-correlated imaging techniques used to characterize tumor motion over the respiratory cycle for planning and image guidance

Effect on marginsUse of 4D-CT and 4D-IG with gating reduced required treatment margins by a median 37%–47% in Korreman et al.'s multisite series

Clinical useRecommended for lung tumors with significant respiratory motion to enable margin reduction and safer dose delivery

Definitive Treatment — updated definition in this policy version (text in source)

Updated definition noteThe policy's definition of 'Definitive Treatment' was updated in this policy version (see Policy History/Revision Information)

Documentation expectationRefer to revised Definitions section in the policy for the exact updated wording and context

Effective dateRevision effective 06/01/2026 per Policy History/Revision Information

Removed a set of older CPT/HCPCS codes (including 77014, 77385, 77386, 77401, and G6001–G6017) from the policy code list.

2026-06-01Coding clarification

Clarified that standard single-isocenter 3D/IMRT/VMAT treatments should be reported under CPT 77407 and that CPT 77412 is reserved for multiple isocenters or specified complexities and requires documentation.

2026-06-01Special dosimetry guidance

Specified use of CPT 77331 for special dosimetry with typical measurements ranging from one to six and that requests beyond this range require supporting documentation; noted IMRT planning (77301) includes special dosimetry and removed prior restrictive notation about 77301.