CurrentUnitedHealthcarePolicy 2026R0130A

IMRT (Intensity Modulated Radiation Therapy) CMS-1500 reimbursement

Defines UnitedHealthcare reimbursement rules for IMRT-related services billed on CMS-1500 forms (simulation, planning, related radiation therapy services, and modifiers) for Commercial and Individual Exchange plans; applies to all providers submitting CMS-1500 or electronic equivalent except UnitedHealthcare Oxford.

Policy Summary

PayerUnitedHealthcare

PolicyIMRT (Intensity Modulated Radiation Therapy) CMS-1500 reimbursement

Policy CodePolicy 2026R0130A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionDo not report simulation services for the same tumor within 90 days prior to IMRT plan (77301) separately when performed by the Same Group; use modifier 59 or XU to report services as separate when distinct.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysSimulation inclusion window

30 daysRelated service inclusion window

77301IMRT plan code

77280-77387Included codes

59, XUSeparate-report modifiers

Policy Summary

PayerUnitedHealthcare

PolicyIMRT (Intensity Modulated Radiation Therapy) CMS-1500 reimbursement

Policy CodePolicy 2026R0130A

Change TypeNo material change

Effective Date

Next Review Date

SourceLink

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IMRT Reimbursement Criteria

IMRT reimbursement criteria

Reimbursement determination rules for IMRT planning and related services

IMRT plan code 77301 includes the work of simulation services (CPT 77280-77290) performed in development of the IMRT plan when reported by the Same Group Physician and/or Other Qualified Health Care Professional and when the simulation date is within 90 days prior to the IMRT plan date.

IMRT plan code 77301 includes the work of specified related radiation therapy services (CPT 77295, 77306, 77307, 77321, 77331, 77370) performed in support of the IMRT plan when reported by the Same Group Physician and/or Other Qualified Health Care Professional and when the service date is 30 days before, on, or after the IMRT plan date.

Image-guided radiation therapy (CPT 77387) will not be separately reimbursed when billed on the same date of service as IMRT treatment plan (CPT 77301); separate reimbursement may be considered when not on the same date of service.

To report simulation services, related radiation therapy services, or an additional IMRT plan as separate and distinct from the original IMRT plan (for a different tumor, boost treatment, or separate course of therapy), report the service with an appropriate modifier (e.g., 59 or XU) to identify it as separate, distinct and unrelated to the IMRT plan.

Do not circumvent same-date procedure-to-procedure edits by performing procedures on different dates of service; NCCI edits address same-date coding but UnitedHealthcare extends inclusion to simulations within the 90-day window for the Same Group as stated above.

Codes, Inclusion Windows, and Related Services

IMRT planning, simulation, related services and deliveryCPT

77301	IMRT plan (includes related simulation and planning work)
77280-77290	Simulation services (included in 77301 when for same tumor within 90 days)
77295	External beam isodose planning (included in 77301 when within specified timeframe)
77306	External beam isodose planning (included)
77307	External beam isodose planning (included)
77321	Special teletherapy port plan (included)
77331	Special dosimetry (included)
77370	Medical physics consultation (included)
77387	Image-guided radiation therapy (not separately reimbursed when billed same date as 77301)
77402, 77407, 77412	IMRT treatment delivery codes (listed as delivery stage)

Simulation inclusion window

Inclusion windowSimulation services with date of service within 90 days prior to IMRT plan (CPT 77301) are considered included in reimbursement for 77301 when reported by the Same Group.

Same Group requirementInclusion applies only when simulation and IMRT plan are reported by the Same Group Physician and/or Other Qualified Health Care Professional (same Federal Tax Identification number).

Different tumor or distinct serviceTo report simulation for a different tumor or distinct from the IMRT plan, append the appropriate modifier to identify the service as separate and unrelated.

Related service inclusion window

Inclusion windowRelated radiation therapy services with date of service 30 days before, on, or after the IMRT plan (CPT 77301) are considered included in 77301 when reported by the Same Group.

Billing and Reporting Guidance for Providers

Billing Rule

Do not separately report same‑tumor simulation within 90 days of 77301

Do not report simulation services (CPT 77280-77290) for the same tumor separately from the IMRT plan (CPT 77301) when performed by the Same Group within 90 days prior to the 77301 date; use an appropriate modifier when the simulation is for a different tumor.

IMRT simulation services with a date of service within 90 days prior to the IMRT plan are considered included in 77301 when reported by the Same Group Physician and/or Other Qualified Health Care Professional.
If the simulation is for a different tumor on a different date of service, report it with the appropriate modifier to identify it as separate, distinct and unrelated to the IMRT plan.

Billing Rule

Related services within ±30 days are included; use modifier 59 or XU to report distinct services

Related radiation therapy services (e.g., 77295, 77306, 77307, 77321, 77331, 77370) reported 30 days before, on, or after the IMRT plan (77301) are considered included when reported by the Same Group; report with modifier 59 or XU when the service is separate and distinct.

Key Terms

Same Group definition

DefinitionAll physicians and/or Other Qualified Health Care Professionals of the same group reporting the same Federal Tax Identification number.

Use in policyRequired to determine when simulation or related services are considered included in CPT 77301 for UnitedHealthcare reimbursement purposes.

ImplicationServices billed by providers sharing the same Federal Tax Identification number will be treated as from the Same Group for inclusion rules.

IMRT definition

DefinitionAdvanced conformal external beam radiation therapy that uses computer-controlled linear accelerators to deliver precise radiation doses to the target while minimizing dose to surrounding critical structures.

ComponentsIMRT care includes three stages: Simulation (CPT 77280-77290), Treatment Planning (CPT 77301), and Treatment Delivery (CPT 77402, 77407, 77412).