ModifiedUnitedHealthcarePolicy N/A

Radiation Therapy - Dosimetry, Simulation/Devices and Management Policy, Professional and Facility

Defines UnitedHealthcare reimbursement limits and unit limitations for radiation therapy dosimetry, simulation, devices, and treatment management services during a 90-day episode of care; affects professional and facility claims in specified states.

Policy Summary

PayerUnitedHealthcare

PolicyRadiation Therapy - Dosimetry, Simulation/Devices and Management Policy, Professional and Facility

Policy CodePolicy N/A

Change TypeNew policy with unit limitsrelated facility and molecular pathology revisions

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionBegin a 90-day episode when CPT 77261, 77262, or 77263 is billed; ensure units billed do not exceed listed reimbursable limits.

SourceLink

POLICY UPDATE CHANGES

UnitedHealthcare will implement a new Radiation Therapy - Dosimetry, Simulation/Devices and Management Policy with unit limitations during a 90-day episode of care.

Modifier Policy, Facility will be effective July 01, 2025 for dates of service on or after October 25, 2024 and UnitedHealthcare Community Plan will deny outpatient facility claim lines reported with modifier 53 on UB-04 forms.

UnitedHealthcare will publish a Hospital Inclusive Charges Policy, Facility effective August 01, 2025 outlining items/services not eligible for separate reimbursement during inpatient and outpatient visits.

Molecular Pathology Policy will be revised and renamed to Molecular Pathology Policy, Professional and Facility, requiring submission of a Palmetto DEX Z-code® for reimbursement; claims missing or invalid DEX Z-code® will be denied.

Routine reimbursement policy code updates have been made to multiple policies to reflect industry code set changes (CPT, HCPCS, ICD-10, modifiers, etc.) effective May 01, 2025.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Reimbursement Rules

Reimbursable units and episode rules

Reimbursement is allowed up to specified unit limits per CPT code during a 90-day episode of care. Units billed beyond the reimbursable units will not be considered for reimbursement.

Reimbursable units and episode rules apply as follows:

ALL of the following

A 90-day episode of care begins when one of the therapeutic radiology treatment planning CPT codes 77261, 77262, or 77263 is billed; a new episode begins again if a radiation treatment occurs.
Each listed CPT code for dosimetry, simulation, devices, and management has a reimbursable unit maximum that applies during the 90-day episode; units billed in excess of the reimbursable units will not be considered for reimbursement.
These unit limits apply only to codes for the dosimetry, simulation, and management aspects of radiation therapy treatment planning and do not apply to radiation therapy treatment itself.

Providers should bill units up to the per-code reimbursable maximum within the 90-day episode; claims with units beyond those limits will not be paid for the excess units.

Coverage criteria summary

Stances and policy-level criteria and applicability notes summarized from the document:

Molecular pathology (professional and facility): submission of a Palmetto DEX Z-code® from the Palmetto DEX Registry is required for claims to be considered for reimbursement; claims missing, invalid, or mismatched DEX Z-code® will be denied but may be resubmitted with required information. The DEX Z-code® should be reported in Loop 2400 or SV-101-7 for professional electronic claims.

Modifier 53 on UB-04 outpatient facility claims: per AMA/CMS guidance, modifier 53 is not appropriate on UB-04 outpatient facility claims; UnitedHealthcare Community Plan will deny outpatient facility claim lines reported with modifier 53.

Hospital Inclusive Charges (facility): effective August 01, 2025, UnitedHealthcare will publish a Hospital Inclusive Charges Policy, Facility that identifies items and services that are included in the room and board or facility fee and therefore are not separately reimbursable for inpatient and outpatient visits.

Routine code set updates: UnitedHealthcare has updated multiple reimbursement policies to reflect industry code set changes (CPT, HCPCS, ICD-10, modifiers, revenue codes, MUEs, etc.). These updates do not change policy intent; review policy history and state-level entries for effective dates and applicability.

CPT/HCPCS Codes, Unit Limits, and Code Updates

Dosimetry, simulation, devices and management CPT codes with unit limitsCPTCovered

77280	Therapeutic radiology simulation-aided field setting; simple
77285	Therapeutic radiology simulation-aided field setting; intermediate
77290	Therapeutic radiology simulation-aided field setting; complex
77295	3 dimensional radiotherapy plan, including dose-volume histograms
77300	Basic radiation dosimetry calculation
77301	Intensity modulated radiotherapy plan including dose-volume histograms
77332	Treatment devices; design and construction; simple
77333	Treatment devices; design and construction; intermediate
77334	Treatment devices; design and construction; complex
77338	Multi-leaf collimator (MLC) design and construction per IMRT plan

1–10 of 13

1/2

Policy-wide code updates (examples)mixed

Code set updates across CPT, HCPCS, ICD-10, modifiers, revenue codes and other industry standard code sets as listed in individual policy sections (examples and affected policies provided in policy history).

Reimbursable units per 90-day episode

77300Reimbursable units: 10 per 90-day episode

77332Reimbursable units: 10 per 90-day episode

77333Reimbursable units: 10 per 90-day episode

77334Reimbursable units: 10 per 90-day episode

77280/77285/77290/77295/77301/77338/77427/77431/77435Reimbursable units: see policy table (units specified per code in policy table); units billed in excess of reimbursable units will not be considered for reimbursement

Medically Unlikely Edits (MUE)

Billing Requirements and Provider Impact

Billing Rule

DEX Z-code® Required for Molecular Pathology

Effective with dates of service on or after June 01, 2025 (Tennessee) and August 01, 2025 (other jurisdictions noted), UnitedHealthcare requires submission of a Palmetto DEX Z-code® for molecular pathology services. Claims for molecular pathology will be denied if the DEX Z-code® is missing, invalid, or does not match the CPT® code reported. Denied claims may be resubmitted with the required information.

Obtain the Palmetto DEX Z-code® from the registry at www.dexzcodes.com.
Report the Palmetto DEX Z-code® on professional electronic claims in Loop 2400 / SV-101-7.
Include the DEX Z-code® on facility claims as required by the Molecular Pathology Policy, Professional and Facility.
Do not expect reimbursement for molecular pathology services if the DEX Z-code® is missing, invalid, or does not match the service represented by the CPT code; such claims will be denied but may be resubmitted with correct information.

Billing Rule

Key Definitions and Scope

90-day episode of care

DefinitionA 90-day episode of care begins when one of the therapeutic radiology treatment planning CPT codes (77261, 77262, 77263) is billed; a new episode begins again if a radiation treatment occurs

Duration90-day period that unit limits apply to

Triggering codes77261, 77262, 77263

Scope of limits

Scope statementLimits apply only to codes for the dosimetry, simulation, and management aspects of radiation therapy treatment planning and not to radiation therapy treatment itself

Affected servicesDosimetry, simulation, treatment device design/construction, and treatment management CPT codes listed in the policy

Policy Summary

PayerUnitedHealthcare

PolicyRadiation Therapy - Dosimetry, Simulation/Devices and Management Policy, Professional and Facility

Policy CodePolicy N/A

Change TypeNew policy with unit limitsrelated facility and molecular pathology revisions

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionBegin a 90-day episode when CPT 77261, 77262, or 77263 is billed; ensure units billed do not exceed listed reimbursable limits.

SourceLink

On This Page

Denial Risk

Modifier 53 Denial on UB-04 Outpatient Facility Claims

Modifier 53 is not appropriate for reporting on a UB-04 outpatient facility claim form. Lines reported with modifier 53 on UB-04 outpatient facility claims will be denied for dates of service on or after July 01, 2025 (effective alignment with AMA/CMS).

Do not report modifier 53 on UB-04 outpatient facility claims; such lines will be denied.
This change aligns with AMA and CMS guidance and is effective for dates of service on or after July 01, 2025.