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Date Printed: March 1, 2015: 03:48 PM

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This medical policy (medical coverage guideline) is Copyright 2014, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-77260-22

Original Effective Date: 06/15/11

Reviewed: 10/25/12

Revised: 01/01/15

Subject: Intensity-Modulated Radiation Therapy (IMRT)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates

DESCRIPTION:

Intensity – modulated radiation therapy (IMRT) is an advanced mode of high – precision radiotherapy that utilizes computer – controlled x–ray accelerators to deliver precise radiation doses to a malignant tumor or specific areas within the tumor. IMRT allows for the radiation dose to conform more precisely to the three – dimensional (3D) shape of the tumor by modulating or controlling the intensity of the radiation beam. IMRT also allows higher radiation doses to be focused to regions within the tumor while minimizing the dose to surrounding normal critical structures. Treatment is planned by using 3D computed tomography (CT) images of the patient in conjunction with computerized dose calculations to determine the dose intensity pattern that will best conform to the tumor shape. IMRT treatment may be delivered using several delivery methods, including, for example multiple static segment treatment (Step – and – shoot), dynamic segment treatment (sliding window), binary – collimator tomotherapy and intensity – modulated arc techniques.

IMRT is complex and requires precision and accuracy, and involves multiple medical specialists (e.g., radiation oncologist, medical physicist, radiation therapists, dosimetrist). IMRT requires multiple or fractionated treatment sessions and different radiation doses. Several factors determine the number of treatment sessions and radiation dose; the type, location and size of the tumor, doses to critical normal structures and the individual’s health. An IMRT schedule may consist of five days a week for five to ten weeks. At the beginning of each treatment, the individual is positioned on the treatment table guided by the marks on the skin defining the treatment area; the individual may be repositioned during the IMRT treatment. Imaging systems on the IMRT treatment delivery systems may be used to check positioning and marker location, molded devices may be used to help the individual maintain proper position. IMRT treatment may take between 10 and 30 minutes.

There are several radiation therapy devices in use for IMRT that have received U.S. Food and Drug Administration (FDA) 510(k) clearance to market, including the TiGRT TPS (Radiation Treatment Planning System, Innocure Intensity Modulating Radiation Therapy Compensators, micro – Multi – Leaf Collimator and the Genesis™ IMRT Medical Linear Accelerator.

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request for Intensity-Modulated Radiation Therapy (IMRT) to expedite the medical review process.

1. Click the link Intensity-Modulated Radiation Therapy (IMRT) - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

Intensity modulated radiation therapy (IMRT) is not a replacement for conventional or three – dimensional conformal radiation therapy.

IMRT meets the definition of medical necessity for the following indications when one or more of the medical necessity criteria are met:

AND

For each of the above indications, at least one or more of the following medical necessity criteria for IMRT planning must be met:

All other indications not listed above are considered experimental or investigational, as there is insufficient evidence to support conclusions regarding the effect of IMRT on health outcomes.

BILLING/CODING INFORMATION:

The following codes may be used to describe intensity modulated radiation therapy (IMRT).

CPT Coding:

77301

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

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

HCPCS Coding:

G6015

Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session

G6016

Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session

ICD – 9 Diagnoses Codes That Support Medical Necessity:

140.0 – 140.9

Malignant neoplasm of the lip

141.0 – 141.9

Malignant neoplasm of base of tongue

142.0 – 142.9

Malignant neoplasm of tongue

144.0 – 144.9

Malignant neoplasm of floor of mouth

145.0 – 145.9

Malignant neoplasm of other and unspecified parts of mouth

146.0 – 146.9

Malignant neoplasm of oropharynx

147.0 – 147.9

Malignant neoplasm of superior of nasopharynx

148.0 – 148.9

Malignant neoplasm of hypopharynx

149.0 – 149.9

Malignant neoplasm of other and ill – defined sites within the lip, oral cavity and pharynx

150.0 – 150.9

Malignant neoplasm of esophagus

151.0 – 151.9

Malignant neoplasm of stomach

153.0 – 153.9

Malignant neoplasm of colon

154.0 – 154.8

Malignant neoplasm of rectum rectosigmoid junction and anus

155.0 – 155.2

Malignant neoplasm of liver and intrahepatic bile ducts

156.0 – 156.9

Malignant neoplasm of gallbladder and extrahepatic bile ducts

157.0 – 157.9

Malignant neoplasm of pancreas

158.0 – 158.9

Malignant neoplasm of retroperitoneum and peritoneum

160.0 – 160.9

Malignant neoplasm of nasal cavities, middle ear and accessory sinus

161.0 – 161.9

Malignant neoplasm of larynx unspecified

162.0 – 162.9

Malignant neoplasm of trachea, bronchus and lung

163.0 – 163.9

Malignant neoplasm of pleura

164.0 – 164.9

Malignant neoplasm of thymus, heart and mediastinum

171.0 – 171.9

Malignant neoplasm of connective tissue and other soft tissue

174.0 – 174.9

Malignant neoplasm of female breast

175.0 – 175.9

Malignant neoplasm of male breast

179

Malignant neoplasm of uterus, part unspecified

180.0, 180.1, 180.8, 180.9

Malignant neoplasm of cervix uteri

182.0, 182.1, 182.8

Malignant neoplasm of body of uterus

183.0 – 183.9

Malignant neoplasm of ovary and other uterine adnexa

184.0 – 184.9

Malignant neoplasm of other and unspecified female genital organs

185

Malignant neoplasm of prostate

188.0 – 188.9

Malignant neoplasm of bladder

189.0 – 189.9

Malignant neoplasm of kidney and other and unspecified urinary organs

190.0 – 190.9

Malignant neoplasm of eye

191.0 – 191.9

Malignant neoplasm of brain

192.0 – 192.9

Malignant neoplasm of other and unspecified parts of nervous system

193

Malignant neoplasm of thyroid gland

194.0

Malignant neoplasm of adrenal gland

194.1

Malignant neoplasm of parathyroid gland

194.5

Malignant neoplasm of carotid body

194.6

Malignant neoplasm of aortic body and other paraganglia

195.0 – 195.8

Malignant neoplasm of other and ill – defined sites (head, face, neck, thorax, abdomen, pelvis, upper limb, lower limb)

198.82

Secondary malignant neoplasm of genital organs

198.3

Secondary malignant neoplasm of brain and spinal cord

198.4

Secondary malignant neoplasm of other parts of nervous system

198.6

Secondary malignant neoplasm of ovary

201.00 – 201.98

Hodgkin’s disease

202.00 – 202.98

Other malignant neoplasms of lymphoid and histiocytic tissue

225.1

Benign neoplasm of cranial nerves

225.2

Benign neoplasm of cerebral meninges

227.3

Benign neoplasm of pituitary gland and craniopharyngeal duct (pouch)

227.4

Benign neoplasm of pineal gland

227.6

Benign neoplasm of aortic body and other paraganglia

233.0

Carcinoma in situ of breast

ICD – 10 Diagnoses Codes That Support Medical Necessity: (Effective 10/01/15)

The following ICD – 10 diagnoses codes supports medical necessity if one or more of the medical necessity criteria are met.

C00.0 – C00.9

Malignant neoplasm of lip

C01

Malignant neoplasm of base of tongue

C02.0 – C02.9

Malignant neoplasm of other and unspecified parts of tongue

C04.0 – C04.9

Malignant neoplasm of floor of mouth

C05.0 – C05.9

Malignant neoplasm of palate

C06.0 – C06.2

Malignant neoplasm of other and unspecified parts of mouth

C06.80 – C06.89

Malignant neoplasm of overlapping sites of other and unspecified parts of mouth

C06.9

Malignant neoplasm of mouth , unspecified

C07

Malignant neoplasm of parotid gland

C08.0 – C08.9

Malignant neoplasm of other and unspecified major salivary glands

C09.0 – C09.9

Malignant neoplasm of tonsil

C10.0 – C10.9

Malignant neoplasm of oropharynx

C11.0 – C11.9

Malignant neoplasm of nasopharynx

C12

Malignant neoplasm of pyriform sinus

C13.0 – C13.9

Malignant neoplasm of hypopharynx

C14.0 – C14.8

Malignant neoplasm of other and ill – defined sites in the lip, oral cavity and pharynx

C15.3 – C15.9

Malignant neoplasm of esophagus

C16.0 – C16.9

Malignant neoplasm of stomach

C18.0 – C18.9

Malignant neoplasm of colon

C19

Malignant neoplasm of rectosigmoid junction

C20

Malignant neoplasm of rectum

C21.0 – C21.8

Malignant neoplasm of anus and anal canal

C22.0 – C22.9

Malignant neoplasm of liver and intrahepatic bile ducts

C23

Malignant neoplasm of gallbladder

C24.0 – C24.9

Malignant neoplasm of other and unspecified parts of biliary tract

C25.0 – C25.9

Malignant neoplasm of pancreas

C26.0 – C26.9

Malignant neoplasm of other and ill – defined digestive organs

C30.0, C30.1

Malignant neoplasm of nasal cavity and middle ear

C31.0 – C31.9

Malignant neoplasm of accessory sinuses

C32.0 – C32.9

Malignant neoplasm of larynx

C33

Malignant neoplasm of trachea

C34.00 – C34.02

Malignant neoplasm of main bronchus

C34.10 – C34.12

Malignant neoplasm of upper lobe, bronchus or lung

C34.2

Malignant neoplasm of middle lob, right bronchus or lung

C34.30 – C34.32

Malignant neoplasm of lower lobe, bronchus or lung

C34.80 – C34.82

Malignant neoplasm of overlapping sites of bronchus and lung

C34.90 – C34.92

Malignant neoplasm of bronchus or lung, unspecified

C37

Malignant neoplasm of thymus

C38.0 – C38.8

Malignant neoplasm of heart, mediastinum and pleura

C47.8, C49.8

Other specified sites of connective and other soft tissue

C48.0 – C48.8

Malignant neoplasm of retroperitoneum and peritoneum

C49.0

Malignant neoplasm of connective and soft tissue of head, face and neck

C49.10

Malignant neoplasm of connective and soft tissue of upper limb, including shoulder

C49.20

Malignant neoplasm of connective and soft tissue of lower limb, including hip

C49.3

Malignant neoplasm of connective and soft tissue of thorax

C49.4

Malignant neoplasm of connective and soft tissue of abdomen

C49.5

Malignant neoplasm of connective and soft tissue of pelvis

C49.6

Malignant neoplasm of connective and soft tissue of trunk, unspecified

C49.9

Malignant neoplasm of connective and soft tissue, site unspecified

C50.011 – C50.019

Malignant neoplasm of nipple and areola, female

C50.021 – C50.029

Malignant neoplasm of nipple and areola, male

C50.111 – C50.119

Malignant neoplasm of central portion of breast, female

C50.121 – C50.129

Malignant neoplasm of central portion of breast, male

C50.211 – C50.219

Malignant neoplasm of upper – inner quadrant of breast, female

C50.221 – C50.229

Malignant neoplasm of upper – inner quadrant of breast, male

C50.311 – C50.319

Malignant neoplasm of lower – inner quadrant of breast, female

C50.321 – C50.329

Malignant neoplasm of lower – inner quadrant of breast, male

C50.411 – C50.419

Malignant neoplasm of upper – outer quadrant of breast, female

C50.421 – C50.429

Malignant neoplasm of upper – outer quadrant of breast, male

C50.511 – C50.519

Malignant neoplasm of lower – outer quadrant of breast, female

C50.521 – C50.529

Malignant neoplasm of lower – outer quadrant of breast, male

C50.611 – C50.619

Malignant neoplasm of axillary tail of breast, female

C50.621 – C50.629

Malignant neoplasm of axillary tail of breast, male

C50.811 – C50.519

Malignant neoplasm of overlapping sites of breast, female

C50.821 – C50.829

Malignant neoplasm of overlapping sites of breast, male

C50.911 – C50.919

Malignant neoplasm of breast of unspecified site, female

C50.921 – C50.929

Malignant neoplasm of breast of unspecified site, male

C53.0 – C53.9

Malignant neoplasm of cervix uteri

C54.0 – C54.9

Malignant neoplasm of corpus uteri

C55

Malignant neoplasm of uterus, part unspecified

C56.0 – C56.9

Malignant neoplasm of ovary

C57.00 – C57.02

Malignant neoplasm of fallopian tube

C57.10 – C57.12

Malignant neoplasm of broad ligament

C57.20 – C57.22

Malignant neoplasm of round ligament

C57.3

Malignant neoplasm of parametrium

C57.4

Malignant neoplasm of uterine adnexa, unspecified

C57.7

Malignant neoplasm of other specified female genital organs

C57.8

Malignant neoplasm of overlapping sites of female genital organs

C57.9

Malignant neoplasm of female genital organ, unspecified

C61

Malignant neoplasm of prostate

C64.9

Malignant neoplasm of kidney, except pelvis

C65.9

Malignant neoplasm of renal pelvis

C66.9

Malignant neoplasm of ureter

C67.0 – C67.9

Malignant neoplasm of bladder

C68.0

Malignant neoplasm of urethra

C68.1

Malignant neoplasm of paraurethral glands

C68.8

Malignant neoplasm of other specified sites of urinary organs

C68.9

Malignant neoplasm of urinary organs, site unspecified

C69.00 – C69.02

Malignant neoplasm of conjunctiva

C69.10 – C69.12

Malignant neoplasm of cornea

C69.20 – C69.22

Malignant neoplasm of retina

C69.30 – C69.32

Malignant neoplasm of choroid

C69.40 – C69.42

Malignant neoplasm of ciliary body

C69.50 – C69.52

Malignant neoplasm of lacrimal gland and duct

C69.60 – C69.62

Malignant neoplasm of orbit

C69.80 – C69.82

Malignant neoplasm of overlapping sites of eye and adnexa

C69.90 – C69.92

Malignant neoplasm of eye, unspecified

C71.0 – C71.9

Malignant neoplasm of brain

C72.0 – C72.1, C72.20 – C72.22, C72.30 – C72.32, C72.40 – C72.42, C72.50 – C72.59

Malignant neoplasm of spinal cord, cranial nerves and other parts of central nervous system

C72.9

Malignant neoplasm of central nervous system, unspecified

C73

Malignant neoplasm of thyroid gland

C74.00 – C74.02, C74.10 – C74.12, C74.90 – C74.92

Malignant neoplasm of adrenal gland

C75.0 – C75.9

Malignant neoplasm of other endocrine glands and related structures

C76.0 – C76.3

Malignant neoplasm of other and ill – defined sites

C79.31 – C79.32

Secondary malignant neoplasm of brain and cerebral meninges

C79.40 – C79.49

Secondary malignant neoplasm of other and unspecified parts of nervous system

C79.51 – C79.52

Secondary malignant neoplasm of bone and bone marrow

C79.60 – C79.62

Secondary malignant neoplasm of ovary

C79.70 – C79.72

Secondary malignant neoplasm of adrenal gland

C79.82

Secondary malignant neoplasm of genital organs

C81.00 – C81.09

Nodular lymphocyte predominant Hodgkin lymphoma

C81.00 – C81.09

Nodular lymphocyte predominant Hodgkin lymphoma

C81.10 – C81.19

Nodular sclerosis classical Hodgkin lymphoma

C81.20 – C81.29

Mixed cellularity classic Hodgkin lymphoma

C81.30 – C81.39

Lymphocytic depletion classical Hodgkin lymphoma

C81.40 – C81.49

Lymphocyte – rich classical Hodgkin lymphoma

C81.70 – C81.79

Other classical Hodgkin lymphoma

C81.90 – C81.99

Hodgkin lymphoma, unspecified

C84.00 – C84.89

Mature T/NK – cell lymphomas

C84.10 – C84.19

Sezary disease

C84.40 – C84.49

Peripheral T – cell lymphoma, not classified

C85.80 – C85.89

Other specified types of non – Hodgkin lymphoma

C91.40 – C91.42

Hairy – cell leukemia

C96.0

Multifocal and multisysemic (disseminated)

C96.2

Malignant mast cell tumor

C96.4

Sarcoma of dendritic cells (accessory cells)

C96.9

Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified

C96.a

Histiocytic sarcoma

C96.z

Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue

D05.90

Carcinoma in situ, unspecified type, unspecified breast

D33.3

Benign neoplasm of cranial nerves

D33.4

Benign neoplasm of spinal cord

D35.2

Benign neoplasm of pituitary gland

D35.3

Benign neoplasm of craniopharyngeal duct

D35.4

Benign neoplasm of pineal gland

D35.6

Benign neoplasm of aortic body and other paraganglia

Q28.2

Arteriovenous malformation of cerebral vessels

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

At least one or more of the medical necessity criteria and an indication that meets the definition of medical necessity in the position statement must be present.

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for intensity-modulated radiation therapy (IMRT).

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following Local Coverage Determination (LCD) was reviewed on the last guideline revised date: Intensity Modulated Radiation Therapy (IMRT), (L29200) located at fcso.com.

DEFINITIONS:

Aerodigestive tract cancers: cancer of the lip, tongue, major salivary glands, gums, and adjacent oral cavity tissues, floor of the mouth, tonsils, oropharynx, nasopharynx and other oral regions, nasal cavity, accessory sinuses, middle ear, and larynx.

Tomotherapy IMRT: a type of imaged – guided IMRT.

RELATED GUIDELINES:

Image – Guided Radiation Therapy for Treatment Planning and Delivery, 04–77260–19

OTHER:

Other names used to report intensity modulated radiation therapy (IMRT):

Compensatory – Based IMRT

Helical Tomotherapy

IMRT Tomotherapy

Inverse Treatment Planning

Segment Radiation Therapy (RT)

Sliding Window Technique

Step – and – Shoot Inverse IMRT

REFERENCES:

  1. Anal Carcinoma National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Version 2.2011, 02/02/11.
  2. ASTRO/ACR Guide To Radiation Oncology Coding 2010 – Intensity Modulated Radiation Therapy (IMRT) Chapter 11.
  3. Bai YR, Wu GH, Guo WJ et al. Intensity modulated radiation therapy and chemotherapy for locally advanced pancreatic cancer: results of feasibility study. World Journal of Gastroenterology 2003; 9(11): 2561 – 2564.
  4. Beriwal S, Gan GN, Heron DE et al. Early clinical outcome with concurrent chemotherapy and extend – field, intensity – modulated radiotherapy for cervical cancer. International Journal Radiation Oncology Biology Physics 2007; 68(1): 166 – 171.
  5. Bhatia A, Rao A, Ang KK et al. Anaplastic thyroid cancer: Clinical outcomes with conformal radiotherapy. Head Neck 2010; 32(7): 829 – 836.
  6. Bhatnagar AK, Brandner E, Sonnik D, et al. Intensity – modulated radiation therapy (IMRT) reduces the dose to the contralateral breast when compared to conventional tangential fields for primary breast irradiation: initial report. The Cancer Journal 2004; 10(6): 381 – 385.
  7. Bhatnagar AK, Brandner E, Sonnik D, et al. Intensity modulated radiation therapy (IMRT) reduces the dose to the contralateral breast when compared to conventional tangential fields for primary breast irradiation. Breast Cancer Research and Treatment 2006; 96(1): 41 – 46.
  8. Blue Cross Blue Shield Association Intensity Modulation Radiation Therapy (IMRT) of the Breast and Lung 8.01.46, 10/08/10.
  9. Blue Cross Blue Shield Association Intensity Modulation Radiation Therapy (IMRT) of the Prostate 8.01.47, 12/10/09.
  10. Blue Cross Blue Shield Association Intensity Modulation Radiation Therapy (IMRT) of the Breast and Lung 8.01.46, 10/08/10.
  11. Blue Cross Blue Shield Association Intensity Modulation Radiation Therapy (IMRT): Cancer of the Head, Neck or Thyroid 8.01.48, 10/08/10.
  12. Blue Cross Blue Shield Association Intensity Modulation Radiation Therapy (IMRT): Abdomen and Pelvis 8.01.49, 05/13/10.
  13. Breast Cancer National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Version 2.2011, 01/05/11.
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  15. Cahlon O, Hunt M, Zelefsky MJ. Intensity – modulated radiation therapy: supportive data for prostate cancer. Seminars in Radiation Oncology 2008; 18(1): 48 – 57.
  16. Cervical Cancer National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Version 1.2011, 10/06/10.
  17. Choi Y, Kim JK, Lee HS et al. Impact of intensity – modulated radiation therapy as a boost treatment on the lung – dose distributions for non – small – cell lung cancer. International Journal Radiation Oncology Biology Physics 2005; 63(3): 683 – 689.
  18. Christian JA, Bedford JL, Webb S, Brada M. Comparison of inverse – planned three – dimensional conformal radiotherapy and intensity – modulated radiotherapy for non – small – cell lung cancer. International Journal Radiation Oncology Biology Physics 2007; 67(3): 735 – 741.
  19. Czito BG, Pepek JM, Meyer JJ et al. Intensity – modulated radiation therapy for anal cancer. Oncology; 23(12):1082 – 1089.
  20. Colon Cancer National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Version 3.2011, 02/25/11.
  21. Das IJ, Cheng CW, Chopra KL et al. Intensity – modulated radiation therapy dose prescription, recording, and delivery: patterns of variability among institutions and treatment planning systems. Journal of the National Cancer Institute 2008; 100(5): 300 – 307.
  22. Dawson LA, Jaffray DA. Advances in image – guided radiation therapy. Journal of Clinical Oncology 2007; 25(8): 938 – 946.
  23. De Meerleer G O, Vakaet L A, De Gersem WR, et al. Radiotherapy of prostate cancer with or without intensity modulated beams: a planning comparison. International Journal Radiation Oncology Biology Physiology 2000; 47(3): 639 – 648.
  24. Ding M, Newman F, Raben D. New radiation therapy techniques for the treatment of head and neck cancer. Otolaryngologic Clinics of North America 2005; 38:371 – 395.
  25. Donovan E, Bleakly N, Denholm E et al. Randomised trial of standard 3D radiotherapy (RT) versus intensity modulated radiotherapy (IMRT) in patients prescribed breast radiotherapy. Radiotherapy and Oncology 2007; 82(3): 254 – 264.
  26. Eccles CL, Bissonnette JP, Craig T et al. Treatment planning study to determine potential benefit of intensity – modulated radiotherapy versus conformal radiotherapy for unresectable hepatic malignancies. International Journal Radiation Oncology Biology Physics 2008; 72(2): 582 – 588.
  27. Esophageal and Esophagogastric Junction Cancers National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Version 1.2011, 03/04/11.
  28. Fang FM, Tsai WL, Chen HC et al. Intensity – modulated or conformal radiotherapy improves the quality of life of patients with nasopharyngeal carcinoma: comparisons of four radiotherapy techniques. Cancer 2007; 109(2): 313 – 321.
  29. Fenwick JD, Riley SW, Scott AJ. Advances in intensity – modulated radiotherapy delivery. Cancer Treatment Research 2008; 139: 193 – 214.
  30. First Coast Service Options, Inc. Intensity Modulated Radiation Therapy (IMRT) L29200, 10/05/09.
  31. Fuller CD, Choi M, Forthuber B et al. Standard fractionation intensity modulated radiation therapy (IMRT) of primary and recurrent glioblastoma multiforme. Radiation Oncology 2007; 2(26).
  32. Freedman GM, Li T, Nicolaou N et al. Breast intensity – modulated radiation therapy reduces time spent with acute dermatitis for women of all breast sizes during radiation. International Journal Radiation Oncology Biology Physics 2009; 74(3): 689 – 694.
  33. Freedman GM, Anderson PR, Li J et al. Intensity modulated therapy (IMRT) decreases acute skin toxicity for women receiving radiation for breast cancer. American Journal Clinical Oncology 2006; 29(1): 66 – 70.
  34. Girinsky T, Pichenot C, Beaudre A, et al. Is intensity – modulated radiotherapy better than conventional radiation treatment and three – dimensional conformal radiotherapy for mediastinal masses in patients with Hodgkin's disease, and is there a role for beam orientation optimization and dose constraints assigned to virtual volumes? International Journal Radiation Oncology Biology Physics 2006; 64(1): 218 – 226.
  35. Gong Y, Wang J, Bai S et al. Conventionally – fractionated image – guided intensity modulated radiotherapy (IG – IMRT): a safe and effective treatment for cancer spinal metastasis. Radiation Oncology 2008; 3:11.
  36. Graff P, Lapeyre M, Desandes E et al. Impact of intensity – modulated radioatherapy on health – related quality of life for head and neck cancer patients: matched – pair comparison with conventional radiotherapy. International Journal Radiation Oncology Biology Physics 2007; 67(5): 1309 – 1317.
  37. Guerrero Urbano MT, Henrys AJ, Adams EJ et al. Intensity – modulated radiotherapy in patients with locally advanced rectal cancer reduces volume of bowel treated to high dose levels. International Journal Radiation Oncology Biology Physics 2006; 65(3): 907 – 916.
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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/28/11.

GUIDELINE UPDATE INFORMATION:

06/15/11

New Medical Coverage Guideline.

8/15/11

Revision; formatting changes.

05/11/14

Revision: Program Exceptions section updated.

01/01/15

Annual HCPCS code update. Deleted 77418, 0073T. Added 77385, 77386, G6015 and G6016.

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Date Printed: March 1, 2015: 03:48 PM