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Date Printed: June 25, 2017: 01:20 PM

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This medical policy (medical coverage guideline) is Copyright 2017, 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 2017 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.

04-77260-19

Original Effective Date: 02/15/10

Reviewed: 10/19/16

Revised: 11/15/16

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Image-Guided Radiation Therapy

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 Update    
           

DESCRIPTION:

Image-guided radiation therapy (IGRT) is the use of frequent imaging during the course of radiation therapy to improve the precision and accuracy of the delivery of external beam radiation treatment. In IGRT, equipment that delivers radiation (e.g., linear accelerator) is equipped with imaging technology, which enables imaging of the tumor immediately before and during radiation treatment delivery. Using specialized computer software, these images are compared to the images taken during simulation. Adjustments are made to the patient’s position and/or radiation beams in order to more precisely target radiation at the tumor and avoid healthy surrounding tissue. IGRT is used in the treatment of tumors in areas of the body that are prone to movement (e.g., lungs, prostate gland, tumors located close to critical organs and tissues).

The process of IGRT begins with the construction of digitally reconstructed radiographs (DRRs) from the approved computer treatment plan computed tomography (CT) data set. These images are compared to the “live” IGRT images obtained before and/or during radiation treatment delivery. The patient is positioned based on the congruence of the images data sets to align the images within predetermined localization criteria. The treatment is delivered precisely and accurately according to the treatment plan approved by the radiation oncologist.

IGRT can be performed to enhance either 3-dimensional conformal radiation therapy (3DCRT) (e.g., intensity modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT)). There are several types of imaging modalities that may be used for IGRT; computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), ultrasound (US) and x-ray imaging. When the target is not clearly visible and bony anatomy is not sufficient for adequate target alignment, fiducial markers may be needed. Fiducial markers are used as aids in simulation and radiation treatment.

IGRT may be performed in real time, during the course of a radiation therapy session. This localization procedure is called intra-fraction. An example of intra-fraction technology includes, but is not limited to the Calypso® 4D Localization System.

Several systems, devices, and components for IGRT and intra-fraction systems have received U.S. Food and Drug Administration (FDA) 510(k) clearance (e.g., Calypso® 4D localization System). The Calypso® 4D Localization System is intended for use as an adjunct in treatment planning and radiation therapy, to align and monitor the patient's position relative to the isocenter of a linear accelerator. The Calypso System provides accurate, precise, and continuous localization of a treatment isocenter by using two or more Beacon® transponders. Beacon transponders are indicated for permanent implantation in the prostate only. The Calypso® 4D localization System is considered equivalent to existing devices such as implanted fiducials.

Several systems, devices, and accessories for respiratory gating for tracking respiratory pattern for respiratory synchronized image acquisition during radiation therapy treatment have received U.S. Food and Drug Administration (FDA) 510(k) clearance (e.g., RPM Respiratory Gating System, SDX-SpiroDynr’X Radiotherapy Breathing Control).

POSITION STATEMENT:

Image-guided radiation therapy (any modality) meets the definition of medical necessity when any of the following indications are met:

• Intensity modulated radiation therapy (IMRT) is being utilized

• Particle beam therapy is being utilized

Use of IGRT will allow significant reduction of radiation dose to sensitive normal structures, e.g.,:

• Left-sided breast cancer treatment with deep inspiration breath hold technique (DIBH) for cardiac sparing is being utilized.

• Implanted fiducial markers have been placed

Bony anatomy fails to accurately delineate a tumor location and fiducial markers or intensity modulated radiation therapy (IMRT) are not indicated (e.g., head and neck cancer or prone breast radiotherapy)

• The treatment field abuts a previously irradiated field

There is significant setup variation affecting the treatment target, e.g.,:

• Member is morbidly obese (BMI>35) and receiving treatment of tumors in the mediastinum, abdomen or pelvis

There is significant organ movement due to respiration and a 4D planning CT scan was performed with documentation demonstrating that the treatment plan addresses tumor motion that is both accounted for and managed.

BILLING/CODING INFORMATION:

CPT Coding:

77014

Computed tomography guidance for placement of radiation therapy fields

77387

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

HCPCS Coding:

G6001

Ultrasonic guidance for placement of radiation therapy fields

G6002

Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy

G6017

Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment

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 imaged-guided radiation therapy (IGRT).

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

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Note: Coverage for imaged-guided radiation therapy performed and billed in an outpatient or office location will be handled through the Radiation Oncology program for select products. AIM Specialty Health will determine coverage for imaged-guided radiation therapy for select products. Refer to member's contract benefits.

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline review date.

DEFINITIONS:

Dosimeter: an instrument used to detect and measure exposure to radiation.

Fraction: a single session of radiation treatment delivered to a specific area of interest at one setting.

Linear accelerator: the device most commonly used for external beam radiation treatments for patients with cancer. It delivers a uniform dose of high-energy x-ray to the region of the patient’s tumor. These x-rays can destroy the cancer cells while sparing the surrounding normal tissue.

Simulation: the process of establishing and documenting the appropriate volume to be treated and identifying the normal structures within or adjacent to this volume.

RELATED GUIDELINES:

None applicable.

OTHER:

Other names used to report image-guided radiation therapy (IGRT):

Dynamic Targeting IGRT
Electromagnetic Transponders
Intra-fraction Image Guidance
On-Board Imager
Real-Time Intra-Fraction

REFERENCES:

  1. ACR-ASTRO Practice Guideline for Image-Guided Radiation Therapy (IGRT), 2014.
  2. AIM Specialty Health Clinical Appropriateness Guideline: Radiation Oncology Image Guidance in Radiation Therapy, 11/16.
  3. Charlie CM, Paskalev K. In-room CT techniques for image-guided radiation therapy. Medical dosimetry 2006; 31(1): 30-39.
  4. Dawson LA, Jaffray DA. Advances in image-guided radiation therapy. Journal of Clinical Oncology 2007; 25(8): 938-46.
  5. Kindblom J, Ekelund-Olvenmark AM, Syren H et al. High precision transponder localization using a novel electromagnetic positioning system in patients with localized prostate cancer. Radiotherapy & Oncology 2009; 90(3): 307-311.
  6. Kupelian PA, Langen KM, Willoughby TR et al. Image-guided radiotherapy for localized prostate cancer; treating a moving target. Seminars in Radiation Oncology 2008; 18(1): 58-66.
  7. Langen, K.M., T. R. Willoughby, S.L. Meeks, A. Santhanam, A. Cunningham, L. Levine, and P. Kupelian. Observations on Real-Time Prostate Gland Motion Using Electromagnetic Tracking. International Journal of Radiation Oncology Biology Physics. 2008; 71(4):1084-190.
  8. Litzenberg, D.W., Willoughby, T.R., Balter, J.M., Sandler, H.M., Wei, J., Kupelian, P.A., Cunningham, A.A., Bock, A., Aubin, M., Roach III, M., Pouliot, J.,and Shinohara, K. Positional stability of electromagnetic transponders used for prostate localization and continuous, real-time tracking. International Journal of Radiation Oncology Biology Physics 2007; 61(4):1199-120.
  9. National Comprehensive Cancer Network (NCCN) Guidelines™ Version 3.2016 Prostate Cancer.
  10. Santanam L, Malinowki K, Hubenshmidt J et al. Fiducial-based translational localization accuracy of electromagnetic tracking system and on-board kilovoltage imaging system. International Journal of Radiation Oncology Biology Physics 2008; 70:892-99.
  11. Scarbrough TJ, Golden NM, Ting JY et al. Comparison of ultrasound and implanted seed marker prostate localization methods: Implications for image-guided radiotherapy. International Journal of Radiation Oncology, Biology, Physics 2006; 65(2): 378-387.
  12. U.S. Food Drug Administration (FDA) 510(k) Premarket Notification-Calypso 4D Localization System (K060906, K0080726).
  13. U.S. Food Drug Administration (FDA) 510(k) Premarket Notification-RPM Respiratory Gating (K107024).
  14. U.S. Food Drug Administration (FDA) 510(k) Premarket Notification-SDX-SpiroDynr’X Radiotherapy Breathing Control (K092479).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/19/16.

GUIDELINE UPDATE INFORMATION:

02/15/10

New Medical Coverage Guideline.

01/01/11

Annual HCPCS update; revised 55876 code descriptor.

02/15/11

Annual review. Maintain position statement. Updated references.

10/01/11

Revision; formatting changes.

05/15/14

Annual review. Maintain position statement. Added heading for “intra-fraction, description section. Revised FDA statement for Calypso 4D Localization System, description section. Added Medicare Advantage products program exception. Updated references.

01/01/15

Annual HCPCS code update. Deleted 0197T, 76050 and 77421. Added 77387, G6001, G6002 and G6017.

05/15/15

Annual review; position statement unchanged. Updated description and references.

05/01/16

Revision; deleted “for Treatment Planning and Delivery” from MCG name; deleted position statement for intra-fraction localization and tracking of target and imaging modalities; added position statement for image-guided radiation therapy; deleted 32553, 49411 and 55876; added LOINC codes; updated program exception; updated references.

11/15/16

Revision; revised position statement. Updated references.

Date Printed: June 25, 2017: 01:20 PM