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04-77260-22

Original Effective Date: 06/15/11

Reviewed: 10/19/16

Revised: 01/01/17

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:

Note: For Fractionation and Radiation Therapy, refer to Fractionation and Radiation Therapy, 04-77260-25.

Intensity modulated radiation therapy (IMRT) meets the definition of medical necessity for the following indications.

Bone Metastases

IMRT for bone metastases meets the definition of medical necessity when ALL of the the following are met:

• To treat a previously irradiated field; AND

Re-treatment with EBRT would result in significant risk of spinal cord injury (e.g., cumulative spinal cord dose >50Gy in 2 Gy equivalent).

Breast Cancer

IMRT for breast cancer meets the definition of medical necessity when ANY one of the following are met:

For members with left-sided breast lesions where the risk of cardiac exposure would be excessive with 3D conformal treatment and when ALL of the following are met:

• 3D planning has been done, with appropriate techniques to limit toxicity; AND

• Despite the use of all appropriate techniques, the dose-volume constraints would lead to unacceptable risk of; AND

• Cardiac toxicity such that greater than 10% of the heart would receive 25 Gy or more (V25 > 10%) ; AND

• IMRT plan demonstrates a reduction in the volume of heart receiving 25 Gy by at least 20% when compared to the 3D plan.

• For members who will receive internal mammary node irradiation based on ANY one of the following:

• Pathologically enlarged (as reported based on imaging technique utilized) internal mammary lymph node(s) by CT, MRI, PET/CT, or CXR; OR

• Pathologically involved internal mammary lymph node(s) (based on aspiration cytology or tissue biopsy pathology).

• For members at high risk of internal mammary lymph node involvement based on ANY one of the following:

• Four or more positive axillary lymph nodes; OR

• Medial quadrant tumor with at least one positive axillary lymph node; OR

• Medial quadrant T3 tumor.

• For members where the 3D conformal plan results in hot spots (> 2 cm3) receiving more than to 110% of the prescription dose despite the use of forward planned field-in-field blocking and/or mixed beam energy (6 MV and 10 MV/15 MV).

• To treat a previously irradiated field.

Note: Forward planning IMRT is a term used to describe field-in-field 3D conformal radiation therapy, and should not be reviewed under IMRT constraints.

Central Nervous System (CNS) Cancers (intracranial, spinal, ocular and neurologic)

Intracranial Lesions

Primary Malignant Brain Lesions

High Grade Gliomas (grade 3-4)

IMRT meets the definition of medical necessity for high grade gliomas in members with good performance status (based on either of the following):

• ECOG 0, 1, or 2; OR

• Karnofsky Scale greater than or equal to 70%; AND

When one of the following is met:

The lesion falls near a critical structure, such as the optic nerve, lens, retina, optic chiasm, cochlea, or brainstem and standard techniques such as 3D conformal radiotherapy would result in significant risk of damage to the critical structure; OR

• To treat a previously irradiated field.

Low Grade Gliomas (grade 1-2)

IMRT meets the definition of medical necessity for low grade gliomas in members with good performance status (based on either of the following)

• ECOG 0, 1, or 2; OR

• Karnofsky Scale greater than or equal to 70%; AND

When one of the following is met:

• The lesion falls near a critical structure, such as the optic nerve, lens, retina, optic chiasm, cochlea, or brainstem and standard techniques such as 3D conformal radiotherapy would result in significant risk of damage to the critical structure; OR

• To treat a previously irradiated field.

Medulloblastoma, supratentorial primitive neuroectodermal tumor (PNET), Ependymoma

IMRT meets the definition of medical necessity for medulloblastoma, supratentorial, PNET, ependymoma when ANY of the following are met:

• The lesion falls near a critical structure, such as the optic nerve, lens, retina, optic chiasm, cochlea, or brainstem and standard techniques such as 3D conformal radiotherapy would result in significant risk of damage to the critical structure; OR

In pediatric members below age 18; OR

• To treat a previously irradiated field.

CNS lymphoma

IMRT meets the definition of medical necessity for CNS lymphoma when ANY of the following are met:

• The lesion falls near a critical structure, such as the optic nerve, lens, retina, optic chiasm, cochlea, or brainstem and standard techniques such as 3D conformal radiotherapy would result in significant risk of damage to the critical structure; OR

• To treat a previously irradiated field.

Metastatic Brain Lesions

IMRT meets the definition of medical necessity for metastatic brain lesions in members with good performance status (based on either of the following):

• ECOG 0, 1, or 2; OR

• Karnofsky Scale greater than or equal to 70%; AND

When one of the following is met:

• The lesion falls near a critical structure, such as the optic nerve, lens, retina, optic chiasm, cochlea, or brainstem and standard techniques such as 3D conformal radiotherapy would result in significant risk of damage to the critical structure; OR

To treat a previously irradiated field.

Benign Brain Lesions

Intracranial arteriovenous malformations (AVMs)

IMRT meets the definition of medical necessity for AVMs when the following is met:

• To treat a previously irradiated field.

Pituitary adenomas

IMRT meets the definition of medical necessity for pituitary adenomas when ANY of the following are met:

• The lesion falls near a critical structure, such as the optic nerve, lens, retina, optic chiasm, cochlea, or brainstem and standard techniques such as 3D conformal radiotherapy would result in significant risk of damage to the critical structure; OR

• To treat a previously irradiated field.

Meningioma

IMRT meets the definition of medical necessity for meningioma when ANY of the following are met:

• The lesion falls near a critical structure, such as the optic nerve, lens, retina, optic chiasm, cochlea, or brainstem and standard techniques such as 3D conformal radiotherapy would result in significant risk of damage to the critical structure; OR

• To treat a previously irradiated field.

Other benign brain tumors (acoustic neuromas, craniopharyngiomas, pineal gland tumors, schwannomas) IMRT meets the definition of medical necessity for other benign brain tumors when ANY of the following are met:

• The lesion falls near a critical structure, such as the optic nerve, lens, retina, optic chiasm, cochlea, or brainstem and standard techniques such as 3D conformal radiotherapy would result in significant risk of damage to the critical structure; OR

• To treat a previously irradiated field.

Ocular Lesions

Uveal Melanoma

IMRT meets the definition of medical necessity for uveal melanoma when the following is met:

• To treat a previously irradiated field.

Retinoblastoma

IMRT meets the definition of medical necessity for retinoblastoma when ANY of the following are met:

In pediatric members (below age 18); OR

• To treat a previously irradiated field.

Spine Lesions (primary or metastatic)

IMRT meets the definition of medical necessity for spine lesions when the following is met:

To treat a previously irradiated field.

Other Neurologic Indication (trigeminal neuralgia)

IMRT meets the definition of medical necessity for trigeminal neuralgia when the following is met:

• To treat a previously irradiated field.

Colorectal and Anal Cancers

Anal Cancer

IMRT meets the definition of medical necessity for anal cancer when the following is met:

• Treatment of cancer of the anus and anal canal.

Rectal Cancer

IMRT meets the definition of medical necessity is appropriate for rectal cancer when the following is met:

• Treatment of rectal adenocarcinoma, when treating the inguinal nodal chain.

Colon Cancer

IMRT meets the definition of medical necessity for colon cancer when the following condition is met:

• To treat a previously irradiated field.

Gastrointestinal Cancers, Non-Colorectal (cholangiocarcinoma, esophageal, gastric, liver and pancreatic)

Cholangiocarcinoma

IMRT meets the definition of medical necessity for curative treatment of cholangiocarcinoma when either of the following is met:

• Where risk of critical structure exposure would be excessive with 3D conformal treatment (both of the following must be met):

• 3D planning has been done with appropriate techniques to limit toxicity, but organ at risk limits have been exceeded (based on QUANTEC limits*); AND

• IMRT demonstrates improvement to tissue exposure to within safe ranges; OR

To treat a previously irradiated field.

Esophageal Cancer

IMRT meets the definition of medical necessity for the curative treatment of esophageal cancer when either of the following is met:

• Where risk of critical structure (heart, lung) exposure would be excessive with 3D conformal treatment (the following must be met)

• 3D planning has been done with appropriate techniques to limit toxicity, but organ at risk limits have been exceeded (based on QUANTEC limits*); AND

IMRT demonstrates improvement to tissue exposure to within safe ranges; OR

• To treat a previously irradiated field.

Gastric Cancer

IMRT meets the definition of medical necessity for curative treatment of gastric cancer when either of the following is met:

• Where risk of critical structure exposure would be excessive with 3D conformal treatment (both of the following must be met):

• 3D planning has been done with appropriate techniques to limit toxicity, but organ at risk limits have been exceeded (based on QUANTEC limits*) ; AND

• IMRT demonstrates improvement to tissue exposure to within safe ranges; OR

• To treat a previously irradiated field.

Liver Cancer

Hepatocellular carcinoma

IMRT meets the definition of medical necessity for the curative treatment of liver cancer when either of the following is met:

• Where risk of critical structure exposure would be excessive with 3D conformal treatment (both of the following must be met):

• 3D planning has been done with appropriate techniques to limit toxicity, but organ at risk limits have been exceeded (based on QUANTEC limits*) ; AND

• IMRT demonstrates improvement to tissue exposure to within safe ranges; OR

• To treat a previously irradiated field.

Liver Metastases

IMRT meets the definition of medical necessity for liver metastases when the following is met:

• To treat a previously irradiated field.

Pancreatic Cancer

IMRT meets the definition of medical necessity for the curative treatment of pancreatic cancer when either of the following is met:

• Where risk of critical structure exposure would be excessive with 3D conformal treatment (both of the following must be met):

• 3D planning has been done with appropriate techniques to limit toxicity, but organ at risk limits have been exceeded (based on QUANTEC limits*) ; AND

• IMRT demonstrates improvement to tissue exposure to within safe ranges; OR

• To treat a previously irradiated field.

Genitourinary Cancers (bladder, penile and testicular)

Bladder Cancer

IMRT meets the definition of medical necessity for bladder cancer when the following is met:

• To treat primary, non-metastatic bladder carcinoma; AND

• Treatment intent is curative.

Penile Cancer

IMRT meets the definition of medical necessity for penile cancer when the following is met:

• To treat a previously irradiated field.

Testicular Cancer

IMRT meets the definition of medical necessity for testicular cancer when the following is met:

• To treat a previously irradiated field.

Gynecologic Cancers (cervical, fallopian tube, ovarian, uterine, and vulvar/vaginal)

Cervical Cancer

IMRT meets the definition of medical necessity for cervical cancer when the following is met:

To treat primary cervical cancer.

Fallopian Tube Cancer

IMRT meets the definition of medical necessity for fallopian tube cancer when the following is met:

• To treat primary fallopian tube cancer.

Ovarian Cancer

IMRT meets the definition of medical necessity for ovarian cancer when the following is met:

• To treat primary ovarian cancer.

Uterine Neoplasms (endometrial carcinoma, uterine sarcoma, uterine carcinosarcoma)

IMRT meets the definition of medical necessity for uterine neoplasms when the following is met:

• To treat members with cancer of the uterus, including uterine sarcoma and endometrial carcinoma

Vulvar/Vaginal Cancer

IMRT meets the definition of medical necessity for vulvar/vaginal cancer when the following is met:

• To treat vulvar/vaginal cancer.

Head and Neck Cancers (including thyroid cancer)

Head and Neck

IMRT meets the definition of medical necessity for head and neck cancers when ANY of the following are met:

Laryngeal cancer, stage III and IV; OR

Other head and neck cancers; OR

To treat a previously irradiated field.

Thyroid

IMRT meets the definition of medical necessity for head and neck cancer when ANY of the following are met:

Anaplastic thyroid cancer; OR

To treat node-positive or node-recurrent thyroid cancer requiring external beam radiation treatment; OR

• To treat a previously irradiated field.

Lung Cancer (small cell and non-small cell)

Primary Lung Cancers

Non-Small Cell Lung Cancer

IMRT meets the definition of medical necessity for non-small cell lung cancer when ANY of the following conditions are met:

• For adjuvant or definitive treatment in the curative setting:

• When a 3D plan has been performed and dose-volume constraints would lead to unacceptable risk for normal lung tissue toxicity such that (all of the following must apply)

• V20 exceeds 30% with 3D conformal plan (the percent of normal tissues receiving 20 Gy or more accounts for more than 30% of normal lung)

• The comparison of the 3D conformal plan and the IMRT plan demonstrates that the IMRT plan will reduce the V20 by 10% as compared to the 3D conformal plan

• V5 would be less than 65% (the percent of normal tissues receiving 5 Gy or more accounts for less than 65% of normal lung) with IMRT

Tumor motion has been accounted for during planning; OR

• When a 3D plan has been performed and dose-volume constraints would lead to unacceptable risk of cardiac toxicity: (any constraints below is exceeded)

• More than 50% of the heart receives 30 Gy (V30 < 50%)

More than 35% of the heart receives 45 Gy (V45 < 35%); OR

• To treat a previously irradiated field.

Small Cell Lung Cancer

IMRT meets the definition of medical necessity for small cell lung cancer when ANY of the following conditions are met:

• For definitive treatment in the curative setting

• When a 3D plan has been performed and dose-volume constraints would lead to unacceptable risk for normal lung tissue toxicity such that (all of the following must apply)

• V20 exceeds 30% with 3D conformal plan (the percent of normal tissues receiving 20 Gy or more accounts for more than 30% of normal lung); AND

• The comparison of the 3D conformal plan and the IMRT plan demonstrates that the IMRT plan will reduce the V20 by 10% as compared to the 3D conformal plan; AND

• V5 would be less than 65% (the percent of normal tissues receiving 5 Gy or more accounts for less than 65% of normal lung) with IMRT; AND

• Tumor motion has been accounted for during planning

• When a 3D plan has been performed and dose-volume constraints would lead to unacceptable risk of cardiac toxicity: (any constraints below is exceeded (i, ii))

• More than 50% of the heart receives 30 Gy (V30 < 50%)

More than 35% of the heart receives 45 Gy (V45 < 35%) ;OR

• To treat a previously irradiated field.

Metastatic Lesions in the Lung

IMRT meets the definition of medical necessity for metastatic lesions in the lung when the following is met:

• To treat a previously irradiated field.

Sarcoma

IMRT meets the definition of medical necessity for sarcoma when ANY of the following are met:

For initial treatment of a primary pelvic soft tissue sarcoma; OR

For treatment of a sarcoma prior to surgery, to spare a joint; OR

• To treat a previously irradiated field.

Pediatric Members (below age 18)

IMRT meets the definition of medical necessity for pediatric members when the following is met:

• To treat pediatric members below age 18 with a radiosensitive tumor.

Other Malignancies

IMRT meets the definition of medical necessity for other malignancies when the following is met:

• Only to treat a previously irradiated field.

Prostate Cancer

Prostate Cancer Disease Definitions

Low-risk of recurrence (all of the following must be present to qualify as low risk)

Stage T1-T2a; AND

Gleason less than or equal to 6; AND

• Prostate-specific Antigen (PSA) below 10 ng/mL.

Intermediate-risk of recurrence (any one of the following)

Stage T2b to T2c; OR

Gleason score of 7; OR

• PSA 10-20 ng/mL.

High-risk of recurrence (any one of the following)

Stage T3a; OR

Gleason score 8-10; OR

• PSA greater than 20 ng/mL.

Localized disease

• T stage of T1-3a (tumor has spread through the capsule on one or both sides but has not invaded the seminal vesicles or other structures); AND

• No (no lymph node involvement).

Locally advanced disease

Any T status with N1 disease (either no spread to lymph nodes or there has been spread to the regional lymph nodes); OR

• T3b and above, no distant metastatic disease beyond local lymph nodes.

Distant metastatic disease

• Beyond the local lymph nodes.

Low risk of recurrence

IMRT meets the definition of medical necessity for prostate cancer when ANY of the following conditions (1 or 2) are met:

When anticipated survival is greater than 10 years; OR

• To treat a previously irradiated field.

Note: Active surveillance is a reasonable alternative to radiation treatment in members with low risk prostate cancer.

Intermediate risk of recurrence

IMRT meets the definition of medical necessity for prostate cancer when ANY of the following are met:

When anticipated survival is greater than 10 years; OR

• To treat a previously irradiated field.

High or very high risk of recurrence

IMRT meets the definition of medical necessity for prostate cancer when ANY of the following are met:

• Localized disease

With or without brachytherapy; OR

• To treat a previously irradiated field.

Post-prostatectomy

IMRT meets the definition of medical necessity for prostate cancer when ANY of the following are met

• Adjuvant therapy, with no evidence of metastatic disease

Detectable PSA ;OR

Any adverse pathologic feature

pT3 disease; OR

Pathology demonstrates positive margin(s); OR

Gleason score 8-10; OR

Seminal vesicle involvement or invasion; OR

• Extracapsular extension.

• Salvage therapy

Undetectable PSA becomes detectable and increases on 2 or more lab measurements; OR

• To treat a previously irradiated field.

Local Recurrence

IMRT meets the definition of medical necessity for prostate cancer for local recurrence when the following is met:

• To treat a previously irradiated field.

*QUANTEC Limits

Lung: V20 ≤ 30%

Heart: V25 ≤ 10%

Pericardium: Mean dose ≤ 26 Gy OR V30 < 46%

Spinal Cord: Mean dose ≤ 45 Gy OR Maximum dose 50 Gy

Esophagus: Mean dose < 34% Gy

Small bowel: Dmax < 54 Gy

Liver: Mean dose < 30 Gy

Kidney: Mean dose < 18 Gy. If one kidney, < 15% to receive 18 Gy

Note: Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) pertains to dose/volume outcome data for organs potentially impaced by radiation treatment. QUANTEC gives physicians and treatment planners resources to assist in determining acceptable dose/volume constraints. (ASTR0, 2015)

BILLING/CODING INFORMATION:

Note: Procedure and diagnoses codes may not be all inclusive.

CPT Coding:

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

77301

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

77338

Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan

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

77402

Radiation treatment delivery, >1 MeV; simple

77407

Radiation treatment delivery, >1 MeV; intermediate

77412

Radiation treatment delivery, >1 MeV; complex

77424

Intraoperative radiation treatment delivery, x-ray, single treatment session

77425

Intraoperative radiation treatment delivery, electrons, single treatment session

77469

Intraoperative radiation treatment management

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

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

C03.0 – C03.9

Malignant neoplasm of gum

C04.0 – C04.9

Malignant neoplasm of floor of mouth

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

Liver cell carcinoma

C22.1

Intrahepatic bile duct carcinoma

C24.0

Malignant neoplasm of extrahepatic bile duct

C25.0 – C25.9

Malignant neoplasm of pancreas

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

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

C41.2

Malignant neoplasm of vertebral column

C49.5

Malignant neoplasm of connective and soft tissue of pelvis

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 – C50.819

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

C51.0 – C51.9

Malignant neoplasm of vulva

C52

Malignant neoplasm of vagina

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

C56.1 – C56.9

Malignant neoplasm of ovary

C57.00 – C57.02

Malignant neoplasm of fallopian tube

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

C60.0 – C60.9

Malignant neoplasm of penis

C62.00 – C62.02

Malignant neoplasm of undescended testis

C62.10 – C62.12

Malignant neoplasm of descended testis

C62.90 – C62.92

Malignant neoplasm of testis, unspecified whether descended or undescended

C61

Malignant neoplasm of prostate

C67.0 – C67.9

Malignant neoplasm of bladder

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

C73

Malignant neoplasm of thyroid gland

C76.0

Malignant neoplasm of head, face and neck

C78.00 -C78.02

Secondary malignant neoplasm of lung

C78.7

Secondary malignant neoplasm of liver and intrahepatic bile duct

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

C79.81

Secondary malignant neoplasm of breast

C79.82

Secondary malignant neoplasm of genital organs

C80.1

Malignant (primary) neoplasm, unspecified

C85.81

Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face, and neck

D33.0 -D33.2

Benign neoplasm of brain and other parts of central nervous system

D35.2

Benign neoplasm of pituitary gland

D35.4

Benign neoplasm of pineal gland

C85.81

Other specified types of non-Hodgkin lymphoma, lymph nodes of head, face, and neck

D05.00 – D05.02

Lobular carcinoma in situ of breast

D05.10 – D05.12

Intraductal carcinoma in situ of breast

D05.80 – D05.82

Other specified type of carcinoma in situ of breast

D05.90 – D05.92

Unspecified type of carcinoma in situ of breast

D35.2

Benign neoplasm of pituitary gland

D35.4

Benign neoplasm of pineal gland

G50.0

Trigeminal neuralgia

Q28.2

Arteriovenous malformation of cerebral vessels

R97.2

Elevated prostate specific antigen [PSA]

Z08

Encounter for follow-up examination after completed treatment for malignant neoplasm

Z51.0

Malignant neoplasm of vertebral column

Z51.5

Encounter for palliative care

Z98.89

Other specified postprocedural states

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

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Note: Coverage for intensity modulated radiation therapy (IMRT) 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 intensity modulated radiation therapy (IMRT) 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: The following Local Coverage Determination (LCD) was reviewed on the last guideline review date: Intensity Modulated Radiation Therapy (IMRT), ( L33378) 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
Fractionation and Radiation Therapy, 04-77260-25

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. Abrams RA, winter KA, Regine WF et al. Failure to adhere to protocol specified radiation therapy guidelines was associated with decreased survival in RTOG 9704--a phase III trial of adjuvant chemotherapy and chemoradiotherapy for patients with resected adenocarcinoma of the pancreas. International Journal of Oncology, Biology, Physics 2012; 82(2): 809-16.
  2. Anal Carcinoma National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Version 2.2011, 02/02/11.
  3. AIM Specialty Health Clinical Appropriateness Guideline: Bone Metastases, Breast Cancer, Central Nervous System Cancers, Colorectal and Anal Cancers, Gastrointestinal Cancers and Non-Colorectal, Genitourinary (Penile and Testicular) Cancers, Gynecologic Cancers, Head and Neck Cancers, Lung Cancer (Small Cell and Non-Small Cell), Other Tumor Types (including Sarcomas, Pediatrics and Other Malignancies) and Prostate Cancer, 2016.
  4. American Society for Radiation Oncology (ASTRO) Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC), accessed 2016.
  5. 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.
  6. 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.
  7. Bhatia A, Rao A, Ang KK et al. Anaplastic thyroid cancer: Clinical outcomes with conformal radiotherapy. Head Neck 2010; 32(7): 829-836.
  8. 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.
  9. 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.
  10. Caglar HB, Allen AM. Intensity-modulated radiotherapy for head and neck cancer. Clinical Advances in Hematology & Oncology 2007; 5(6): 425-431.
  11. Cahlon O, Hunt M, Zelefsky MJ. Intensity-modulated radiation therapy: supportive data for prostate cancer. Seminars in Radiation Oncology 2008; 18(1): 48-57.
  12. 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.
  13. 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.
  14. Czito BG, Pepek JM, Meyer JJ et al. Intensity-modulated radiation therapy for anal cancer. Oncology; 23(12):1082-1089.
  15. 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.
  16. Dawson LA, Jaffray DA. Advances in image-guided radiation therapy. Journal of Clinical Oncology 2007; 25(8): 938-946.
  17. 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.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. Fenwick JD, Riley SW, Scott AJ. Advances in intensity-modulated radiotherapy delivery. Cancer Treatment Research 2008; 139: 193-214.
  23. First Coast Service Options, Inc. Intensity Modulated Radiation Therapy (IMRT) L33378, 10/01/2015.
  24. 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).
  25. 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.
  26. 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.
  27. 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.
  28. 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.
  29. 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.
  30. 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.
  31. Haffty BG. Should intensity-modulated radiation therapy be the standard of care in the conservatively managed breast cancer patient? Journal of clinical Oncology 2008; 26(13): 2072-2074.
  32. Hatano K, Araki H, Sakai M, et al. Current status of intensity-modulated radiation therapy (IMRT). International Journal of Clinical Oncology 2007; 12(6): 408-415.
  33. Iuchi T, Hatano K, Narita Y et al. Hypofractionated high-dose irradiation for the treatment of malignant astrocytomas using simultaneous integrated boost technique by IMRT. International Journal Radiation Oncology Biology Physics 2006; 64(5): 1317-1324.
  34. Kam MK, Leung SF, Zee B et al. Prospective randomized study of intensity-modulated radiotherapy on salivary gland function in early-stage nasopharyngeal carcinoma patients. Journal of Clinical Oncology 2007; 25(31): 4873-4879.
  35. Kavanagh BD, Schefter TE, Wu, O, et al. Clinical application of intensity-modulated radiotherapy for locally advanced cervical cancer. Seminars in Radiation Oncology 2002; 12(3): 260-271.
  36. Kestin LL, Sharpe MB, Frazier RC et al. Intensity modulation to improve dose uniformity with tangential breast radiotherapy: initial clinical experience. International Journal Radiation Oncology Biology Physics 200; 48(5): 1559-1568.
  37. Kruger, EA, Fraas BA, Pierce LJ. Clinical aspects of intensity-modulated radiotherapy in the treatment of breast cancer. Seminars Radiation Oncology 2002; 12(3): 250-259.
  38. Liao ZX, Komaki RR, Thames HD et al. Influence of technologic advances on outcomes in patients with unresectable, locally advanced non-small-cell lung cancer receiving concomitant chemoradiotherapy. International Journal Radiation Oncology Biology Physics 2010; 76(3): 775-781.
  39. Laskar S, Bahl G, Muckaden M et al. Nasopharyngeal carcinoma in children: comparison of conventional and intensity-modulated radiotherapy. International Journal Radiation Oncology Biology Physics 2008; 72(3): 728-736
  40. Lee NY, Terezakis SA. Intensity-modulated radiation therapy. Journal of Surgical Oncology 2008; 97(8): 691-696.
  41. Leonard C, Carter D, Kercher J et al. Prospective trial of accelerated partial breast intensity-modulated radiotherapy. International Journal Radiation Oncology Biology Physics 2007; 67(5): 1291-1298.
  42. Lips I, Dehnad H, Kruger AB et al. Health-related quality of life in patients with locally advanced prostate cancer after 76 Gy intensity-modulated radiotherapy vs. 70 Gy conformal radiotherapy in a prospective and longitudinal study. International Journal Radiation Oncology Biology Physiology 2007; 69(3): 656-661.
  43. MacDonald SM, Ahmad S, Kachris S et al. Intensity modulated radiation therapy versus three-dimensional conformal radiation therapy for the treatment of high grade glioma: a dosimetric comparison. Journal of Applied Clinical Medical Physics 2007; 8(2): 47-60.
  44. Macdonald JS, Smalley SR, Benedetti J et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. New England Journal of Medicine 2001; 345(10): 725-730.
  45. Milano MT, Chmura SJ, Garofalo MC, et al. Intensity-modulated radiotherapy in treatment of pancreatic and bile duct malignancies: toxicity and clinical outcome. International Journal Radiation Oncology Biology Physics 2004; 2004; 59(2): 445-453.
  46. Murshed H, Liu HH, Liao Z et al. Dose and volume reduction for normal lung using intensity-modulated radiotherapy for advanced-stage non-small-cell lung cancer. International Journal Radiation Oncology Biology Physics 2004; 58(4): 1258-1267.
  47. Pawlik TM, Ahuja N, Herman JM. The role of radiation in retroperitoneal sarcomas: a surgical perspective. Current Opinion in Oncology 2007; 17(4): 359-366.
  48. Penagaricano JA, Papanikolaou N, Yan Y, et al. Application of intensity-modulated radiation therapy for pediatric malignancies. Medical Dosimetry 2004; 29(4): 247-253.
  49. Pepek JM, Willett CG, Czito BG. Radiation therapy advances for treatment of anal cancer. Journal of the National Comprehensive Cancer Network 2010 Jan; 8(1): 123-129.
  50. Pignol JP, Olivotto I, Rakovitch E, et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. Journal of Clinical Oncology 2008; 26(13): 2085-2092.
  51. Salma JK, Mell LK, Schomas DA et al. Concurrent chemotherapy and intensity-modulated radiation therapy for anal canal cancer patients: a multicenter experience. Journal of Clinical Oncology 2007; 25(29): 4581-4586.
  52. Santanam L, Malinowski K, Hubenshmidt J et al. Fiducial-based translational localization accuracy of electromagnetic tracking system and on-board kilovoltage imaging system. International Journal Radiation Oncology Biology Physics 2008; 70(3): 892-799.
  53. Smalley SR, Benedetti JK, Haller DG et al. Updated analysis of SWOG-directed intergroup study 0116: a phase III trial of adjuvant radiochemotherapy versus observation after curative gastric cancer resection. Journal of Clinical Oncology 30(19): 2327-2333.
  54. Sura S, Gupta V, Yorke E et al. Intensity-modulated radiation therapy (IMRT) for inoperable non-small cell lung cancer: the Memorial Sloan-Kettering Cancer Center (MSKCC) experience. Radiotherapy Oncology 2008; 87(1): 17-23.
  55. Teh BS, Mai WY, Uhl BM et al. Intensity-modulated radiation therapy (IMRT) for prostate cancer with the use of a rectal balloon for prostate immobilization: acute toxicity and dose-volume analysis. International Journal Radiation Oncology Biology Physics 2001; 49(3): 705-712.
  56. Trofimov A, Nguyen PL, Coen JJ et al. Radiotherapy treatment of early-stage prostate cancer with IMRT and protons: a treatment planning comparison. International Journal Radiation Oncology Biology Physiology 2007; 69(4): 444-453.
  57. U.S. Food and Drug Administration (FDA) 510(k) Summary-TiGRT TPS Radiation Treatment Planning System K090893, 07/15/09.
  58. U.S. Food and Drug Administration (FDA) 510(k) Summary-Innocure Intensity Modulating Radiation Therapy Compensators K052383, 03/29/06.
  59. U.S. Food and Drug Administration (FDA) 510(k) Summary-micro-Multi-Leaf Collimator K020860, 06/06/02.
  60. U.S. Food and Drug Administration (FDA) 510(k) Summary-Genesis™ IMRT Medical Linear Accelerator K982502, 07/31/98.
  61. Vaidya JS, Wenz F, Bulsara et al. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet 2014; 383 (9917): 603-613.
  62. Veldeman L, Madani I, Hulstaert F et al. Evidence behind use of intensity-modulated radiotherapy: a systematic review of comparative clinical studies. Lancet Oncology 2008; 9(4): 367-375.
  63. Wang SJ, Choi M, Fuller CD et al. Intensity-modulated radiotherapy for patients with brain metastases: a mature outcomes analysis. Technology in Cancer Research and Treatment 2007; 6(3): 161-166.
  64. Williams PC. IMRT: delivery techniques and quality assurance. The British Journal of Radiology 2003; 76:766-776.
  65. Zelefsky MJ, Fuks Z, Happensett L, et al. Clinical experience with intensity-modulated radiation therapy (IMRT) in prostate cancer. Radiotherapy and Oncology 2000; 55: 241-249.
  66. Zelefsky MJ, Fuks Z, Hunt M, et al. High dose radiation delivered by intensity modulated conformal radiotherapy improves the outcomes of localized prostate cancer. The Journal of Urology 2001; 166(3): 876-881.
  67. Zelefsky MJ, Fuks Z, Hunt M, et al. High-dose intensity modulated radiation therapy for prostate cancer: early toxicity and biochemical outcome in 772 patients. International Journal Radiation Oncology Biology Physics 2002b; 53(5): 1111-1116.
  68. Zelefsky MJ, Fuks Z, Leibel SA. Intensity-modulated radiation therapy for prostate cancer. Seminars Radiation Oncology 2002a; 12:229-237.

COMMITTEE APPROVAL:

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

GUIDELINE UPDATE INFORMATION:

06/15/11

New Medical Coverage Guideline.

08/15/11

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.

10/01/15

Revision; updated ICD9 and ICD10 coding section.

11/01/15

Revision: ICD-9 Codes deleted.

05/01/16

Added/revised indications: bone metastases, breast cancer, CNS cancers, intracranial lesions, medulloblastoma, supratentorial, PNET, ependymoma, CNS lymphoma, metastatic brain lesions, benign brain lesions, pituitary adenomas, meningioma, other benign brain tumors (acoustic neuromas, carniopharyngiomas, pineal gland tumors, schwannomas), ocular lesions, retinoblastoma, spine lesions (primary or metastatic), other neurologic indication (trigeminal neuralgia), colorectal and anal cancers, gastrointestinal cancers, non-colorectal (cholangiocarcinoma, esophageal, gastric, liver and pancreatic), genitourinary cancers (bladder, penile and testicular), gynecologic cancers (cervical, fallopian tube, ovarian, uterine, and vulvar/vaginal), head and neck cancers (including thyroid cancer), lung cancer (small cell and non-small cell), other tumor types (including sarcoma, pediatrics, and other malignancies), and prostate cancer; added 77280, 72285, 77290, 77295, 77338, 77402, 77407 and 77412; updated ICD-10 codes; updated program exception; updated references.

06/02/16

Code update; change code C50.519 in code range to C50.811-C50.819.

08/15/16

Updated program exceptions.

11/15/16

Revision; revised position statement. Added 77424, 77425 and 77469. Updated references.

01/01/17

Annual HCPCS code update. Revised 77402, 77407 and 77412 code descriptor.

Date Printed: August 18, 2017: 10:28 AM