Aetna Intensity Modulated Radiation Therapy (IMRT) coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Overarching gate: IMRT is considered medically necessary for certain indications where critical structures cannot be adequately protected with standard 3-dimensional (3D) conformal radiotherapy; medical necessity is determined per the eviCore Healthcare Radiation Therapy Clinical Guidelines.
• Definition of the gate (THRESHOLD): critical structures cannot be adequately protected with standard 3D conformal radiotherapy if IMRT would decrease the probability of grade 2 or grade 3 radiation toxicity, as compared to conventional 3D conformal radiation therapy, in greater than 15% of irradiated similar cases.
• Medically necessary (when the above gate is met) for: Adrenal cancer
• Medically necessary (when gate met) for: Anal cancer
• Medically necessary (when gate met) for: Anaplastic thyroid cancer
• Medically necessary (when gate met) for: Bladder cancer
• Medically necessary (when gate met) for: Brain metastases
• Medically necessary (when gate met) for: Brain tumors in close proximity to critical structures
• Medically necessary (when gate met) for: Cervical cancer
• Medically necessary (when gate met) for: Cutaneous melanoma
• Medically necessary (when gate met) for: Endometrial cancer
• Medically necessary (when gate met) for: Esophageal cancer
• Medically necessary (when gate met) for: Gallbladder cancer
• Medically necessary (when gate met) for: Gastric cancer
• Medically necessary (when gate met) for: Head and neck cancer, EXCLUDING T1 and T2 glottic cancer
• Medically necessary (when gate met) for: Hepatobiliary cancer
• Medically necessary (when gate met) for: Hodgkin's lymphoma
• Medically necessary (when gate met) for: Left breast cancer ONLY IF the lesion is in close proximity to the heart or other cardiovascular structures, where 3D CRT would exceed acceptable constraints
• Medically necessary (when gate met) for: Lung cancer (small cell and non-small cell)
• Medically necessary (when gate met) for: Malignant pleural mesothelioma
• Medically necessary (when gate met) for: Merkel cell carcinoma
• Medically necessary (when gate met) for: Non-Hodgkin's lymphoma
• Medically necessary (when gate met) for: Non-melanoma skin cancer
• Medically necessary (when gate met) for: Pancreatic cancer
• Medically necessary (when gate met) for: Penile cancer
• Medically necessary (when gate met) for: Prostate cancer
• Medically necessary (when gate met) for: Small bowel cancer
• Medically necessary (when gate met) for: Soft tissue sarcoma
• Medically necessary (when gate met) for: Solitary plasmacytoma
• Medically necessary (when gate met) for: T4 rectal cancer with external iliac and inguinal lymph node involvement
• Medically necessary (when gate met) for: Testicular cancer
• Medically necessary (when gate met) for: Thymic cancer/Thymoma
• Medically necessary (when gate met) for: Uveal melanoma
• Medically necessary (when gate met) for: Vulvar cancer
• Placement of fiducial markers is medically necessary IF the above IMRT criteria are met AND the radiation target is not clearly visible AND bony anatomy is not sufficient for adequate target alignment.
• Inter-fraction image guidance systems are considered medically necessary (in conjunction with medically necessary IMRT as above).
• Intra-fraction image guidance systems (e.g., Calypso 4D Localization System, RayPilot System) are considered medically necessary (in conjunction with medically necessary IMRT as above).

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 77301·PA verdict·Rate
• 77338·PA verdict·Rate
• 77385·PA verdict·Rate
• 77386·PA verdict·Rate
• 77387·PA verdict·Rate

Frequently asked questions

When does Aetna cover Intensity Modulated Radiation Therapy (IMRT) (CPT 77301), and what gets it denied?

Aetna covers IMRT only when standard 3D conformal radiotherapy cannot adequately protect critical structures — specifically when IMRT would reduce grade 2 or grade 3 radiation toxicity versus 3D CRT in more than 15% of similar cases — for a defined list of cancer sites (e.g., head and neck excluding T1/T2 glottic, prostate, lung, esophageal, anal, and many others), with left breast covered only if the lesion is near the heart/cardiovascular structures. Right breast cancer and all unlisted indications are considered experimental/investigational and not medically necessary. The bulletin is silent on precertification/prior authorization. Coverage criteria include: Overarching gate: IMRT is considered medically necessary for certain indications where critical structures cannot be adequately protected with standard 3-dimensional (3D) conformal radiotherapy; medical necessity is determined per the eviCore Healthcare Radiation Therapy Clinical Guidelines.; Definition of the gate (THRESHOLD): critical structures cannot be adequately protected with standard 3D conformal radiotherapy if IMRT would decrease the probability of grade 2 or grade 3 radiation toxicity, as compared to conventional 3D conformal radiation therapy, in greater than 15% of irradiated similar cases.; Medically necessary (when the above gate is met) for: Adrenal cancer; Medically necessary (when gate met) for: Anal cancer; Medically necessary (when gate met) for: Anaplastic thyroid cancer; Medically necessary (when gate met) for: Bladder cancer; Medically necessary (when gate met) for: Brain metastases; Medically necessary (when gate met) for: Brain tumors in close proximity to critical structures; Medically necessary (when gate met) for: Cervical cancer; Medically necessary (when gate met) for: Cutaneous melanoma; Medically necessary (when gate met) for: Endometrial cancer; Medically necessary (when gate met) for: Esophageal cancer; Medically necessary (when gate met) for: Gallbladder cancer; Medically necessary (when gate met) for: Gastric cancer; Medically necessary (when gate met) for: Head and neck cancer, EXCLUDING T1 and T2 glottic cancer; Medically necessary (when gate met) for: Hepatobiliary cancer; Medically necessary (when gate met) for: Hodgkin's lymphoma; Medically necessary (when gate met) for: Left breast cancer ONLY IF the lesion is in close proximity to the heart or other cardiovascular structures, where 3D CRT would exceed acceptable constraints; Medically necessary (when gate met) for: Lung cancer (small cell and non-small cell); Medically necessary (when gate met) for: Malignant pleural mesothelioma; Medically necessary (when gate met) for: Merkel cell carcinoma; Medically necessary (when gate met) for: Non-Hodgkin's lymphoma; Medically necessary (when gate met) for: Non-melanoma skin cancer; Medically necessary (when gate met) for: Pancreatic cancer; Medically necessary (when gate met) for: Penile cancer; Medically necessary (when gate met) for: Prostate cancer; Medically necessary (when gate met) for: Small bowel cancer; Medically necessary (when gate met) for: Soft tissue sarcoma; Medically necessary (when gate met) for: Solitary plasmacytoma; Medically necessary (when gate met) for: T4 rectal cancer with external iliac and inguinal lymph node involvement; Medically necessary (when gate met) for: Testicular cancer; Medically necessary (when gate met) for: Thymic cancer/Thymoma; Medically necessary (when gate met) for: Uveal melanoma; Medically necessary (when gate met) for: Vulvar cancer; Placement of fiducial markers is medically necessary IF the above IMRT criteria are met AND the radiation target is not clearly visible AND bony anatomy is not sufficient for adequate target alignment.; Inter-fraction image guidance systems are considered medically necessary (in conjunction with medically necessary IMRT as above).; Intra-fraction image guidance systems (e.g., Calypso 4D Localization System, RayPilot System) are considered medically necessary (in conjunction with medically necessary IMRT as above).. Applies to 5 codes: 77301, 77338, 77385, 77386, 77387. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Policy exclusions and limitations: Right breast cancer: Aetna considers IMRT experimental, investigational, or unproven, and not medically necessary for right breast cancer.; T1 and T2 glottic cancer: excluded from the medically necessary head and neck cancer indication (head and neck cancer is covered EXCLUDING T1 and T2 glottic cancer).; All other indications not listed as medically necessary: Aetna considers IMRT experimental, investigational, or unproven for all other indications (i.e., any indication not on the medically necessary list above).; IMRT is not medically necessary for any otherwise-covered indication when critical structures CAN be adequately protected with standard 3D conformal radiotherapy (i.e., when IMRT would NOT decrease the probability of grade 2 or grade 3 radiation toxicity vs. conventional 3D CRT in greater than 15% of irradiated similar cases). Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for Intensity Modulated Radiation Therapy (IMRT)?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source.

What does Aetna exclude for Intensity Modulated Radiation Therapy (IMRT)?

Policy exclusions and limitations: Right breast cancer: Aetna considers IMRT experimental, investigational, or unproven, and not medically necessary for right breast cancer.; T1 and T2 glottic cancer: excluded from the medically necessary head and neck cancer indication (head and neck cancer is covered EXCLUDING T1 and T2 glottic cancer).; All other indications not listed as medically necessary: Aetna considers IMRT experimental, investigational, or unproven for all other indications (i.e., any indication not on the medically necessary list above).; IMRT is not medically necessary for any otherwise-covered indication when critical structures CAN be adequately protected with standard 3D conformal radiotherapy (i.e., when IMRT would NOT decrease the probability of grade 2 or grade 3 radiation toxicity vs. conventional 3D CRT in greater than 15% of irradiated similar cases). Claims may be denied when the requested service falls under these.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT