SUPERCEDED LCD: Centers for Medicare & Medicaid Services

Superceded Stamp
Please note: This version is not currently in effect.

Please note: If you are printing this document and it is truncated on the right margin, please try printing landscape.

Contractor Information

Contractor Name ^{back to top}

NHIC, Corp.
Contractor Number ^{back to top}
31142
Contractor Type ^{back to top}
Carrier

LCD Information

LCD ID Number ^{back to top}

L3244

LCD Title ^{back to top}
INTENSITY MODULATED RADIATION THERAPY (IMRT)

Contractor's Determination Number ^{back to top}
01-02-02

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
. Title XVIII of the Social Security Act, Section 1862 (a)(1) (A). This section allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis and treatment of an illness or injury. . Title XVIII of the Social Security Act, Section 1862 (a) (7). This section excludes routine physical examinations. . Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim. . CMS Manual System,Pub 100-4, Medicare Claims Processing Manual, Chapter 12, Section 70 . CMS Manual System,Pub 100-4, Medicare Claims Processing Manual, Chapter 13, Section 20,90 . CMS Manual System,Pub 100-20, One-Time Notification, Transmittal 32, CR 3007, December 19, 2003

Primary Geographic Jurisdiction ^{back to top}
Massachusetts Maine New Hampshire Vermont

Oversight Region ^{back to top}
Region I

Original Determination Effective Date ^{back to top}
For services performed on or after 10/15/2002

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 01/01/2005

Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Intensity Modulated Radiation Therapy (IMRT) is a new technology, a computer-based method of planning for, and delivery of, narrow, patient specific, spatially and/or temporally modulated beams of radiation to solid tumors within a patient. IMRT planning and delivery uses a new approach for obtaining the highly conformal dose distributions needed to irradiate complex targets positioned near or invaginated by sensitive normal tissues, thus, improving the therapeutic ratios. IMRT delivers a more precise radiation dose to the tumor while sparing the surrounding normal tissues by using non-uniform radiation beam intensities that are determined by various computer-based optimization techniques. The computer based optimization process is referred to as ‘inverse planning’. Inverse planning develops a dose distribution based on the input of specific dose constraints for the planned treatment volume (PTV) and nearby clinical structures, and is the beginning of the IMRT treatment planning process. The gross tumor volume (GTV), the PTV, and surrounding normal tissues must be identified by a contouring procedure, and the optimization must sample the dose with a grid- spacing of 1.0 centimeter or less. IMRT uses non-uniform and customized fluence distributions in treatment delivery. Delivery of IMRT may require the use of a multi-leaf collimator (MLC) with leaves that project to a nominal 1cm or less at the treatment unit isocenter. The MLC may be in a dynamic (DMLC) or segmented mode (SMLC) (typical segments per gantry position or ‘steps’ required to meet IMRT delivery is 5) to create the 3-dimensional, intensity-modulated dose distribution. The exact delivery method is not restricted as long as the particular technique chosen has the ability to model the highly modulated intensity patterns that result from the planning process described above. However, the use of a MLC to produce simple one-dimensional ramp intensity distributions is excluded because the inverse planning process is not expected to produce these intensity patterns. IMRT delivery imposes a more stringent requirement than conventional radiation therapy in terms of accounting for patient position and organ motion. Methods that account for organ motion include but are not limited to: 1) use of published studies on organ movement when developing the PTV, 2) image guided adaptive radiotherapy (e.g., ultrasound guided or portal image guided setup with implanted fiducial markers), and 3) respiratory gating of diaphragm movement for thoracic and upper abdominal sites. INDICATIONS OF COVERAGE: - IMRT is considered reasonable and necessary for the patients who have primary brain tumors, brain metastasis, prostate cancer, lung cancer, pancreas cancer, and other upper abdominal sites, spinal cord tumors, head and neck cancer, adrenal tumors, pituitary tumors, and one of the following criteria is met: · Where sparing the surrounding normal tissue is essential · Only IMRT techniques would decrease the probability of grade 2 or grade 3 radiation toxicity as compared to conventional radiation in greater than 15 percent of irradiated similar cases · Important dose limiting structures adjacent to, but outside the PTV are sufficiently close and require IMRT to assure for safety and morbidity reduction · An immediately adjacent volume has been irradiated and abutting portals must be established with high precision · Gross Tumor Volume (GTV) margins are in close proximity to critical structures that must be protected to avoid unacceptable morbidity. Note: The decision process for using IMRT requires an understanding of accepted practices that take into account the risks and benefits of such therapy compared to conventional treatment techniques. While IMRT technology may empirically offer advantages over conventional or 3-Dimensional conformal radiation, a comprehensive understanding of all consequences is required before applying this technology. LIMITATIONS OF COVERAGE: - IMRT is not considered reasonable and necessary when the type of cancer and at least one of the criteria listed in the indications of coverage section of this policy is not present, or - Where sparing surrounding normal tissue is not essential.

Coding Information

Bill Type Codes: ^{back to top}

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes: ^{back to top}

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes ^{back to top}

77301	INTENSITY MODULATED RADIOTHERAPY PLAN, INCLUDING DOSE-VOLUME HISTOGRAMS FOR TARGET AND CRITICAL STRUCTURE PARTIAL TOLERANCE SPECIFICATIONS
77418	INTENSITY MODULATED TREATMENT DELIVERY, SINGLE OR MULTIPLE FIELDS/ARCS, VIA NARROW SPATIALLY AND TEMPORALLY MODULATED BEAMS, BINARY, DYNAMIC MLC, PER TREATMENT SESSION
0073T	COMPENSATOR-BASED BEAM MODULATION TREATMENT DELIVERY OF INVERSE PLANNED TREATMENT USING THREE OR MORE HIGH RESOLUTION (MILLED OR CAST) COMPENSATOR CONVERGENT BEAM MODULATED FIELDS, PER TREATMENT SESSION

ICD-9 Codes that Support Medical Necessity ^{back to top}

142.0	MALIGNANT NEOPLASM OF PAROTID GLAND
142.1	MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND
142.2	MALIGNANT NEOPLASM OF SUBLINGUAL GLAND
142.8	MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS
142.9	MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED
144.0	MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH
144.1	MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH
144.8	MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH
144.9	MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED
145.0	MALIGNANT NEOPLASM OF CHEEK MUCOSA
145.1	MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH
145.2	MALIGNANT NEOPLASM OF HARD PALATE
145.3	MALIGNANT NEOPLASM OF SOFT PALATE
145.4	MALIGNANT NEOPLASM OF UVULA
145.5	MALIGNANT NEOPLASM OF PALATE UNSPECIFIED
145.6	MALIGNANT NEOPLASM OF RETROMOLAR AREA
145.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH
145.9	MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED
146.0	MALIGNANT NEOPLASM OF TONSIL
146.1	MALIGNANT NEOPLASM OF TONSILLAR FOSSA
146.2	MALIGNANT NEOPLASM OF TONSILLAR PILLARS (ANTERIOR) (POSTERIOR)
146.3	MALIGNANT NEOPLASM OF VALLECULA EPIGLOTTICA
146.4	MALIGNANT NEOPLASM OF ANTERIOR ASPECT OF EPIGLOTTIS
146.5	MALIGNANT NEOPLASM OF JUNCTIONAL REGION OF OROPHARYNX
146.6	MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNX
146.7	MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX
146.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF OROPHARYNX
146.9	MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE
147.0	MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX
147.1	MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX
147.2	MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX
147.3	MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX
147.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX
147.9	MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE
148.0	MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX
148.1	MALIGNANT NEOPLASM OF PYRIFORM SINUS
148.2	MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD HYPOPHARYNGEAL ASPECT
148.3	MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL
148.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX
148.9	MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE
149.0	MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED
149.1	MALIGNANT NEOPLASM OF WALDEYER'S RING
149.8	MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY
149.9	MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY
150.0	MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS
150.1	MALIGNANT NEOPLASM OF THORACIC ESOPHAGUS
150.2	MALIGNANT NEOPLASM OF ABDOMINAL ESOPHAGUS
150.3	MALIGNANT NEOPLASM OF UPPER THIRD OF ESOPHAGUS
150.4	MALIGNANT NEOPLASM OF MIDDLE THIRD OF ESOPHAGUS
150.5	MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS
150.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS
150.9	MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE
153.0	MALIGNANT NEOPLASM OF HEPATIC FLEXURE
153.1	MALIGNANT NEOPLASM OF TRANSVERSE COLON
153.2	MALIGNANT NEOPLASM OF DESCENDING COLON
153.3	MALIGNANT NEOPLASM OF SIGMOID COLON
153.4	MALIGNANT NEOPLASM OF CECUM
153.5	MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS
153.6	MALIGNANT NEOPLASM OF ASCENDING COLON
153.7	MALIGNANT NEOPLASM OF SPLENIC FLEXURE
153.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE
153.9	MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
154.0	MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION
154.1	MALIGNANT NEOPLASM OF RECTUM
154.2	MALIGNANT NEOPLASM OF ANAL CANAL
154.3	MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE
154.8	MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS
155.0	MALIGNANT NEOPLASM OF LIVER PRIMARY
155.1	MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS
155.2	MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY
156.0	MALIGNANT NEOPLASM OF GALLBLADDER
156.1	MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS
156.2	MALIGNANT NEOPLASM OF AMPULLA OF VATER
156.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF GALLBLADDER AND EXTRAHEPATIC BILE DUCTS
156.9	MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE
157.0	MALIGNANT NEOPLASM OF HEAD OF PANCREAS
157.1	MALIGNANT NEOPLASM OF BODY OF PANCREAS
157.2	MALIGNANT NEOPLASM OF TAIL OF PANCREAS
157.3	MALIGNANT NEOPLASM OF PANCREATIC DUCT
157.4	MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS
157.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS
157.9	MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED
158.0	MALIGNANT NEOPLASM OF RETROPERITONEUM
158.8	MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM
158.9	MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED
160.0	MALIGNANT NEOPLASM OF NASAL CAVITIES
160.1	MALIGNANT NEOPLASM OF AUDITORY TUBE MIDDLE EAR AND MASTOID AIR CELLS
160.2	MALIGNANT NEOPLASM OF MAXILLARY SINUS
160.3	MALIGNANT NEOPLASM OF ETHMOIDAL SINUS
160.4	MALIGNANT NEOPLASM OF FRONTAL SINUS
160.5	MALIGNANT NEOPLASM OF SPHENOIDAL SINUS
160.8	MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES
160.9	MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED
162.0	MALIGNANT NEOPLASM OF TRACHEA
162.2	MALIGNANT NEOPLASM OF MAIN BRONCHUS
162.3	MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG
162.4	MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG
162.5	MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG
162.8	MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG
162.9	MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED
163.0	MALIGNANT NEOPLASM OF PARIETAL PLEURA
163.1	MALIGNANT NEOPLASM OF VISCERAL PLEURA
163.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PLEURA
163.9	MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED
164.0	MALIGNANT NEOPLASM OF THYMUS
164.1	MALIGNANT NEOPLASM OF HEART
164.2	MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM
164.3	MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM
164.8	MALIGNANT NEOPLASM OF OTHER PARTS OF MEDIASTINUM
164.9	MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED
171.0	MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK
171.2	MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER
171.3	MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP
171.4	MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF THORAX
171.5	MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF ABDOMEN
171.6	MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF PELVIS
171.7	MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF TRUNK UNSPECIFIED
171.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CONNECTIVE AND OTHER SOFT TISSUE
171.9	MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED
174.0	MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST
174.1	MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST
174.2	MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST
174.3	MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST
174.4	MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST
174.5	MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST
174.6	MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST
174.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST
175.0	MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST
175.9	MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST
185	MALIGNANT NEOPLASM OF PROSTATE
190.0	MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID
190.1	MALIGNANT NEOPLASM OF ORBIT
190.2	MALIGNANT NEOPLASM OF LACRIMAL GLAND
190.3	MALIGNANT NEOPLASM OF CONJUNCTIVA
190.4	MALIGNANT NEOPLASM OF CORNEA
190.5	MALIGNANT NEOPLASM OF RETINA
190.6	MALIGNANT NEOPLASM OF CHOROID
190.7	MALIGNANT NEOPLASM OF LACRIMAL DUCT
190.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE
190.9	MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED
191.0	MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES
191.1	MALIGNANT NEOPLASM OF FRONTAL LOBE
191.2	MALIGNANT NEOPLASM OF TEMPORAL LOBE
191.3	MALIGNANT NEOPLASM OF PARIETAL LOBE
191.4	MALIGNANT NEOPLASM OF OCCIPITAL LOBE
191.5	MALIGNANT NEOPLASM OF VENTRICLES
191.6	MALIGNANT NEOPLASM OF CEREBELLUM NOS
191.7	MALIGNANT NEOPLASM OF BRAIN STEM
191.8	MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN
191.9	MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE
192.0	MALIGNANT NEOPLASM OF CRANIAL NERVES
192.1	MALIGNANT NEOPLASM OF CEREBRAL MENINGES
192.2	MALIGNANT NEOPLASM OF SPINAL CORD
192.3	MALIGNANT NEOPLASM OF SPINAL MENINGES
192.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM
192.9	MALIGNANT NEOPLASM OF NERVOUS SYSTEM PART UNSPECIFIED
193	MALIGNANT NEOPLASM OF THYROID GLAND
194.0	MALIGNANT NEOPLASM OF ADRENAL GLAND
194.1	MALIGNANT NEOPLASM OF PARATHYROID GLAND
195.0	MALIGNANT NEOPLASM OF HEAD FACE AND NECK
195.1	MALIGNANT NEOPLASM OF THORAX
195.2	MALIGNANT NEOPLASM OF ABDOMEN
195.3	MALIGNANT NEOPLASM OF PELVIS
195.4	MALIGNANT NEOPLASM OF UPPER LIMB
195.5	MALIGNANT NEOPLASM OF LOWER LIMB
195.8	MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES
198.3	SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD
225.1	BENIGN NEOPLASM OF CRANIAL NERVES
225.2	BENIGN NEOPLASM OF CEREBRAL MENINGES
227.3	BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT
227.4	BENIGN NEOPLASM OF PINEAL GLAND
227.6	BENIGN NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA
747.81	CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM

Diagnoses that Support Medical Necessity ^{back to top}

Codes that indicate primary tumors or metastases as listed in the indications section and the ICD-9-CM codes that support medical necessity section of this policy.

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

ICD-9-CM Codes not listed under the “ICD-9 Codes That Support Medical Necessity” section of this policy are not covered.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

Conditions not listed in the indications of coverage section or the ICD-9-CM codes that support medical necessity section of this policy.

General Information

Documentation Requirements ^{back to top}

Documentation should clearly provide evidence of indications, rationale and medical necessity for rendering this procedure. Documentation should also support the fact that the procedure meets Medicare's statutory and benefit category requirements. Finally, such documentation should be legible, maintained in the patient's medical record, and made available to Medicare Contractor upon request.

The following documentation must be in the medical record:

- A prescription that clearly defines the goals and requirements of the treatment plan, including the specific dose constraints for the target(s) and nearby critical structures.

- A statement by the treating physician documenting the special need for performing IMRT on the patient in question, rather than performing conventional or 3-dimensional treatment planning and delivery.

- Approved IMRT inverse plan that meets prescribed dose constraints for the planning target volume (PTV) and surrounding normal tissue using either dynamic multi-leaf collimator (DMLC) or Segmented multi-leaf collimator (SMLC) (typical number of steps (segments) per gantry angle required to meet IMRT delivery is 5), or inverse planned IMRT solid compensator to achieve intensity modulated radiation delivery.

- The target verification methodology must include the following:

· Documentation of the clinical treatment volume (CTV) and the planning target volume (PTV).

· Documentation of immobilization and patient positioning.

- Evidence that monitor units (MU’s) obtained from the IMRT treatment plan were checked by an independent method before the patient’s first treatment, and that agreement met documented department standards.

- Documentation that fluence distributions were re-computed in a phantom and that this distribution was shown to be in good agreement with an independent dosimetric measurement.

- Documentation of measures taken into account for respiratory organ motion if necessary. Voluntary breath holding is not considered appropriate and the solution for movement can best be accomplished with gating technology.

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

Sources of Information and Basis for Decision ^{back to top}

· ACR/ASTRO Radiation Oncology Users Guide (2001)

· American College of Radiology (ACR)

· American Society for Therapeutic Radiology and oncology (ASTRO)

· CANCER, Principles & Practice of Oncology; by DeVita, Hellman, Rosenberg, Fifth Edition, Volume 2 Chapter 66, pp3090-3106; published by Pippincott-Raven

· Current Procedural Terminology; American Medical Association, 2002

· Fraass BA; Kessler ML; McShan DL; Marsh LH; Watson BA; Dusseau WJ; Eisbruch A; Sandler HM; Lichter AS: Optimization and clinical use of multisegment intensity-modulated radiation therapy for high-dose conformal therapy. Seminars Radiation Oncology 1999 Jan;9(1):60-7

· HCPCS 2001 National Level II Codes

· Intensity-Modulated Radiotherapy Collaborative Working Group. Intensity-Modulated Radiotherapy: Current Status and Issues of Interest. Int J Radiat Oncol Biol Phys 2001; 54(4): 880-914

· Kuppersmith RB; GrecoSC; Teh BS et al: Intensity modulated radiotherapy: first results with this new technology on neoplasms of the head and neck. Ear Nose Throat J 1999 April;78(4):238-248

· Nutting CM; Convery DJ; Cosgrove VP et al: Reduction of small and large bowel irradiation using an optimized intensity modulated pelvic radiotherapy technique in-patients with prostate cancer. Int J Radiat Oncol Biol Phys 2000; 48(3): 649-56

· Pirzkall A, Carol M, Lohr F, et al. Comparison of Intensity Modulated Radiotherapy with Conventional Conformal Radiotherapy for Complex-Shaped Tumors. Int J Radiat Oncol Biol Phys 2000; 48(5): 1371-1380

· Shu HG, Lee T, Vigneault E, et al. Toxicity Following High-Dose 3-Dimensional and Intensity-Modulated radiation Therapy for Clinically Localized Prostate Cancer. Urology 2001; 57(1) 102-107

· Teh BS; Woo SY; Butler EB: Intensity modulated radiation therapy (IMRT): a new promising technology in radiation oncology. Oncologist 1999;4(6):433-42

· Textbook of Radiation Oncology, by Leibel, Phillips, 1st Edition, Chapter 8 pp138-149, published by Saunders

· Xia P, Fu K, Wong G, et al. Comparison of Treatment Plans Involving Intensity Modulated radiotherapy for Nasopharyngeal Carcinoma. Int J Radiat Oncol Biol Phys 2000; 48(2): 329-337

· Zelefsky MJ; Fuks Z; et al:Clinical experiences with intensity modulated radiation therapy (IMRT) in prostate cancer. Radiother Oncol 2000 Jun;55(3)241-249

· Other Contractors’ policies

· Contractor Advisory Committee Radiation Oncology/Cardiology physician workgroup

Advisory Committee Meeting Notes ^{back to top}

Advisory Committee Meeting Date: 05/13/02

Radiation Oncology Members of the Carrier Advisory Committee

Start Date of Comment Period ^{back to top}

05/13/2002

End Date of Comment Period ^{back to top}

06/26/2002

Start Date of Notice Period ^{back to top}

09/01/2002

Revision History Number ^{back to top}

Revision History Explanation ^{back to top}

R5
12/09/2004
Added CPT code 0073T to reflect compensator-based modulation

R4
09/15/2004
Added language in description and documentation sections to reflect the use of solid compensators. Added reference in National Coverage Policy section that indicates that solid compensator use is allowed under the hospital outpatient prospective payment system.

R3
02/02/2004
National Coverage Policy crosswalked to CMS Manual System (Internet Only Manual).

R2
01/23/2004
This LCD was converted from an LMRP on 01/23/2004
The LMRP description was added to the Indications and Limitations Section of the LCD

R1
01/07/2004
Technical correction: Deleted invalid diagnosis code 174 and note as of 1/01/2004 added 174.0-174.9

11/07/2004 - The description for CPT/HCPCS code 77418 was changed in group 1

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

02/13/2008

Medicare Coverage Database

LCD for INTENSITY MODULATED RADIATION THERAPY (IMRT) (L3244)