Intensity-Modulated Radiotherapy Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 10|01|2025 POLICY LAST REVIEWED: 07|16|2025 OVERVIEW Intensity-modulated radiotherapy (IMRT) has been proposed as a method of RT that allows adequate RT to the tumor while minimizing the radiation dose to surrounding normal tissues and critical structures.
MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Not applicable POLICY STATEMENT Effective 10/1/2025, Intensity-modulated radiotherapy (IMRT) is covered for both Medicare Advantage Plans and Commercial Products. COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable radiology benefits/coverage. BACKGROUND Not applicable CODING Medicare Advantage Plans and Commercial Products The following CPT code(s) are covered for Medicare Advantage Plans and Commercial Products and prior authorization is not required: 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 (Institutional providers) (Code Deleted Effective 12/31/2025) 77386 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex (Institutional providers) (Code Deleted Effective 12/31/2025) G6015 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session (Professional providers) (Code Deleted Effective 12/31/2025) G6016 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 (Professional providers) (Code Deleted Effective 12/31/2025) The following code(s) are not separately reimbursed for Institutional Providers: A4648 Tissue marker, implantable, any type, each (Note: This code is not separately reimbursed for institutional providers.) Note: To ensure correct pricing of HCPC code A4648 for the Calypso 4D localization system, the procedure/clinical notes and the invoice must be submitted. Medical Coverage Policy | Intensity-Modulated Radiotherapy

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

RELATED POLICIES Non-Reimbursable Health Service Codes

PUBLISHED Provider Update, September 2025 Provider Update, August/December 2024 Provider Update, June 2023

REFERENCES Not applicable i

This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS