Point32 Intensity-Modulated Radiation Therapy (IMRT) Form
This procedure is not covered
Intensity-modulated radiation therapy (IMRT)
IMRT is an advanced form of three-dimensional conformal radiation therapy (3D- CRT). IMRT changes the intensity of radiation in different parts of a single radiation, allowing multiple treated areas to receive different doses. Conformal radiation therapy uses a three-dimensional image, typically CT, MRI or PET, to create a planning target volume and calculate dose distribution to the targeted area.
The goal of IMRT is to deliver high radiation dose and conform the radiation dose to the target while avoiding and/or reducing radiation exposure to healthy tissue, limiting the side effects of treatment. IMRT is a treatment option when tumor targets are positioned near sensitive normal tissues and/or critical structures.
Clinical Guideline Coverage Criteria
- The Plan considers intensity-modulated radiation therapy as medically necessary for definitive treatment of the following neoplasms when sparing of surrounding normal tissue and/or critical structure(s) (e.g. heart, lung, esophagus, optic nerve) is of proven clinical benefit and cannot be achieved by 3-D conformal radiation therapy:
- Anal
- Breast
- Central nervous system (CNS) tumors (primary, metastatic or benign) including the brain, brainstem and spinal cord
- Esophageal
- Gynecological malignancies including uterine, cervical, vulvar
- Head and neck cancers including nasopharyngeal, oropharyngeal, sinonasal
- Hepatocellular carcinoma (HCC)
- Mediastinal including thymoma, lymphoma, thymic carcinoma, tracheal
- Non-small cell lung cancer
- Pancreatic
- Prostate
- Small bowel adenocarcinoma
- Thyroid
- Re-irradiation using IMRT is considered medically necessary to limit dose and minimize toxicity of previously irradiated tissue and/or critical structures.
Limitations
The Plan considers simultaneous use of proton beam therapy and intensity-modulated radiation therapy (IMRT) to be noncovered, investigational for any diagnosis