Point32 Commercial Clinical Policy

Point32 Intensity-Modulated Radiation Therapy (IMRT) Form


Intensity-Modulated Radiation Therapy (IMRT)

Notes: Coverage for IMRT is subject to the Plan's determination of medical necessity and the presence of clinical benefit when sparing surrounding normal tissue and/or critical structures.

Indications

(515437) Is the IMRT procedure intended for definitive treatment of a neoplasm? 
(515438) Is the objective of IMRT to spare surrounding normal tissue and/or critical structures that cannot be achieved by 3-D conformal radiation therapy? 
(515439) Is IMRT being used for the treatment of any of the following neoplasms: Anal, Breast, CNS tumors (including primary, metastatic or benign tumors of 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, or Thyroid? 
(515440) Is the IMRT procedure being considered for re-irradiation to limit dose and minimize toxicity of previously irradiated tissue and/or critical structures? 

Contraindications

(515441) Is the patient receiving simultaneous use of proton beam therapy and IMRT for any diagnosis? 
Effective Date

08/01/2023

Last Reviewed

06/21/2023

Original Document

  Reference



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

  1. 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
  2. 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

Codes