Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Intensity Modulated Radiation Therapy (IMRT) is a technology for delivering highly conformal external beam radiation to solid tumors.  This therapy is considered medically necessary where critical structures cannot be adequately protected with standard 3-D conformal radiation therapy.

IMRT is considered medically necessary for treatment of the following cancers, when the use of external beam or 3D conformal radiation therapy is likely to damage surrounding critical structures:

1.     Radiosensitive tumors of the brain, head, neck, spine and Para-spinal regions (C00.0-C14.8, C30.0-C32.9, C41.0-C41.1, C69.00-C72.9, C73, C75.0-C75.3); or

2.     Pleural mesothelioma (C45.0) if done as a component of a curative treatment regimen; or

3.     Localized prostate cancer (C61) when the patient will be treated with dose escalation greater than 75 Gy; or

4.     Anal cancer; or

5.     Anaplastic thyroid cancer; or

6.     Esophageal cancer where dose exceeds 50 Gy; or

7.     Gallbladder cancer where dose exceeds 50 Gy; or

8.     Pancreatic cancer where dose exceeds 50 Gy; or

9.     Head and neck cancer; or

10.  Lymphomas involving the head and neck regions (C81.01, C81.11,  C81.21,  C81.31, C81.41,  C81.71,  C81.91,  C82.01,  C82.11,  C82.21,  C82.31,  C82.41,  C82.51, C82.61,  C82.81,  C82.91,  C83.01,  C83.11,  C83.31,  C83.51,  C83.71,  C83.81, C83.91, C84.01, C84.11, C84.41, C84.61,  C84.71,  C84.A1, C84.Z1,  C84.91, C85.11, C85.21, C85.81, C85.91)

11. Left breast cancer if the lesion is in proximity to cardiovascular structures; or

12. Lung cancer if the lesion is in close proximity to critical structures; or

13. Postoperative radiation to pelvis for endometrial cancer; or

14. Cervical cancer.

IMRT requires:

Documentation from Radiation Oncologist that conventional Radiation therapy will exceed the safe threshold for normal tissues surrounding the tumor. 

Codes Used in This Policy:

Use of IMRT for any other indications is considered experimental and investigational and is not covered.

Adams EJ, Nutting CM, Convery DJ, et al. (2001) Potential role of intensity modulated radiotherapy in the treatment of tumors of the maxillary sinus. Int J Radiat Oncol Biol Phys 2001; 51:579-88.

Arthur DW, Morris MM, Vicini FA. (2004) Breast cancer: new radiation treatment options. Oncology 2004; 18:1621-9.

Ashman JB, Zelefsky MJ, et al. (2005) whole pelvic radiotherapy for prostate cancer using 3D conformal and intensity modulated radiotherapy. Int J Radiat Oncol Biol 2005; May 20[Epub ahead print].

Bhatnagar AK, Brandner E, et al.(2004) Intensity-modulated radiation therapy (IMRT) reduces the dose to the contralateral breast when compared to conventional tangential fields for primary breast irradiation: initial report. Cancer J 2004; 10:381-5.

Bucci, MK, Bevan, A, Roach III, M. (2005) Advances in Radiation Therapy: Conventional to 3D, to IMRT, to 4D, and Beyond. CA Cancer J Clin 2005; 55(2):117-34.

Chao KS, Majhail N, Huang CJ, et al.(2001) Intensity modulated radiation therapy reduces late salivary toxicity without compromising tumor control in patients with oropharyngeal carcinoma: A comparison with conventional techniques. Radiother Oncol 2001; 61:275-80.

Cozzi L, Fogliata A, Lomax A, et al.(2001) A treatment planning comparison of 3D conformal therapy, intensity modulated photon therapy and proton therapy for treatment of advanced head and neck tumors. Radiother Oncol 2001; 61:287-97.

Eisbruch A, Kim HM, Terrell JE, et al.(2001) Xerostomia and its predictors following parotid-sparing irradiation of head-and-neck cancer. Int J Radiat Oncol Biol Phys 2001; 50:695-704.

Guerrero M, Li XA, et al. (2004) Simultaneous integrated boost for breast cancer using IMRT: a radiobiological and treatment planning study. Int J Radiat Oncol Biol Phys 2004; 59:1513-22.

Guerrero Urbano MT, Nutting CM. (2004) Clinical use of intensity-modulated radiotherapy: part 1. Br J Radiol 2004; 77:88-96.
Haffty BG, Buchholz TA, McCormick B. (2008) Should IMRT be the standard of care in the conservatively managed breast care patient. J Clin Oncol, 2008; 26: [epub 2/19/08].

Harris EER, Correa C, Hwang W, et al.(2006) Late Cardiac Mortality and Morbidity in Early-Stage Breast Cancer Patients After Breast-Conservation Treatment. J Clin Oncol 2006; 24.

Li JS, Freedman GM, et al. (2004) Clinical implementation of intensity-modulated tangential beam irradiation for breast cancer. Med Phys 2004; 31:1023-31.

Murshed H, Liu HH, et al. (2004) Dose and volume reduction for normal lung using intensity-modulated radiotherapy for advanced stage non-small-cell lung cancer. Int J Radiat Oncol Biol Phys 2004; 58:1258-67.

Nutting CM, Convery DJ, Cosgrove VP, et al.(2001) Improvements in target coverage and reduced spinal cord irradiation using intensity-modulated radiotherapy in patients with carcinoma of the thyroid gland. Radiother Oncol 2001; 60:173-80.

Nutting CM, Rowbottom CG, Cosgrove VP, et al. (2001) Optimization of radiotherapy for carcinoma of the parotid gland: A comparison of conventional, three dimensional conformal and intensity-modulated technique. Radiother Oncol 2001; 60:163-70.

Patel RR, Das RK. (2006) Image-guided breast brachytherapy: an alternative to whole-breast radiotherapy. Lancet Oncol 2006; 7:407-15.

Pignol JP, Olivotto I, et al. (2008) A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol, 2008; 26: [epub 2/19/08].

Recht A. (2005) Lessons of Studies of Breast-Conserving Therapy With and Without Whole-Breast Irradiation for Patient Selection for Partial-Breast Irradiation. Semin Radiat Oncol 2005; 15:123-132.

Schwartz GF, Veronesi U, Clough KB, et al. (2006) Consensus Conference on Breast Conservation. American College of Surgeons 2006; 203(2); 198-207.

Taghian AG, Kozak KR, Doppke KP, et al. (2006) Initial dosimetric experience using simple three-dimensional conformal external-beam accelerated partial-breast irradiation. Int J Radiat Oncol Biol Phys Mar 15 2006; 64(4):1092-9.

The National Cancer Institute Guidelines for the Use of Intensity-Modulated Radiation Therapy in Clinical Trials. National Cancer Institute Guidelines; 2005.

Vicini F, Winter K, Straube W, et al. (2005) A phase I/II trial to evaluate three-dimensional conformal radiation therapy confined to the region of the lumpectomy cavity for Stage I/II breast carcinoma: initial report of feasibility and reproducibility of Radiation Therapy Oncology Group (RTOG) Stu3 Int J Radiat Oncol Biol Phys 2005; 63(5):1531-7.

Weed DW, Edmundson GK, Vicini FA, et al. (2005) Accelerated partial breast irradiation: a dosimetric comparison of three different techniques. Brachytherapy 2005; 4(2):121-9.

Zelefsky MJ, Fuks Z, Hunt M, et al. (2001) High dose radiation delivered by intensity modulated conformal radiotherapy improves the outcomes of localized prostate cancer. J Urol 2001:166:876-881.

Addendum:

1.     Effective 03/01/2017:  Added Head and neck region lymphomas as covered diagnosis for IMRT.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.