Intensity-Modulated Radiation Therapy (IMRT) 

Medical Policy: 08.01.10 
Original Effective Date: February 2003 
Reviewed: July 2011 
Revised: July 2011 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Intensity-modulated radiation therapy (IMRT) is an advanced form of three-dimensional conformal radiation therapy capable of varying the intensity of radiation exposure in a portion of a treatment field depending on whether tumor or critical normal structures are in the beam pathway. Multiple radiation beamlets are calculated to target tumor tissue with high dose radiation by shaping or conforming the dose to the contour of the tumor thereby sparing surrounding normal structures. By dividing the radiation beam into multiple slices, the intensity of the beam in any given slice can be varied by computer-controlled multileaf collimation during the radiation exposure. Planning for IMRT utilizes computer programs that calculate the optimal arrangement of beam angle configurations and dosage intensities. IMRT is the standard of care for external beam radiotherapy in the treatment of many cancer types.

Intrafraction or “real-time” image guidance is intended to increase the accuracy of radiation therapy by tracking the exact position and motion of target organs during treatment. In some anatomic locations (i.e. lung, liver, and prostate tumors) intrafraction motion can be significant due to respiratory or cardiac motion or, in the case of the prostate, constant changes in bladder and bowel filling. This organ motion may present significant limitations for margin reduction around the clinical target volume and negatively impact safe dose escalation.

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Prior Approval: 

Not applicable

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Policy: 

IMRT may be considered medically necessary in instances where sparing the surrounding normal tissue is essential and the patient has at least one of the following conditions met:

• The target volume is in close proximity to critical structures that must be protected
• The volume of interest must be covered with narrow margins to adequately protect immediately adjacent structures
• An immediately adjacent area has been previously irradiated and abutting portals must be established with high precision
• The target volume is concave or convex, and critical normal tissues are within or around that convexity or concavity
• Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors with conventional treatment

Intrafraction localization may be considered medically necessary.

IMRT is not a replacement therapy for conventional and 3D conformal radiation therapy methods.

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• 77418 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session 
• 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 
• A4648 Tissue marker, implantable, any type, each
• A4650 Implantable radiation dosimeter, each
• C1879 Tissue marker (implantable)
• 0197T Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment   

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Selected References: 

• Intensity-Modulated Radiation Therapy for Breast Cancer: Technology Assessment Brief. Winifred S. Hays Inc., Hays Alert 2002 September;5(9):5-7.
• Zabel A, Thilmann C, Zuna I, Schlegel W, Wannenmacher M, Cevus J. Comparison of forward planned conformal radiation therapy and inverse planned intensity modulated radiation therapy for esthesioneuroblastoma. The British Journal of Radiology 2002;75:356-361.
• Nutting CM et al. Potential improvements in the therapeutic ratio of prostate cancer irradiation: dose escalation of pathologically identified tumor nodules using intensity modulated radiotherapy. The British Journal of Radiology 2002;75:151-161.
• Chan JL et al. Survival and failure patterns of high-grade gliomas after three-dimensional conformal radiotherapy. Journal of Clinical Oncology 2002;20(6):1635-1642.
• Consensus Development Conference NIH, Intensity-modulated radiation therapy collaborative working group. Intensity-modulated radiotherapy: Current status and issues of interest. International Journal of Radiation Oncology, Biology and Physics 2001;51(4):880-914.
• Chang EL, Shiu AS, Lii MF et al. Phase I clinical evaluation of near-simultaneous computed tomographic image-guided stereotactic body radiotherapy for spinal metastasis. Int J Radia Oncolo Biol Phys. 2004 Aug 1;59(5):1288-94.
• Heron DE, Gerszten K, Selvaraj RN et al. Conventional 3D conformal versus intensity-modulated radiotherapy for the adjuvant treatment of gynecologic malignancies: a comparative dosimetric study of dose-volume histograms small star, filled. Gynecol Oncol. 2003 Oct;91(1):39-45.
• Milano MT, Chmura SJ, Garofalo MC et al. Intensity-modulated radiotherapy in treatment of pancreatic and bile duct malignancies: toxicity and clinical outcomes.   Int J Radiat Oncol Biol Phys. 2004 Jun1;59(2(:445-53.
• De Neve W, Duthoy W. Intensity-modulated radiation therapy for head and neck cancer. Expert Rev Anticancer Ther. 2004 Jun;4(3):425-34.
• Bhatnagar AK, Brandner E, Sonnick D et al. 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 Nov-Dec; 10(6):381-5.
• Cho BC, Schwarz M, Mijnheer BJ et al. Simplified intensity modulated radiotherapy using pre-defined segments to reduce cardiac complications in left-sided breast cancer. Radiother Oncol. 2004 Mar; 70(3):231-41.
• Technology Evaluation Center (TEC). Special Report: Intensity-Modulated radiation therapy for Cancer of the Breast or Lung. Assessment Program 20(15); December 2005.
• Coles CE, Moody AM, Wilson CB et al. Reduction of radiotherapy-induced late complications in early breast cancer: the role of intensity-modulated radiation therapy and partial breast irradiation. Part I-Normal tissue complications. Clin Oncol (R Coll Radiol). 2005; 17(1):16-24.
• Coles CE, Moody AM, Wilson CB et al. Reduction of radiotherapy-induced late complications in early breast cancer: the role of intensity-modulated radiation therapy and partial breast irradiation. Part II-Radiotherapy strategies to reduce radiation-induced late effects. Clin Oncol (R Coll Radiol). 2005; 17(2):98-110.
• Chandra A, Guerrero TM, LIU HH et al. Feasibility of using intensity-modulated radiotherapy to improve lung sparing in treatment planning for distal esophageal cancer. Radiother Oncol. 2005 Dec; 77(3):247-53.
• Taylor A, Rocall AG, Reznek RH, Powell ME. Mapping pelvic lymph nodes: guidelines for delineation in intensity-modulated radiotherapy. Int J Radiat Oncol Biol Phys. 2005 Dec 1; 63(5):1604-12.
• Jani AB, Gratzle J, Correa D. Influence of intensity-modulated radiotherapy on acute genitourinary and gastrointestinal toxicity in the treatment of localized prostate cancer. Technol Cancer Res Treat. 2007;6(1):11-15.
• Pignol JP, Olivotto I, Rakovitch E et al. A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiation dermatitis. J Clin Oncol. 2008 May 1;26(13):2085-92.
• Fenwick JD, Riley SW, Scott AJ. Advances in intensity-modulated radiotherapy delivery. Cancer treat Res. 2008;139:193-214.
• McDonald MW, Godette KD, Butker EK et al. Long-term outcomes of IMRT for breast cancer: a single-institution cohort analysis. Int J Radiat Oncol Biol Phys. 2008 Nov 15; 72(4):1031-40. Epub 2008 Apr 25.
• Harsolia A, Kestin L, Grills I et al. Intensity-modulated radiotherapy results in significant decrease in clinical toxicities compared with conventional wedge-based breast radiotherapy. Int J Radiat Oncol Biol Phys. 2007; 68(5):1375-80.
• Sura S, Gupta V, Yorke E et al. Intensity-modulated radiation therapy (IMRT) for inoperable non-small cell lung cancer: the Memorial Sloan-Kettering Cancer Center (MSKCC) experience. Radiother Oncol 2008; 87(1):17-23.
• Veldeman L, Madani I, Hulstaert F et al. Evidence behind use of intensity-modulated radiotherapy: a systematic review of comparative clinical trials. Lancet Oncol 2008; 9:367-75.
• Jakob J, Wenz F, Dinter DJ et al. Preoperative intensity-modulated radiotherapy combined with temozolomide for locally advanced soft tissue sarcoma. Int. J Radiat Oncol Biol Phys. 2009 Nov 1; 75(3):810-16. Epub 2009 Mar 21.
• Videtic GM, Stephans K, Reddy C et al. Intensity-modulated radiotherapy-based stereotactic body radiotherapy for medically inoperable early-stage lung cancer: excellent local control. Int J Radiat Oncol Biol Phys. 2009 Sep 16. Epub 2009 Sep 16.
• Bhatnagar AK, Beriwal S, Heron DE et al. Initial outcomes analysis for large multicenter integrated cancer network implementation of intensity modulated radiation therapy for breast cancer. Breast J. 2009 Sep-Oct; 15(5):468-74. Epub 2009 Jul 13.
• Eisbruch A, Harris J, Garden AS et al. Multi-institutional trial of accelerated      hypofractionated intensity-modulated radiation therapy for early-stage oropharyngeal cancer. Int J Radia Oncol Biol Phys. 2009 Jun 17. Epub 2009 Jun 17.
• Tanyi JA, He T, Summers PA et al. Assessment of planning target volume margins for intensity-modulated radiotherapy of the prostate gland: role of daily inter-and intrafraction motion. Int J Radiat Oncol Biol Phys. 2010 Dec 1;78(5):1579-85. Epub 2010 May 14.
• Shah AP, Kupelian PA, Willoughby TR et al. An evaluation of intrafraction motion of the prostate in the prone and supine positions using using electromagnetic tracking. Radiother Oncol. 2011 Apr;99(1):37-43. Epub 2011 Mar 30
• Quigley MM, Mate TP, Sylvester JE. Prostate tumor alignment and continuous, real-time adaptive radiation therapy using electromagnetic fiducials: clinical and cost-utility analyses. Urol Oncol. 2009 Sep-Oct;27(5):473-82. Epub 2008 Jul 14.
• Kupelian P, Willoughby T, Mahadevan A et al. Multi-institutional clinical experience with the Calypso System in localization and continuous, real-time monitoring of the prostate gland during external radiotherapy. Int J Radiat Oncol Biol Phys. 2007 Mar 15;67(4):1088-98. Epub 2006 Dec 21.
• Nguyen PL, Gu X, Lipsitz SR et al. Cost implications of the rapid adoption of newer technologies for treating prostate cancer. J Clin Oncol 2011 Apr 20; 29(12):1517-24. Epub 2011 Mar 14.
• Smith BD, Pan IW, Shih Y-C T et al. Adoption of intensity-modulated radiation therapy for breast cancer in the United States. J Natl Cancer Inst 2011 May 18 103(10):798-809. Epub 2011 Apr 27.
• Kachnic LA, Powell SN. IMRT for breast cancer-balancing outcomes, patient selection, and resource utilization. J Natl Cancer Inst 2011 May 18 103(10):777-9. Epub 2011 Apr 27.
• Health technology forecast [database online]. Plymouth Meeting (PA): ECRI Institute; 2010 Jun 2. Intensity modulated radiation therapy (IMRT). Available: http://www.ecro.org.

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Policy History: 

Date                                        Reason                              Action

July 2011                                Annual review                   Revised

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.