Image-Guided Radiation Therapy (IGRT)
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
IGRT is a method by which image guidance is applied to place the isocenter for the upcoming treatment appropriately. This technology typically is applied for an individual undergoing Intensity-Modulated Radiation Therapy (IMRT). However, in some cases in which the isocenter is the main concern, IGRT occasionally can be used with three-dimensional (3D) conformal radiation therapy (3DCRT). The American Society for Radiation Oncology (ASTRO) together with the American College of Radiology (ACR) have published practice parameters (Loo et al, 2014) and technical standards (Cheng et al, 2014) regarding IGRT. In addition, in their 2018 Radiation Oncology Coding Resource, ASTRO has addressed IGRT in detail.
Historical methodology of using port films to confirm patient set-up and block placement has not been replaced by IGRT. For example, the Coding Resource states “…guidance and tracking are not indicated…" when "…replacing ’port check’ imaging when target localization is not medically necessary." Outside of treatment procedures requiring only isocenter placement, port films and/or verification simulations are still the appropriate modalities. If the isocenter placement is the primary concern, i.e. for IMRT, then IGRT is typically the method utilized. This does, however, imply the target can be localized with the specific IGRT modality requested, i.e., stereoscopic imaging for target localization, computed tomography (CT) guidance for field placement or ultrasound (US) guidance for field placement (Weiss et al., 2011). In the event no target is localized, blocking and patient set-up is accomplished through typical alignment of bony structures using portal imaging; appropriate coding for port films would apply.
Effective 1/1/2015, IGRT techniques are covered under two different coding systems. CPT® code 77387 is for billing in the Hospital Outpatient Prospective Payment System (HOPPS) and for those non-Medicare health plans that accept this definition. It may be necessary to check with the individual health plan directly before billing this code for this purpose. Also, the new IMRT treatment delivery CPT® codes (77385 and 77386) include IGRT guidance and tracking, when performed. The technical component of IGRT (77387-TC) is packaged into the IMRT service with which it is performed and is not reported separately. In the Medicare Physician Fee Schedule (MPFS) setting, as well as the Healthcare Common Procedure Coding System (HCPCS) setting, the G-Code system has replaced CPT® codes. G6001 replaces CPT® code 76950, G6002 replaces CPT® code 77421, and G6017 replaces CPT® code 0197T. In contrast to the HOPPS reporting, IGRT is not bundled into IMRT for MPFS and HCPCS and is reported separately.
Respiratory motion management may be clinically appropriate for treating some cancers, including lung cancer and some cases of breast cancer (deep inspiration breath hold [DIBH]). Respiratory tracking by continuous localization systems or four-dimensional CT (4D-CT) are now included in CPT® code 77387. This code is for billing in the HOPPS and for those non-Medicare health plans that accept this definition. It may be necessary to check with the individual health plan directly before billing this code for this purpose. In the MPFS setting as well as the HCPCS setting, the G-Code G6017 has replaced CPT® code 0197T. In the hospital-outpatient setting, G6017 is considered image guidance and is packaged into the primary service payment. For all other purposes, this code is considered carrier-priced and may be accepted or refused by different health plans and Medicare contractors.
In IGRT-approved cases, only one method or technique of IGRT is allowed daily.
CPT® codes 77370 and 77470 should not be billed based on the use of IGRT.
(NOTE: This policy only applies to adult members. It does not apply to pediatric members.
For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. IGRT during IMRT
II. IGRT during 3DCRT
IGRT is considered medically necessary when IMRT has been approved and is being utilized.
III. IGRT during SRS/SBRT
IGRT in conjunction with 3DCRT is medically necessary in the following circumstances:
A. When the planning target volume (PTV) is in close proximity to a previously irradiated area
B. Treatment of the hepatobiliary tract
C. Treatment of head and neck cancer
D. Treatment of Hodgkin and Non-Hodgkin’s Lymphoma
E. Treatment of lung cancer
F. Treatment of prostate cancer
G. Treatment of esophageal cancer
H. Treatment of gastric cancer
I. Treatment of pancreatic cancer
J. Treatment of pelvic cancers (i.e. rectal cancer) when the individual is in the prone position on a belly board
K. During breast boost when using photons
L. During external beam-based accelerated partial breast irradiation (APBI)
M. During treatment of left breast cancer when a DIBH (deep inspiration breath hold) technique is being used
N. Treatment of breast cancer when the individual is in the prone position
O. During the boost to the bladder
P. Preoperative or postoperative treatment of sarcomas
IV. IGRT and brachytherapy
A. For Stereotactic Body Radiation Therapy (SBRT), the IGRT codes may not be billed separately because by American Medical Association (AMA) definition they are bundled and included in the daily treatment codes. In addition, the IGRT codes may not be billed separately with Stereotactic Radiosurgery (SRS) as stated in the ASTRO coding guide.
V. IGRT and superficial radiation therapy or electron beam therapy
In brachytherapy cases, imaging is medically necessary to verify source position in all but the simplest of cases. The images may also be used to perform dosimetry calculations. Use of applicable simulation and/or field verification codes is appropriate, such as CPT® Code 77280.
The use of IGRT with either superficial radiation therapy or electron beam therapy is not considered medically necessary.
VI. The use of IGRT is based on medical necessity for the specific diagnoses. A requirement from the vendor does not support the medical necessity of IGRT.
There is no National Coverage Determination (NCD) for Image-Guided Radiation Therapy (IGRT). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for IGRT. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy for image-guided therapy (IGRT).
Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has issued a determination for Intensity-Modulated Radiation Therapy (IMRT). For additional information and eligibility, refer to Local Coverage Determination (LCD): Intensity Modulated Radiation Therapy (IMRT) (L36711) and Local Coverage Article:
Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56725). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36711&ver=18&name=314*1&UpdatePeriod=749&bc=AAAAEAAAAAAAAA%3d%3d&.
There is no National Coverage Determination (NCD) or Local Coverage Determination by Novitas Solutions, Inc, the Local Medicare Carrier for Jurisdiction JL for electron beam therapy, stereotactic radiosurgery (SRS), Stereotactic Body Radiation Therapy (SBR), 3DCRT, or Brachytherapy.
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP: For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
Image-Guided Radiation Therapy (IGRT)
IGRT (Image-Guided Radiation Therapy)
1. ASTRO coding FAQS and tips.
2. ASTRO Radiation Oncology Coding Resource. Available on-line for purchase.
3. Chadha M, Young A, Geraghty C, et al. Image guidance using 3D-ultrasound (3D-US) for daily positioning of lumpectomy cavity for boost irradiation. Radiat Oncol. 2011 May 9; 6:45.
4. Chen Y-J, Suh S, Nelson RA, et al. Setup variations in radiotherapy of anal cancer: Advantages of target volume reduction using image-guided radiation treatment (IGRT). Int J Radiat Oncol Biol Phys. 2012 Sep 1; 84(1):289-295.
5. Eldredge HB, Studenski M, Keith S, et al. IGRT after prostatectomy: Evaluation of corrective shifts and toxicity using online conebeam CT vs. weekly port films for target localization. Int J Radiat Oncol Biol Phys. 2010 Nov 1; 78(3 Suppl):S380.
6. Graff P, Hu W, Yom SS, et al. Does IGRT ensure target dose coverage of head and neck IMRT patients? Radiother Oncol. 2012 Jul; 104(1):83-90.
7. Hyer DE, Serago CF, Kim S, et al. An organ and effective dose study of XVI and OBI cone-beam CT systems. J Appl Clin Med Phys. 2010 Apr 17; 11(2):3183.
8. Jaffray D, Langen KM, Mageras G, et al. Safety considerations for IGRT: Executive summary. Practical Radiation Oncology. 2013 Jul-Sep; 3(3):167-170.
9. Kan MW, Leung LHT, Wong W, et al. Radiation dose from cone beam computed tomography for image-guided radiation therapy. Int J Radiat Oncol Biol Phys. 2008 Jan 1; 70(1):272-279.
10. Leonard CE, Tallhamer M, Johnson T, et al. Clinical experience with image-guided radiotherapy in an accelerated partial breast intensity-modulated radiotherapy protocol. Int J Radiat Oncol Biol Phys. 2010 Feb 1; 76(2):528-534.
11. Lisbona A, Averbeck D, Supiot S, et al. IMRT combined to IGRT: increase of the irradiated volume consequences? Cancer Radiother. 2010 Oct; 14(6-7):563-570.
12. Loo Jr. BW, Bajaj GK, Galvin JM, et al. ACR-ASTRO practice parameter for image-guided radiation therapy (IGRT). Revised 2014 (CSC/BOC), Effective June 25, 2014.
13. Mohammed N, Kestin L, Grills I, et al. Comparison of IGRT registration strategies for optimal coverage of primary lung tumors and involved nodes based on multiple four-dimensional CT scans obtained throughout the radiotherapy course. Int J Radiat Oncol Biol Phys. 2012 Mar 15; 82(4):1541-1548.
14. Ottosson W, Baker M, Hedman M, et al. Evaluation of setup accuracy for NSCLC patients; studying the impact of different types of cone-beam CT matches based on whole thorax, columna vertebralis, and GTV. Acta Oncol. 2010 Oct; 49(7):1184-1191.
15. Park CK, Pritz J, Zhang GG, et al. Validating fiducial markers for image-guided radiation therapy for accelerated partial breast irradiation in early-stage breast cancer. Int J Radiat Oncol Biol Phys. 2012 Mar 1; 82(3):e425-e431.
16. Sangalli G, Passoni P, Cattaneo GM, et al. Planning design of locally advanced pancreatic carcinoma using 4DCT and IMRT/IGRT technologies. Acta Oncol. 2011 Jan; 50(1):72-80.
17. Shah A, Aird E, Shekhdar J. Contribution to normal tissue dose from concomitant radiation for two common kV-CBCT systems and one MVCT system used in radiotherapy. Radiother Oncol. 2012 Oct; 105(1):139-144.
18. Wang D, Zhang Q, Eisenberg BL, et al. Significant reduction of late toxicities in patients with extremity sarcoma treated with image-guided radiation therapy to a reduced target volume: Results of Radiation Therapy Oncology Group RTOG-0630 trial. J Clin Oncol. 2015 Feb 9. Published online before print.
19. Weiss, K. IGRT, are you applying it correctly? Revenue Cycle. Radiation Oncology News. January 2011.
20. Zelefsky MJ, Kollmeier M, Cox B, et al. Improved clinical outcomes with high-dose image guided radiotherapy compared with non-IGRT for the treatment of clinically localized prostate cancer. Int J Radiat Oncol Biol Phys. 2012 Sep 1; 84(1):125-129.
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
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