Intensity Modulated Radiation Therapy (CPB 0590, reviewed 2025-12-02)

By December 2, 2025: Billing team must update system edits to require verification that IMRT claims meet eviCore Healthcare Radiation Therapy Clinical Guidelines criteria before submission. Providers must document that critical structures cannot be adequately protected with standard 3D conformal radiotherapy (defined as >15% reduction in grade 2 or 3 radiation toxicity compared to 3D conformal therapy). For fiducial marker placement (CPT 32553, 49327, 49411, 49412, HCPCS A4648, C1739, C9728), require documentation that the radiation target is not clearly visible and bony anatomy is insufficient for alignment. For image guidance codes (CPT 77387, HCPCS G6017), verify this guidance is being used for IMRT or conformal radiotherapy delivery. Update prior authorization templates and clinical review criteria to reference current eviCore guidelines (note: these guidelines are reviewed annually and may change without prior notice—monitor eviCore website for updates 90 days before implementation). Claims lacking proper medical necessity documentation will be denied. Radiation oncology providers should be notified of these requirements.