Intensity Modulated Radiation Therapy (IMRT)

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Intensity Modulated Radiation Therapy (IMRT)

The Cyberknife Robotic Radiosurgery System obtained FDA clearance in September 2007 through the510(k) process (K072504) for any location in the body when radiation therapy is indicated. This systemwas considered equivalent to existing devices.Medical Criteria:Not applicable.Policy:IMRT that utilizes multi-leaf collimator (MLC), tomotherapy delivery methods and compensator-basedbeam modulation are covered. Intrafraction tracking is covered, including the use of transponders asfiducials.Coverage:Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage,Subscriber Agreement, or Benefit Booklet for radiology benefit/coverage.Coding:Intensity-modulated radiation therapy77301774180073TFiducial and Intra-fraction Tracking0197T325534941155876A4648 Tissue marker, implantable, any type, each (Note: This code is not separately reimbursed forinstitutional providers.)Note: To ensure correct pricing of A4648, the procedure/clinical notes and the invoice must besubmitted.A4650Also known as:Calypso® 4D Localization System4-D imagingRelated to:Not applicablePublished:Provider Update, January 2010Provider Update, September 2011Provider Update, April 2012References:Center for Medicare & Medicaid Services. MLN Matters. Published August 6, 2010 with an effective dateof November 6, 2010. Payment for Implantable Tissue Markers (Healthcare Common Procedure CodingSystem (HCPCS) Code A4648) and Implantable Radiation Dosimeters (HCPCS Code A4650). Accessedon 4/12/11: http://www.cms.gov/MLNMattersArticles/Downloads/MM6968.pdf.


Chaiken LM, Steinberg ML . Targeting For Cure: Intensity Modulated Radiation Therapy Current Statusand Future Directions in the Treatment of Prostate Cancer. Reprinted from PCRI Insights August2004;7(3).2 Dawson LA, Jaffray DA. Advances in image-guided radiation therapy. Journal of Clinical Oncology; 2007;25(8):938-46.Kindblom J, Ekelund-Olvenmark AM, Syren H et al. High precision transponder localization using a novelelectromagnetic positioning system in patients with localized prostate cancer. Radiotherapy Oncology;2009; 90(3):307-11.1 Wong JR, Gao Z, Merrick S , Wilson P, Uematsu M, Woo K, AND Cheng CW. Potential for highertreatment failure in obese patients: correlation of elevated body mass index and increased daily prostatedeviations from the radiation beam isocenters in an analysis of 1,465 computed tomographic images.International Journal of Radiation Oncology * Biology* Physics*; 2009; 75(1):49-55.This medical policy is made available to you for informational purposes only. It is not a guaranteeof payment or a substitute for your medical judgment in the treatment of your patients. Benefitsand eligibility are determined by the member's subscriber agreement or member certificate and/orthe employer agreement, and those documents will supersede the provisions of this medicalpolicy. For information on member-specific benefits, call the provider call center. If you provideservices to a member which are determined to not be medically necessary (or in some casesmedically necessary services which are non-covered benefits), you may not charge the memberfor the services unless you have informed the member and they have agreed in writing in advanceto continue with the treatment at their own expense. Please refer to your participationagreement(s) for the applicable provisions. This policy is current at the time of publication;however, medical practices, technology, and knowledge are constantly changing. BCBSRIreserves the right to review and revise this policy for any reason and at any time, with or withoutnotice.

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