DESCRIPTION
Intraoperative radiation therapy (IORT) is designed to increase the intensity of radiation directly delivered to tumors. The tumor volume and associated tissues at risk for micrometastatic spread are directly visualized at the time of the surgery. IORT is delivered directly to the tumor volume, and normal or uninvolved tissues are not exposed to radiation because they are removed or shielded from the treatment field.
IORT is performed with applicators and cones that attach to the treatment head of high-energy medical linear accelerators and that are designed to direct radiation to defined surface structures. Most individuals are concurrently treated with high dose external beam photon irradiation
POLICY
Intraoperative radiation therapy (IORT) for the treatment of cancer is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Intraoperative radiation therapy (IORT) for all other oncologic applications is considered investigational.
MEDICAL APPROPRIATENESS
Intraoperative radiation therapy (IORT) is considered medically appropriate if ANY ONE of the following criteria are met:
Recurrent, noncentral cervical cancer with positive or close margins
Recurring uterine/endometrial cancer confined to the pelvis
Retroperitoneal/intra abdominal sarcoma with positive or close margins
Colon cancer with T4 or recurrent cancer
Rectal cancer with positive or close margins with T4 or recurrent cancer
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member’s health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
There is insufficient scientific evidence to show that intraoperative radiation is as effective as established standards of practice in improving health outcomes for other oncologic applications.
SOURCES
Abeloff, M. D., Armitage, J. O., Niederhuber, J., E., Kastan, M. B., & McKenna, W. G. (Eds.). (2008). Abeloff: Clinical Oncology (4th ed., pp. 1550 - 1551). Philadelphia: Elsevier, Inc.
American College of Radiology. (2008). ACR appropriateness criteria®. Recurrent Rectal Cancer. Retrieved June 30, 2009 from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologyRectalAnalWorkGroup/RecurrentRectalCancerUpdateinProgress.aspx.
American College of Radiology. (2010). ACR appropriateness criteria®. Retreatment of recurrent head and neck cancer after prior definitive radiation. Retrieved June 2, 2011 from http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonRadiationOncologyHeadNeckWorkGroup/RecurrentHeadNeckCancer.aspx.
BlueCross BlueShield Association. Medical Policy Reference Manual. (10:2009). Intraoperative Radiation Therapy. (8.01.08). Retrieved May 27, 2011 from BlueWeb. (17 articles and/or guidelines reviewed)
ECRI Institute. Health Technology Information Service. Hotline Response. (2008, June). Intraoperative radiation therapy for breast cancer. Retrieved June 30, 2009 from ECRI Institute. (72 articles and/or guidelines reviewed)
Hulvat, M., Hansen, N., & Jeruss, J. (2009). Multidisciplinary care for patients with breast cancer. The Surgical Clinics of North America, 89 (1), 133 - 176. (Level 5 Evidence)
National Comprehensive Cancer Network. (2011, April). NCCN clinical practice guidelines in oncology™. Rectal cancer (V.4.2011). Retrieved May 27, 2011 from http://www.nccn.org/professionals/physician/gls/PDF/rectal.pdf.
National Comprehensive Cancer Network. (2011, February). NCCN clinical practice guidelines in oncology™. Pancreatic adenocarcinoma (V.2.2011). Retrieved May 27, 2011 from http://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf.
National Comprehensive Cancer Network. (2011, February). NCCN clinical practice guidelines in oncology™. Uterine neoplasms (V.2.2011). Retrieved May 27, 2011 from http://www.nccn.org/professionals/physician_gls/pdf/uterine.pdf.
National Comprehensive Cancer Network. (2011, January). NCCN clinical practice guidelines in oncology™. Cervical cancer (V.1.2011). Retrieved May 27, 2011 from http://www.nccn.org/professionals/physician/gls/PDF/cervical.pdf.
National Comprehensive Cancer Network. (2011, January). NCCN clinical practice guidelines in oncology™. Soft tissue sarcoma (V.1.2011). Retrieved May 27, 2011 from http://www.nccn.org/professionals/physician_gls/pdf/sarcoma.pdf.
National Comprehensive Cancer Network. (2011, March). NCCN clinical practice guidelines in oncology™. Colon cancer (V.3.2011). Retrieved May 27, 2011 from http://www.nccn.org/professionals/physician/gls/PDF/colon.pdf.
Technology Evaluation Center. (2010, June). Accelerated radiotherapy after breast-conserving surgery for early stage breast cancer (Vol. 24, No. 9). Chicago: BlueCross BlueShield Association. (47 articles and/or guidelines reviewed)
Williams, C., Reynolds, H., Delaney, C., Champagne, B., Obias, V., Joh, Y., et al. (2008). Clinical results of intraoperative radiation therapy for patients with locally recurrent and advanced tumors having colorectal involvement. American Journal of Surgery, 195 (3), 405 - 409. (Level 4 Evidence)
ORIGINAL EFFECTIVE DATE: 8/1985
MOST RECENT REVIEW DATE: 10/8/2011
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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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