Intensity-modulated radiotherapy (IMRT) allows adequate dosing to the tumor while minimizing the radiation dose to surrounding normal tissues and critical structures, especially the heart in left-sided breast cancer. IMRT, which uses CT images and magnetic resonance imaging (MRI), offers better conformality than 3-dimensional conformal radiation therapy (3D-CRT), as it is able to modulate the intensity of the overlapping radiation beams projected on the target. The radiation oncologist delineates the target on each slice of a CT scan and specifies the target’s prescribed radiation dose, adjacent normal tissue volumes to avoid, and acceptable dose limits within the normal tissues. Based on these parameters and a digitally reconstructed radiographic image of the tumor and surrounding tissues and organs at risk, computer software optimizes the location, shape and intensities of the beams to achieve the treatment plan’s goals. Increased conformality may permit escalated tumor doses without increasing normal tissue toxicity and thus may improve local tumor control with decreased exposure to surrounding normal tissues, potentially reducing acute and late radiation toxicities. Better dose homogeneity within the target may also improve local tumor control by avoiding underdosing within the tumor and may decrease toxicity by avoiding overdosing.
BCBST uses MCG Care Guidelines for all other uses of IMRT - Intensity Modulated Radiation Therapy (IMRT) ACG: A-0455)
Intensity-modulated radiotherapy (IMRT) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Intensity-modulated radiotherapy (IMRT) for palliative treatment of lung cancer is considered not medically necessary.
Intensity-modulated radiotherapy (IMRT) for the treatment of the following is considered investigational:
Partial breast irradiation after breast-conserving surgery
Irradiation of the chest wall post-mastectomy
Intensity-modulated radiotherapy (IMRT) is considered medically appropriate if ANY ONE of the following are met:
Whole-breast irradiation for left-sided breast cancer if ALL of the following are met:
Individual had breast-conserving surgery
Significant cardiac radiation exposure cannot be avoided using alternative radiation techniques
Whole-breast irradiation in individuals with large breasts if ALL of the following are met:
Individual had breast-conserving surgery
Documentation in medical records state that 3-D conformal radiation therapy cannot achieve adequate precision and will result in hot spots (focal regions with dose variation greater than 10% of target)
Treatment is indicated for lung cancer if ALL of the following are met:
Intent is curative
Documentation in the medical records state 3-dimensional (3-D) conformal radiation therapy will expose greater than 35% of normal lung tissue to more than 20 Gy dose-volume and IMRT demonstrates a reduction in normal tissue exposure by a minimum of 10%
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
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.
Studies on IMRT for partial-breast irradiation are limited and have not demonstrated improvements in health outcomes. No studies have reported on health outcomes after IMRT for chest wall irradiation in post-mastectomy cases.
BlueCross BlueShield Association. Evidence Positioning System. (8:2020). Intensity-modulated radiotherapy of the breast and lung. (8.01.46). Retrieved December 10, 2020 from https://www.evidencepositioningsystem.com/. (30 articles and/or guidelines reviewed)
Livi, L., Meattini, I., Marrazzo, L., Simontacchi, G., Pallotta, S., Saieva, C., et al. (2015). Accelerated partial breast irradiation using intensity-modulated radiotherapy versus whole breast irradiation: 5-year survival analysis of a phase 3 randomised controlled trial. European Journal of Cancer, 51 (4), 451-463. Abstract retrieved June 27, 2016 from PubMed database.
National Comprehensive Cancer Network. (2020, August). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Small cell lung cancer. V1.2021. Retrieved December 10, 2020 from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2020, November). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Non-small cell lung cancer.V1.2021. Retrieved December 10, 2020 from the National Comprehensive Cancer Network.
National Comprehensive Cancer Network. (2020, September). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Breast cancer.V6.2020. Retrieved December 10, 2020 from the National Comprehensive Cancer Network.
Winifred S. Hayes, Inc. Medical Technology Directory. (2018, October; last search updated January 2020). Accelerated partial breast irradiation for breast cancer using conformal and intensity-modulated radiation therapy. Retrieved February 19, 2020 from www.Hayesinc.com/subscribers. (50 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 11/18/2015
MOST RECENT REVIEW DATE: 2/11/2021
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.
This document has been classified as public information.