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Part B Insider (Multispecialty) Coding Alert

COVERAGE:

New Radiation Reimbursement Restrictions Could Burn You

Published on Fri May 23, 2003

Cahaba GBA announced a policy on coverage of intensely moderated radiation therapy (IMRT), a new technology that uses computers to direct specific beams of radiation at a solid tumor inside a patient. The Georgia carrier said it will pay for IMRT if:

  • there are "important dose limiting structures" close to the planned treatment volume but outside of it, and these structures require IMRTto assure safety and morbidity reduction;

  • clinicians have already irradiated a volume immediately adjacent to the treatment area, and they need to establish "abutting portals" with high precision.

  • the gross tumor volume has margins that are concave or convex, and are close to "critical structures" that clinicians must protect to avoid "unacceptable morbidity."

  • only IMRT techniques will succeed in decreasing the probability of grade-2 or grade-3 radiation toxicity, compared to the record for conventional radiation in more than 15 percent of similar cases.

  • there are situations that require extremely high precision, such as primary brain tumors, brain metastasis, prostate cancer, lung cancer with special provision for organ motion, pancreas cancer and other upper abdominal sites, spinal cord tumors, head and heck cancer, adrenal tumors or pituitary tumors.

    Cahaba says that using IMRT requires more careful accounting for patient position and organ motion than conventional radiation therapy. Physicians can use published studies on organ movement, image-guided adaptive radiotherapy such as ultrasound-guided or portal image-guided setup with implanted fiducial markers, or respiratory gating of diaphragm movement for thoracic and upper abdominal sites.

    Providers have until April 15 to comment on this policy.

     

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