INTENSITY-MODULATED RADIATION THERAPY (IMRT) HS-094

Easy Choice Health Plan, Inc.

Exactus Pharmacy Solutions, Inc.

Harmony Health Plan of Illinois, Inc.

Missouri Care, Incorporated

WellCare Health Insurance of Arizona, Inc., operating in Hawai‘i as ‘Ohana Health Plan, Inc.

WellCare of Kentucky, Inc.

WellCare Health Plans of Kentucky, Inc.

WellCare Health Plans of New Jersey, Inc.

WellCare of Connecticut, Inc.

WellCare of Florida, Inc., operating in Florida as Staywell Intensity-Modulated WellCare of Georgia, Inc. Radiation Therapy WellCare of Louisiana, Inc. Policy Number: HS-094 WellCare of New York, Inc.

WellCare of South Carolina, Inc. Original Effective Date: 4/2/2009

WellCare of Texas, Inc. Revised Date(s): 4/30/2010; 4/30/2011; WellCare Prescription Insurance, Inc. 4/5/2012; 4/11/2013; 3/6/2014; 3/5/2015; Windsor Health Plan, Inc. 3/3/2016

APPLICATION STATEMENT

The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.

Clinical Coverage Guideline page 1

Original Effective Date: 4/2/2009 - Revised: 4/30/2010, 4/30/2011, 4/5/2012, 4/11/2013, 3/6/2014, 3/5/2015, 3/3/2016 INTENSITY-MODULATED RADIATION THERAPY (IMRT) HS-094

DISCLAIMER

The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. Note: Lines of business (LOB) are subject to change without notice; current LOBs can be found at www.wellcare.com – select the Provider tab, then “Tools” and “Clinical Guidelines”.

BACKGROUND

Intensity-modulated radiation therapy (IMRT) is a specialized form of external beam radiation treatment that allows clinicians to shape radiation doses to more closely match the contours of a tumor. By precisely targeting only the cancerous tissue, clinicians may be able to apply much higher radiation doses to tumors while minimizing unnecessary radiation of surrounding normal tissues. Larger, precisely targeted radiation doses may result in better local control with fewer side effects.

IMRT should be distinguished from conformal radiotherapy. Conformal radiotherapy uses computed tomography (CT)-based treatment planning to construct a precise target and more focused (conformal) delivery of radiation dose. Three-dimensional conformal radiation therapy (3D-CRT) systems are intended to permit higher radiation dosing of tumor tissue, limit dosing of normal tissue, and ultimately improve local control of radiation exposure. IMRT involves adjusting the beam-intensity to permit even more conformal dose distributions. In IMRT, the intensity of the radiation exposure in one portion of the field is modified depending on whether tumor or normal tissue is present in the beam pathway. To do this IMRT divides the beam into multiple beamlets. When the beamlet hits normal tissues, the intensity is lowered, and when the beamlet hits tumor, the intensity is higher. The changing of beam intensity is computer controlled. Conformal radiotherapy does not allow for this type of beam adjustment.

The first step in IMRT is treatment planning using computed tomography and magnetic resonance imaging to produce a model of the tumor. The patient is immobilized during scanning and treatment, often with a custom-fitted plastic mask. Using computer software, the radiation oncologist and medical physicist develop a plan to deliver the desired amount of radiation to the tumor. The treatment step involves the delivery of a radiation beam produced by a linear accelerator and modified by the computerized MLC as the whole unit is moved around the patient’s head. The total dose is delivered in small daily amounts (fractions) over 15 to 30 minutes, 5 days a week, for 2 to 6 weeks. Treatment is given in a hospital radiation oncology outpatient unit. The oncology team includes the radiation oncologist, medical physicist, dosimetrist, radiation therapist, and oncology nurses.

The decision process for using IMRT requires an understanding of accepted practices that take into account the risks and benefits of such therapy compared to conventional treatment techniques. While IMRT technology may empirically offer advances over conventional or three-dimensional conformal radiation, a comprehensive understanding of all consequences is required before applying this technology. IMRT is not a replacement therapy for conventional radiation therapy methods. Medicare will consider IMRT reasonable and necessary in instances where sparing the surrounding normal tissue is essential.1,2,3,4,5

Accelerated Partial Breast Irradiation (APBI)

Accelerated partial breast irradiation (APBI) is a type of radiation therapy used in patients with early-stage breast cancer who have undergone breast-conserving surgery. With APBI, only the lumpectomy bed plus a 1- to 2- centimeter (cm) margin receives irradiation, generally consisting of daily doses > 2 grays (GY) delivered in < 5 weeks. The goal of APBI is to allow treatment to be accomplished in a shorter period of time through greater radiation fraction size and reduced target volume.

3D-CRT is the most recently developed technique for delivery of APBI. In the most widely used 3D-CRT approach, first described by investigators at the William Beaumont Hospital, patients lie in the supine position with the ipsilateral arm elevated and undergo scanning by computed tomography (CT). Some researchers have used prone positioning of the patient to minimize target tissue movement during breathing and to enable greater sparing of heart and lung tissue; however, the prone position requires the use of a special immobilization device and is uncomfortable for some patients.6,7 Clinical Coverage Guideline page 2

Original Effective Date: 4/2/2009 - Revised: 4/30/2010, 4/30/2011, 4/5/2012, 4/11/2013, 3/6/2014, 3/5/2015, 3/3/2016 INTENSITY-MODULATED RADIATION THERAPY (IMRT) HS-094

The American Society of Breast Surgeons (ASBS) issued a revised consensus statement regarding APBI in August 2011. Patients should undergo careful selection for APBI and be properly informed of the risks and benefits of this type of radiation treatment. The ASBS recommends the following selection criteria for patients being considered for treatment with APBI as a sole form of radiation therapy instead of (WBI):1  Age ≥ 45 years  Invasive ductal carcinoma or ductal carcinoma in situ (DCIS)  Total tumor size (invasive and DCIS) ≤ 3 cm in size  Negative microscopic surgical margins of excision  Negative sentinel lymph nodes  Surgeons, radiation oncologists, and physicists utilizing APBI techniques should be adequately trained to permit optimum radiation therapy planning and delivery.  Multi-lumen catheter devices or multi-catheter interstitial approaches may allow for greater flexibility in treatment planning for thin skin-to-lumpectomy cavity distances or devices that abut the pectoralis muscle to avoid high skin and chest wall doses.  All patients should undergo regular monitoring to identify adverse events and local recurrences.  Continuous, long-term, outcomes-based monitoring of APBI is required.

The American Society for Radiation Oncology (ASTRO) assembled a task force in 2008 consisting of experts in breast cancer to review all available prospective data on the use of APBI. Patients who select APBI should be informed that WBI is considered an established treatment due to a much longer track record with documented long- term effectiveness and safety. The selection criteria and best practices for use of APBI outside of the clinical trial setting were stated; recommendations arising from this statement proposed three patient groups:2  A “suitable” group for whom APBI is acceptable outside of a clinical trial.  A “cautionary” group for whom concern and caution should be used when APBI outside of a clinical trial is considered as a treatment approach.  An “unsuitable” group for whom APBI outside of a clinical trial is not usually considered warranted.

Whole Breast Irradiation (WBI)

Three-dimensional conformal radiation therapy (3D-CRT) uses advanced computer technology to tailor the radiotherapy beam to the exact size and shape of a tumor, while minimizing incidental irradiation of surrounding normal tissues. Conformal radiation therapy allows the delivery of higher doses of radiation than would be possible with conventional external beam radiation therapy, with the objective of improving local control and, ultimately, survival. Intensity-modulated radiation therapy (IMRT), a refinement of conformal radiation therapy, combines two advanced concepts to deliver 3D-CRT to tumors at the higher dosages with enhanced precision: (1) inverse treatment planning with optimization by computer; and (2) computer-controlled intensity modulation of the radiation beam during treatment.7

The American Society for Radiation Oncology (ASTRO) issued guidelines on fractionation for WBI. Guidelines noted that novel techniques for the delivery of WBI, such as IMRT, have shown promise for decreasing radiation dose to the lungs and/or heart without compromising coverage of the breast in small studies.2

The National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology breast cancer guideline states that, under local-regional treatment, whole breast radiation including the majority of the breast tissue is recommended. Breast irradiation should be performed following computed tomography (CT)-based treatment planning in order to limit irradiation exposure of the heart and lungs and to assure adequate coverage of the primary tumor and surgical site. In addition, tissue wedging, forward planning with segments (step-and-shoot), or IMRT is recommended.5

POSITION STATEMENT

Applicable To: Medicaid – Florida, Georgia, Hawaii, Kentucky Medicare – Easy Choice Health Plan, Florida, Hawaii

NOTE: For other markets, please route request to the authorized vendor. Clinical Coverage Guideline page 3

Original Effective Date: 4/2/2009 - Revised: 4/30/2010, 4/30/2011, 4/5/2012, 4/11/2013, 3/6/2014, 3/5/2015, 3/3/2016 INTENSITY-MODULATED RADIATION THERAPY (IMRT) HS-094

Intensity-Modulated Radiation Therapy (IMRT) is considered medically necessary to treat the following indications:

 Primary, metastatic, or benign tumors of the central nervous system, including brain, brain stem, and spinal cord; OR,  Primary, metastatic tumors of the spine where spinal cord tolerance may be exceeded by conventional treatment; OR,  Primary, metastatic, or benign lesions to the head and neck area, including: o Orbits; OR, o Sinuses; OR, o Skull base; OR, o Aero-digestive tract; OR, o Salivary glands  Carcinoma of the prostate; OR,  Selected cases of thoracic and abdominal malignancies when target volume is in proximity to critical structures; OR,  Selected cases (i.e., not routine) of breast cancers with close proximity to critical structures; OR,  Other pelvic and retroperitoneal tumors that meet requirements for medical necessity (see below); OR,  Reirradiation that meets the requirements for medical necessity (see below).

IMRT is considered medically necessary if the member has AT LEAST ONE of the following conditions:

 Important dose limiting structures adjacent to but outside the Planned Treatment Volume (PTV) are sufficiently close and require IMRT to assure safety and morbidity reduction; OR,  An immediately adjacent volume has been irradiated and abutting portals must be established with high precision; OR,  Gross Tumor Volume (GTV) margins are concave or convex and in close proximity to critical structures that must be protected to avoid unacceptable morbidity; OR,  Only IMRT techniques would decrease the probability of grade 2 or grade 3 radiation toxicity, as compared to conventional radiation in greater than 15% of radiated similar cases.

NOTE: The first step in IMRT is treatment planning using computed tomography and magnetic resonance imaging to produce a model of the tumor. CT or MRI results must verify the need for IMRT.

CODING

CPT® Codes 77014 Computed tomography guidance for placement of radiation therapy fields 77301 Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications 77338 Multi-leaf collimator (MLC) device(s) for intensity-modulated radiation therapy (IMRT), design and construction per IMRT plan 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt-60 based 77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based 77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions 77385 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; Simple 77386 Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; Complex 77387 Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed 77401 Radiation treatment delivery, superficial and/or orthovoltage

Clinical Coverage Guideline page 4

Original Effective Date: 4/2/2009 - Revised: 4/30/2010, 4/30/2011, 4/5/2012, 4/11/2013, 3/6/2014, 3/5/2015, 3/3/2016 INTENSITY-MODULATED RADIATION THERAPY (IMRT) HS-094

77402 Radiation treatment delivery, > 1 MeV; simple All of the following criteria are met (and none of the complex or intermediate criteria are met): single treatment area; one or two ports; and two or fewer simple blocks. 77407 Radiation treatment delivery, > 1 MeV; intermediate Any of the following criteria are met (and none of the complex criteria are met): two separate treatment areas; three or more ports on a single treatment area; or three or more simple blocks. 77412 Radiation treatment delivery, > 1 MeV; complex Any of the following criteria are met: three or more separate treatment areas; custom blocking; tangential ports; wedges; rotational beam; field-in-field or other tissue compensation that does not meet IMRT 77417 Therapeutic radiology port film(s) 77418 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams (eg, binary, dynamic MLC), per treatment session 77423 High energy neutron radiation treatment delivery; single treatment area using a single port or parallel- opposed ports with no blocks or simple blocking 77424 Intraoperative radiation treatment delivery, X-ray, single treatment session 77425 Intraoperative radiation treatment delivery, electrons, single treatment session 77423 High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with simple or complex blocking and/or wedge, and/or compensator(s) 77424 Intraoperative radiation treatment delivery, X-ray, single treatment session 77425 Intraoperative radiation treatment delivery, electrons, single treatment session 77520 Proton treatment delivery; simple, without compensation 77522 Proton treatment delivery; simple, with compensation 77523 Proton treatment delivery; intermediate 77525 Proton treatment delivery; complex 77600 Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4 cm or less) 77605 Hyperthermia, externally generated; deep (i.e., heating to depths greater than 4 cm) 77610 Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators 77615 Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators 77620 Hyperthermia generated by intracavitary probe 77750 Infusion or instillation of radioelement solution (includes 3 months follow-up care) 77761 Intracavitary radiation source application; simple 77762 Intracavitary radiation source application; intermediate 77763 Intracavitary radiation source application; complex 77776 Interstitial radiation source application; simple 77777 Interstitial radiation source application; intermediate 77778 Interstitial radiation source application; complex

Category III CPT© Codes G6002 Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy G6003 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5MeV G6004 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 6-10MeV G6005 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 11-19MeV G6006 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: 20 MeV or greater G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; up to 5MeV G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 6-10MeV G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 11-19MeV G6010 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use

Clinical Coverage Guideline page 5

Original Effective Date: 4/2/2009 - Revised: 4/30/2010, 4/30/2011, 4/5/2012, 4/11/2013, 3/6/2014, 3/5/2015, 3/3/2016 INTENSITY-MODULATED RADIATION THERAPY (IMRT) HS-094

of multiple blocks; 20 MeV or greater G6011 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5MeV G6012 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10MeV G6013 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19MeV G6014 Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20MeV or greater G6015 Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session G6016 Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session G6017 Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment

C Codes A9517 Iodine I-131, I-131 sodium iodide capsule A9527 Iodine I-125 sodium iodide, therapeutic A9530 Iodine I-131, I-131 sodium iodide solution A9563 Sodium phosphate P-32, therapeutic, per millicurie A9564 Chromic phosphate P-32 suspension, therapeutic, per millicurie A9600 Strontium Sr-89 chloride, therapeutic, per millicurie A9605 Samarium Sm-153 lexidronam, therapeutic, per 50 millicuries A9542 Indium In-111 ibritumomab tiuxetan, diagnostic, per study dose up to 5 millicuries A9543 Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries A9544 Iodine I-131 tositumomab, diagnostic, per study dose A9545 Iodine I-131 tositumomab, therapeutic, per treatment dose C1716 Brachytx, non-stranded, Gold-198 C1717 Brachytx, non-stranded,HDR Ir-192 C1719 Brachytx, non-stranded, Non-HDRIr-192 C2616 Brachytx, non-stranded,Yttrium-90 C2634 Brachytx, non-stranded, high activity, I-125 C2635 Brachytx, non-stranded, high activity, Pd-103 C2636 Brachy linear, non-stranded,Pd-103 C2638 Brachytx, stranded, I-125 C2639 Brachytx, non-stranded,I-125 C2640 Brachytx, stranded, P-103 C2641 Brachytx, non-stranded,P-103 C2642 Brachytx, stranded, Cs-131 C2643 Brachytx, non-stranded, Cs-131 C2698 Brachytx, stranded, NOS C2699 Brachytx, non-stranded, NOS Q3001 Radioelements for brachytherapy, any type, each

Category II CPT© Code 4165F Three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT) received (PRCA)1

ICD-9-CM Procedure Code 92.29 Nuclear medicine; therapeutic radiology and nuclear medicine; Other radiotherapeutic procedure

HCPCS Codes – No applicable codes.

Clinical Coverage Guideline page 6

Original Effective Date: 4/2/2009 - Revised: 4/30/2010, 4/30/2011, 4/5/2012, 4/11/2013, 3/6/2014, 3/5/2015, 3/3/2016 INTENSITY-MODULATED RADIATION THERAPY (IMRT) HS-094

ICD-9-CM Diagnosis Codes – This list may not be all inclusive. 140.0 - 140.9 Malignant neoplasm of lip 141.0 - 141.9 Malignant neoplasm of tongue 142.0 - 142.9 Malignant neoplasm of major salivary gland 144.0 - 144.9 Malignant neoplasm of floor of mouth 145.0 - 145.9 Malignant neoplasm of other and unspecified parts of mouth 146.0 - 146.9 Malignant neoplasm of oropharynx 147.0 - 147.9 Malignant neoplasm of nasopharynx 148.0 - 148.9 Malignant neoplasm of hypopharynx 149.0 - 149.9 Malignant neoplasm of ill-defined sites within the lip, oral cavity and pharynx 150.0 - 150.9 Malignant neoplasm of esophagus 151.0 - 150.9 Malignant neoplasm of stomach 153.0 - 153.9 Malignant neoplasm of colon 154.0 - 154.8 Malignant neoplasm of rectum, rectosigmoid junction and anus 155.0 - 155.2 Malignant neoplasm of liver and intrahepatic bile ducts 156.0 - 156.9 Malignant neoplasm of gallbladder and extrahepatic bile ducts 157.0 - 157.9 Malignant neoplasm of pancreas 158.0 - 158.9 Malignant neoplasm of retroperitoneum and peritoneum 160.0 - 160.9 Malignant neoplasm of nasal cavities, middle ear and accessory sinuses 161.0 - 161.9 Malignant neoplasm of larynx 162.0 - 162.9 Malignant neoplasm of trachea, bronchus and lung 163.0 - 163.9 Malignant neoplasm of pleura 164.0 - 164.9 Malignant neoplasm of thymus, heart, and mediastinum 171.0 - 171.9 Malignant neoplasm of connective and other soft tissue 174.0 - 174.9 Malignant neoplasm of female breast 175.0 - 175.9 Malignant neoplasm of male breast 179 Malignant neoplasm of uterus, part unspecified 180.0 - 180.9 Malignant neoplasm of cervix uteri 182.0 - 182.8 Malignant neoplasm of body of uterus 183.0 - 183.9 Malignant neoplasm of ovary and other uterine adnexa 184.0 - 184.9 Malignant neoplasm of other an unspecified female genital organs 185 Malignant neoplasm of prostate 188.0 - 188.9 Malignant neoplasm of bladder 189.0 - 189.9 Malignant neoplasm of kidney and other and unspecified urinary organs 190.0 - 190.9 Malignant neoplasm of eye 191.0 - 191.9 Malignant neoplasm of brain 192.0 - 192.9 Malignant neoplasm of other and unspecified parts of the nervous system 193 Malignant neoplasm of thyroid gland 194.0 - 194.6 Malignant neoplasm of other endocrine gland and related structures 195.0 - 195.8 Malignant neoplasm of other and ill-defined sites 196.0 - 196.8 Secondary and unspecified malignant neoplasm of lymph nodes 197.0 - 197.8 Secondary malignant neoplasm of respiratory and digestive systems 198.0 - 198.89 Secondary malignant neoplasm of other specified sites 201.00 - 201.98 Hodgkins Disease 202.00 - 202.98 Other malignant neoplasm of lymphoid and histiocytic tissue 225.1 Benign neoplasm of cranial nerves 225.2 Benign neoplasm of cerebral meninges 227.3 Benign Neoplasm of pituitary gland and craniopharyngeal duct 227.4 Benign Neoplasm of pineal gland 227.6 Benign neoplasm of aortic body and other paraganglia 233.0 Carcinoma in situ of breast 747.81 Anomalies of cerebrovascular system

Clinical Coverage Guideline page 7

Original Effective Date: 4/2/2009 - Revised: 4/30/2010, 4/30/2011, 4/5/2012, 4/11/2013, 3/6/2014, 3/5/2015, 3/3/2016 INTENSITY-MODULATED RADIATION THERAPY (IMRT) HS-094

ICD-10-CM Diagnosis Codes – This list may not be all inclusive. C00.0 - C14.8 Malignant neoplasm of lip, oral cavity and pharynx C15.3 - C26.9 Malignant neoplasm of digestive organs C300 - C39.9 Malignant neoplasm of respiratory and intrathoracic organs C47.0 - C47.9 Malignant neoplasm of peripheral nerves and autonomic nervous system C48.0 - C48.9 Malignant neoplasm of retroperitoneum and peritoneum C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck C50.011 - C50.929 Malignant neoplasm of breast C52 Malignant neoplasm of vagina C53.0 - C53.9 Malignant neoplasm of cervix uteri C54.0 - C54.9 Malignant neoplasm of corpus uteri C55 Malignant neoplasm of uterus, part unspecified C56.1 - C56.9 Malignant neoplasm of ovary C57.00 - C57.9 Malignant neoplasm of other an unspecified female genital organs C61 Malignant neoplasm of prostate C64.1 - C68.9 Malignant neoplasm of urinary tract C69.00 - C7209 Malignant neoplasm of eye, brain and other parts of central nervous system C72.00 - C72.9 Malignant neoplasm of spinal cord, cranial nerves and other parts of central nervous system C73 - C75.9 Malignant neoplasm of thyroid and other endocrine glands C76.0 - C79.9 Malignant neoplasm of ill-defined, other secondary and unspecified sites C81.00 - C88.9 Malignant neoplasms of lymphoid, hematopoietic and related tissue D05.00 - D05.92 Carcinoma in situ of breast D16.00 - D16.9 Benign neoplasm of bone and articular cartilage D33.0 - D33.9 Benign neoplasm of brain and other parts of central nervous system D35.00 - D35.92 Benign neoplasm of other and unspecified endocrine glands Q28.2 Arteriovenous malformation of cerebral vessels Q28.3 Other malformations of cerebral vessels

*Current Procedural Terminology (CPT) 2016 American Medical Association: Chicago, IL.®©

REFERENCES

1. Consensus statement for accelerated partial breast irradiation. American Society of Breast Surgeons Web site. https://www.breastsurgeons.org/statements/PDF_Statements/APBI.pdf. Published 2011. Accessed February 29, 2016. 2. Local coverage determination for intensity modulated radiation therapy (L28892). Centers for Medicare and Medicaid Services Web site. http://www.cms.hhs.gov/mcd/search.asp. Published February 16, 2009. Accessed February 29, 2016. 3. National Cancer Institute guidelines for the use of intensity-modulated radiation therapy in clinical trials. National Cancer Institute Web site. http://rpc.mdanderson.org/rpc/nci%20guidelines/new%20nci%20guidelines.pdf. Published January 14, 2005. Accessed February 29, 2016. 4. Clinical practice guidelines in oncology: breast cancer. National Comprehensive Cancer Network Web site. http://www.nccn.org. Published 2016. Accessed February 29, 2016. 5. Accelerated partial breast irradiation for breast cancer using conformal and intensity-modulated radiation therapy. Hayes Directory Web site. http://www.hayesinc.com. Published March 12, 2012 [reviewed on March 19, 2015]. Accessed February 29, 2016. 6. Whole breast irradiation for breast cancer using three-dimensional conformal and intensity-modulated radiation therapy for breast cancer. Hayes Directory Web site. http://www.hayesinc.com. Published March 8, 2012 [reviewed on January 7, 2016]. Accessed February 29, 2016.

MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS

Date Action

3/3/2016, 3/5/2015, 3/6/2014, 4/11/2013  Approved by MPC. No changes. 4/5/2012  Approved by MPC. Added two Hayes references (2012) for APBI and WBI. 12/1/2011  New template design approved by MPC. 4/30/2011  Approved by MPC.

Clinical Coverage Guideline page 8

Original Effective Date: 4/2/2009 - Revised: 4/30/2010, 4/30/2011, 4/5/2012, 4/11/2013, 3/6/2014, 3/5/2015, 3/3/2016