Knowledge Base Article

When I provided patient care years ago, we had a young patient whose mother was overbearing, demanding, and well-informed. As difficult as it was to deal with this parent, due to the child’s age and mental capacity, she needed a healthcare advocate. In recent years, I have had to be such an advocate for my parents’ healthcare. Thankfully it is much easier to be well-informed these days than it was years ago for that mother. Television ads promote a drug for everything, Facebook includes posts on numerous medical technologies such as TAVR and IMRT, and the internet allows research of any condition and any treatment. This is good and bad – knowledgeable and educated patients can make wiser healthcare decisions, but overzealous and ill-advised patients may make demands that are not the best choice for their healthcare. In today’s environment, I can easily envision a patient demanding of their oncologist, “I want some of that IMRT.”

Intensity Modulated Radiation Therapy (IMRT) is not for everyone. Healthcare providers have to keep up with the latest treatment protocols and the coverage requirements of numerous payers.  With the transition of the Jurisdiction J MAC from Cahaba to Palmetto, Palmetto elected to adopt the Cahaba Local Coverage Determination (LCD) for IMRT for both jurisdictions JJ and JM. Palmetto JM had not previously had a coverage policy for IMRT. This policy became effective on January 29, 2018. Several other MACs also have policies addressing the coverage of IMRT.

IMRT is generally reserved for treatment of tumors when adjacent structures need to be protected from the radiation dose or to deliver higher doses than commonly used. There are certain types of tumors that due to their location, shape, or dose requirements support the use of IMRT.  The LCDs describe the specific circumstances and types of tumors for which IMRT may be indicated. Some LCDs also include limitations where the use of IMRT is not supported, such as clinical urgency, palliative treatments, motion concerns, or “where IMRT does not offer an advantage over conventional or three-dimensional conformal radiation therapy techniques that deliver good clinical outcomes and low toxicity.”

There are also documentation requirements in the LCDs for IMRT.  The rationale of the advantage of IMRT versus the use of other radiation therapy methods must be documented in the medical record. In addition to this rationale, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, there are documentation requirements specific to IMRT.  For example, the Palmetto LCD indicates the following components must be included:

• Prescription defining the goals and requirements of the treatment plan, including the specific dose constraints for the target(s) and nearby critical structures
• Signed and dated IMRT inverse plan that meets prescribed dose constraints
• Target verification methodology including documentation of the clinical treatment volume (CTV) and the planning target volume (PTV), immobilization and patient positioning, and means of dose verification
• Documentation of fluence distributions re-computed in a phantom or an equivalent methodology
• Documentation that accounts for structures moving in and out of high and low dose regions created by respiration
• Documentation for clinical treatment planning (77261-77263) should evidence the criteria are met which are outlined in “The ASTRO/ACR Guide to Radiation Oncology Coding 2015”

Note: This is not a complete list or descriptions of all the Palmetto LCD documentation requirements. Please see the Palmetto IMRT LCD or your MAC’s LCD for complete documentation requirements. 

As you can see, just the partial requirements for IMRT treatment and documentation are daunting. It is good that patients are more involved in their healthcare choices, but hopefully they will understand the complexity of treatment decisions and defer to their physician’s judgement.