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Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities
Description of Procedure or Service
Soft tissue sarcomas (STS) are a heterogeneous group of rare solid tumors that arise from mesenchymal cells at all body sites. The malignant precursor cell(s) can differentiate along one or several lineages, such as muscle, adipose, fibrous, cartilage, nerve, or vascular tissue. These tumors arise most often in the limbs (particularly the lower extremity), followed in order of frequency by the abdominal cavity and retroperitoneum, the trunk/thoracic region, and the head and neck. In treating both primary and recurrent STS of the extremities, the major therapeutic goals are survival, avoidance of a local recurrence, maximizing function, and minimizing morbidity. There is a wide variety of clinical situations that arise due to involvement of different anatomic sites, range of histologies, and variability in grade and tumor size.
Radiation therapy (RT) can be administered in appropriately selected patients as primary treatment or as an adjunct to surgery. RT can be the main treatment for sarcoma in someone whose general health is too poor to undergo surgery and can also be used as palliative treatment to help symptoms of sarcoma when it has spread. A potential advantage of IMRT is its ability to contour a high-dose radiation volume more closely to the target and minimize the volume of high-dose radiation to surrounding normal tissues.
Related Policies:
Intensity-Modulated Radiation Therapy (IMRT) of the Prostate
Intensity-Modulated Radiation Therapy (IMRT) of the Head and Neck
Intensity-Modulated Radiation Therapy (IMRT) of the Chest
Intensity-Modulated Radiation Therapy (IMRT) of the Abdomen and Pelvis
Maximum Units of Service
Radiation Therapy Services
***Note: This Medical Policy is complex and technical. For questions concerning the technical language and/or specific clinical indications for its use, please consult your physician.
Policy
BCBSNC will provide coverage for Intensity modulated radiation therapy (IMRT) for sarcoma of the extremities when it is determined to be medically necessary because the medical criteria and guidelines noted below are met.
Benefits Application
This medical policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this medical policy.
When Intensity-Modulated Radiation Therapy (IMRT) for sarcoma of the extremities is covered
Intensity-modulated radiation therapy (IMRT) may be considered medically necessary for the treatment of sarcoma of the extremities when the following criteria are met:
- 3D results in >=25% of the full circumference of the femur or humerus cortex receiving >=40Gy, AND
- IMRT results in a reduction in the absolute percent of the circumference of the bone receiving >=40Gy of at least 15% (e.g., from 40% to 25% of the bone’s circumference)
OR - 3D results in >=25% of the joint spaces (e.g., shoulder, elbow, wrist, hip, knee, ankle) receiving >=35Gy, AND
- IMRT results in a reduction in the absolute percent of the joint space receiving >=35Gy of at least 15% (e.g., from 40% to 25% of the joint space).
When Intensity-Modulated Radiation Therapy (IMRT) for sarcoma of the extremities is not covered
Intensity modulated radiation therapy (IMRT) is considered not medically necessary and therefore not covered when above criteria are not met.
Policy Guidelines
Soft tissue sarcomas (STS) are uncommon. In the United States, approximately 11,930 cases are diagnosed annually, representing less than 1 percent of all newly diagnosed malignant tumors.
Because IMRT maximizes radiation dose distributions to the target while reducing exposure of adjacent non-target structures, it has been utilized when there is particular concern about damage to an adjacent organ or vital tissue with improvement of treatment outcomes in appropriately selected patients with STS.
CPT 77338 is reported once per IMRT plan and is limited to 3 units per 60-day treatment course.
Billing/Coding/Physician Documentation Information
This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.
Applicable service codes: 77301, 77338, 77385, 77386, G6015, G6016
Scientific Background and Reference Sources
American Cancer Society. Radiation Therapy for Soft Tissue Sarcomas 2015. Accessed January 25, 2016.
Leibel SA, Fuks Z, Zelefsky MJ, et al. Intensity-modulated radiotherapy. Cancer J 2002; 8:164- 176.
Alektiar KM, Brennan MF, Healey JH, Singer S. Impact of intensity-modulated radiation therapy on local control in primary soft-tissue sarcoma of the extremity. J Clin Oncol 2008; 26:3440- 3444
Senior Medical Director review 3/2016
Specialty Matched Consultant Advisory Panel 5/2016
Specialty Matched Consultant Advisory Panel 5/2017
Specialty Matched Consultant Advisory Panel 5/2018
Medical Director review 5/2018
Specialty Matched Consultant Advisory Panel 5/2019
Medical Director review 5/2019
American Cancer Society. Radiation Therapy for Soft Tissue Sarcomas 2020. Accessed May 7, 2020.
Specialty Matched Consultant Advisory Panel 5/2020
Medical Director review 5/2020
American Cancer Society. Radiation Therapy for Soft Tissue Sarcomas 2021. Accessed May 3, 2021.
Specialty Matched Consultant Advisory Panel 5/2021
Medical Director review 5/2021
Specialty Matched Consultant Advisory Panel 5/2022
Medical Director review 5/2022
Specialty Matched Consultant Advisory Panel 5/2023
Medical Director review 5/2023
American Cancer Society. Radiation Therapy for Soft Tissue Sarcomas 2024. Accessed May 30, 2024.
Specialty Matched Consultant Advisory Panel 5/2024
Medical Director review 5/2024
Policy Implementation/Update Information
4/1/16 New policy issued. Intensity-modulated radiation therapy (IMRT) may be considered medically necessary for the treatment of sarcoma of the extremities when the following criteria are met: 3D results in >=50% of the full circumference of the femur or humerus cortex receiving >=40Gy, AND IMRT results in a reduction in the absolute percent of the circumference of the bone receiving >=40Gy of at least 20% (e.g. from 60% to 40% of the bone’s circumference);
OR 3D results in >=50% of the joint spaces (e.g. shoulder, elbow, wrist, hip, knee, ankle) receiving >=35Gy, AND IMRT results in a reduction in the absolute percent of the joint space receiving >=35Gy of at least 20% (e.g. from 60% to 40% of the joint space). Senior medical director review 3/2016. Specialty Matched Consultant Advisory Panel review. Notification given 4/1/16 for effective date 5/31/16. (lpr)
5/31/16 Specialty Matched Consultant Advisory Panel review 5/25/16. No change to policy statement. (lpr)
6/30/17 Specialty Matched Consultant Advisory Panel review 5/31/2017. No change to policy statement. (lpr)
6/8/18 Specialty Matched Consultant Advisory Panel review 5/2018. No changes to policy statements. Medical Director review 5/2018. (mco)
5/28/19 Specialty Matched Consultant Advisory Panel review 5/15/2019. Under When Covered section: changed statement A parameters from 50% to 25%; Statement B bone circumference parameters changed from 20% to 15% (eg.changed from 60% to 40% and 40% to 25%); Statement C parameters changed from 50% to 25%; Statement D percent of joint space changed from 20% to 15% (eg. changed from 60% to 40% and from 40% to 25%). Medical Director review 5/2019. (lpr)
6/9/20 Specialty Matched Consultant Advisory Panel review 5/20/2020. Reference added. No change to policy statement. (lpr)
6/15/21 Specialty Matched Consultant Advisory Panel review 5/19/2021. Reference added. No change to policy statement. (lpr)
5/31/22 Specialty Matched Consultant Advisory Panel review 5/18/2022. Added Radiation Therapy Services to related policies section. No change to policy statement. (lpr)
6/13/23 Specialty Matched Consultant Advisory Panel review 5/17/2023. No change to policy statement. (lpr)
6/12/24 Specialty Matched Consultant Advisory Panel review 5/15/2024. Reference added. No change to policy statement. (lpr)
Disclosures:
Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and BCBSNC reserves the right to review and revise its medical policies periodically.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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