REVIEW REQUEST FOR
Intensity Modulated Radiation Therapy (IMRT)
Provider Data Collection Tool Based on Medical Policy THER-RAD.00007
Policy Last Review Date:
11/05/2015
Policy Effective Date:
11/09/2015
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
11/09/2015
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Service Requested (CPT if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
This medical policy based data collection tool is for a medical necessity review request for the use of intensity
modulated radiation therapy (IMRT).
Select the applicable IMRT treatment area and check all options that apply to the individual:
Request is for Intensity Modulated Radiation Therapy (IMRT) (Please check all of the following that apply to this
individual)
Individual is less than 21 years of age with a radiosensitive tumor
Individual requires repeat irradiation of a field that has received prior irradiation
IMRT is for treatment of prostate cancer
Localized prostate cancer
Post-prostatectomy for dose escalation greater than or equal to 64 Gy (check all that apply)
PSA remains detectable at 6 months after surgery
PSA is detectable and increases on two or more lab determinations
Individual has post-operative stage T3b to T4
Individual’s post-operative pathology reveals positive surgical margins
Other (Please list);
Other (Please list);
IMRT is for treatment of head and neck cancer
Larynx cancer (Stage I and II)
Larynx cancer (Stage III or IV) Mucosal melanoma arising in head and neck region
Nasal cavity
Occult primary arising in the head and neck region
Oral Cavity, Lips, or Pharynx (oropharynx, hypopharynx, or nasopharynx)
Paranasal sinuses (frontal, sphenoid, ethmoid, maxillary)
Salivary glands
Other (Please list);
REVIEW REQUEST FOR
Intensity Modulated Radiation Therapy (IMRT)
Provider Data Collection Tool Based on Medical Policy THER-RAD.00007
Policy Last Review Date:
11/05/2015
Policy Effective Date:
11/09/2015
Provider Tool Effective Date:
11/09/2015
IMRT is for treatment of Thyroid cancer
IMRT is for treatment of Tumor(s) within the Chest and Chest Wall
Tracheal
Cervical esophagus
Lymphoma arising in the head and neck region
Lung cancer (check all of the following that apply)
Individual with primary lung cancer where concurrent chemotherapy and radiation is to be used
Percent of normal lung receiving more than 20 Gy (V20) accounts for more than 35% of the
normal lung, defined as the total lung volume minus the planning target volume (PTV)
The IMRT plan will reduce the V20 to at least 10% below the V20 that is achieved with
the 3D-CRT plan (for example, from 40% down to 30% or lower)
There is documentation that the treatment plan addresses tumor motion that is both accounted
for and managed such as: (check all that apply)
A 4D planning CT scan was performed and the primary tumor and included lymph
nodes were observed to move less than 1 cm and this degree of motion was included in
the planning tumor volume
A 4D planning CT scan was performed and respiratory gating will be employed to
minimize the risk of inadequate coverage.
A 3D planning CT scan was performed with free-breathing, end-inspiration and endexpiration breath-hold to minimize risk of inadequate coverage
Other (Please list);
IMRT is for treatment of Central Nervous System (CNS) primary or metastatic lesions.
(Check the following when it applies to the individual)
The lesion is located in close proximity to optic nerve, lens, retina, optic chiasm, cochlea, or brainstem
Other (Please list);
IMRT for the treatment of cancer of PELVIC ORGANS
IMRT is for treatment of cancer of the anus or anal canal
IMRT is for treatment of primary malignant gynecologic tumor (uterus, cervix, ovary, fallopian tube)
IMRT is for treatment of primary pelvic sarcoma
IMRT is for treatment of bladder carcinoma
IMRT is for treatment of rectal adenocarcinoma
Other: ____________
REVIEW REQUEST FOR
Intensity Modulated Radiation Therapy (IMRT)
Provider Data Collection Tool Based on Medical Policy THER-RAD.00007
Policy Last Review Date:
11/05/2015
Policy Effective Date:
11/09/2015
Provider Tool Effective Date:
11/09/2015
IMRT is for treatment of breast cancer (If checked, mark all of the following that apply to the individual)
Individual has left sided breast lesions
Target volume coverage results in cardiac radiation exposure that is expected to be greater than
or equal to 25 Gy to 10cc or more of the heart (V25 greater than or equal to 10cc) with 3D
conformal radiation therapy (3D-CRT) despite the use of a complex positioning device (such as
VAC-LokTM)
With the use of intensity modulated radiation therapy (IMRT), there is a reduction in the
absolute heart volume receiving 25 Gy or higher by at least 20% (for example, volume predicted
to receive 25 Gy by 3D-C-RT is 20cc and the volume predicted by IMRT is 16 cc or less)
Other (Please list);
Individual has large breasts when the treatment planning with 3D-CRT results in hot spots (focal regions
with dose variation greater than 10% of target) and the hot spots can be avoided with IMRT.
Individual is to receive internal mammary node irradiation (If checked, mark the reason for the
irradiation)
Individual has pathologically enlarged internal mammary
lymph node(s) as reported based on imaging technique by CT, MRI, PET/CT or CXR
Individual has pathologically involved internal mammary lymph node(s) (based on aspiration
cytology or tissue biopsy pathology)
Individual is high risk for internal mammary lymph node involvement
(If checked, mark the individual’s risk factors)
Equal to or greater than 4 positive axillary lymph nodes
Medial quadrant tumor with 1 or more positive axillary lymph nodes
Medial quadrant T3 tumor
Other (Please list);
IMRT is for treatment of abdominal cancer. (If checked, mark the following cancer location that applies
to this individual)
gastric
gastroesophageal junction
pancreas
hepatobiliary
Other (Please list);
Mark all of the following that apply to the individual
The disease is non-metastatic
Dosimetric treatment planning comparisons between 3D-CRT and IMRT have been made
Dosimetric treatment planning with IMRT predicts the radiation dose to adjacent organs would be within
normal tissue tolerance; (If checked, mark the following predictions that apply)
3D-CRT planning predicts the mean liver dose will be greater than 30 Gy and IMRT planning
predicts the mean liver dose would be less than or equal to 25 Gy
3D-CRT planning predicts a mean dose to the bilateral kidneys of greater than 18 Gy and IMRT
planning predicts that no more than 90% of the volume of one kidney receives greater
than 18 Gy. If only one kidney is present, the IMRT planning predicts that no more than 15% of
the kidney receives greater than 18 Gy
3D-CRT planning predicts the maximum spinal cord dose would exceed 50 Gy and IMRT
planning predicts the maximum spinal cord dose would be less than or equal to 45 Gy
3D-CRT planning predicts the maximum dose to the small bowel will be greater than 54 Gy
and IMRT planning predicts the maximum dose to the small bowel would be less than 50 Gy.
Note: The maximum dose of radiation is defined as the highest dose to a volume of 0.03 cc.
IMRT is for treatment of cancer of unknown primary
IMRT is for treatment of treatment of large arteriovenous malformations (AVM)
REVIEW REQUEST FOR
Intensity Modulated Radiation Therapy (IMRT)
Provider Data Collection Tool Based on Medical Policy THER-RAD.00007
Policy Last Review Date:
11/05/2015
Policy Effective Date:
11/09/2015
Provider Tool Effective Date:
11/09/2015
IMRT treatment is for other organ/location not specified above (Please list):
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.