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Intensity Modulated Radiation Therapy for Prostate Cancer Update

Audience: Radiation Oncologists

Excellus BlueCross BlueShield works to ensure that the development of corporate medical policies occurs through an open, collaborative process. We encourage participating providers to become actively involved in medical policy development. Each month, draft policies are available for review and comment. To access, click here. Providers now have the capability of attaching supporting documentation related to their comments.

The following updated medical policy has been reviewed and was approved on August 20, 2020 by the Corporate Medical Policy Committee, including practitioner representatives from all Health Plan regions. 

Corporate Medical Policy #6.01.24 – Intensity Modulated Radiation Therapy (IMRT), has been updated to be consistent with the National Comprehensive Cancer Network (NCCN) recommendations.  This updated policy will be effective December 14, 2020. The policy applies to all lines of business, and to the services of all practitioners and facilities.

The Intensity Modulated Radiation Therapy (IMRT) policy provides updates to the criteria for the following indications:

Prostate Cancer; clinically localized disease:

IMRT to be delivered as:

Hypofractionation – 20 to 28 fractions per treatment course.

The rationale section of the medical policy provides information related to the Health Plan’s change in coverage criteria based on the NCCN Guideline Panel (2020) recommendations for prostate cancer, which include examples of radiation therapy regimens that have shown acceptable efficacy and toxicity. The optimal regimen for an individual patient warrants evaluation of comorbid conditions, voiding symptoms, and toxicity of therapy. A moderate hypofractionation regimen is preferred for all localized prostate cancer stages.

These services are subject to audit and policy updates at the Health Plan’s discretion. You can access the individual policies.

If you have any questions regarding this policy, please contact your Provider Relations representative.

Thank you for the quality of care and service that you provide to our members.

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