Local Coverage Article Response to Comments

Response to Comments: Intensity Modulated Radiation Therapy (IMRT), L36773

A55854

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Article ID
A55854
Article Title
Response to Comments: Intensity Modulated Radiation Therapy (IMRT), L36773
Article Type
Response to Comments
Original Effective Date
11/07/2016
Retirement Date
N/A
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Comment summaries and MAC JN response to comments for comment period 06/02/2016 – 07/16/2016.

For Comment #s 1 through 4, the contractor acknowledges that an extensive number of comments on behalf of the American Society for Radiation Oncology (ASTRO) were received in support of the local coverage determination (LCD) for Intensity Modulated Radiation Therapy (IMRT).

Response To Comments

NumberCommentResponse
1

ASTRO expresses that the draft LCD verbiage contains limiting language about indications for disease sites that can be treated with IMRT.

We acknowledge your concern and will revise the LCD to add the following language in the Indications section of the LCD: "Other malignancies not delineated in the above can be supported with submission of documentation for medical necessity should a denial occur. The determination of appropriateness and medical necessity for IMRT for any site shall be found in the documentation from the radiation oncologist and must be available when requested or submitted in the appeals process."

2

The CMS Manual System Publication 100-08 should be edited to clearly delineate the physician’s required qualifications for ordering a course of radiation therapy from the more general requirements of physician supervision, which are described in the Medicare Benefit Policy Manual, Chapter 6, Section 20.5.2 and Chapter 15, Section 90. As written, the paragraph is vague regarding this important distinction.

We agree that the physician required qualification for ordering a course of radiation therapy should be more specific to radiation oncology, and therefore, the LCD will be revised.

3

ASTRO recommends CPT® procedure code 77293 (Respiratory motion management simulation) should be added to the "CPT®/HCPCS Codes" section of the LCD as an add-on CPT® procedure code for 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications).

The LCD does not include all procedure codes (HCPCS/CPT®) in the IMRT process of care. Other applicable procedure codes must be consistent with the AMA CPT® guidance (if active status), the General Correct Coding Policies, as well as, specific policies for radiology services in reporting services to the Medicare MCS and FISS claim processing systems, as addressed in the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services. As always, accurate coding and supporting documentation is required for payment when claims are audited. Most importantly, accurate coding and documentation support quality of patient care.

4

ASTRO recommends adding ICD-10-CM codes to the final LCD in the Group 1 "ICD-10 Codes that Support Medical Necessity" section of the LCD.

We agree to include diagnoses suggested to be included in the ICD-10-CM section of the LCD.

5

In the proposed policy, it states that prostate cancer is appropriate for IMRT. A recently published definitive clinical trial showed no advantage for IMRT over three-dimensional (3D) treatment. Therefore, it should not be used for prostate cancer.

Thank you for your comment. The LCD does include prostate cancer as an acceptable indication. If we were to remove prostate cancer from the acceptable indications, we would be tightening the LCD and would be required to take the policy back through the 45-day comment process.

6

More recently, combined modality treatment with chemotherapy and radiation therapy has become the standard of care for advanced head-and-neck disease because of the greater survival rates. The experience in many centers with IMRT for patients with unknown primary in head and neck cancer has shown promising clinical outcomes. In fact, IMRT, compared with the conventional technique, allows excellent bilateral neck and putative pharyngeal mucosa coverage, with few late salivary function toxicities. The National Comprehensive Cancer Network (NCCN) guideline in 2016 also recommends that head and neck cancer with unknown primary should be treated with IMRT or three-dimensional conformal therapy. Two codes need to be added in the list, which is C77.0 and C80.1 for Head and Neck cancer of unknown primary (Occult Primary).

Thank you for your comment. ICD-10-CM code C77.0 (Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck) will be added to the LCD.

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