I Got Denied or Downcoded

Noridian

Noridian has identified and is correcting a system error that was denying CPT 77387 for POS 19 and 22, with claim reprocessing expected in a few weeks.

UnitedHealthcare (UHC)

UHC’s revised RT guideline requires CPT 77387 to be billed with the -26 modifier starting March 1. For private payers still denying 77387 due to the modifier, ASTRO suggests resubmitting claims without it until there is payer consensus. Please check with individual payers on their policy on how to bill 77387 to avoid future denials. Members should continue to report inappropriate denials and payer issues to [email protected].

EviCore

EviCore’s updated guideline should reduce high denial rates for CPT 77412. However, members should submit feedback to ASTRO if initial denials or the need for peer-to-peer calls does not decrease.

ASTRO and eviCore met to align on documentation expectations, and coding clarifications. The emphasis is on clear, concise documentation that supports medical necessity without adding administrative burden.

1. Active Motion Management Documentation (Including DIBH)

• eviCore is not looking for checkboxes alone or simply stating "DIBH."
• A brief sentence or two is sufficient if it clearly confirms:
  • The technology used (e.g., DIBH, AlignRT, surface guidance) or
  • Active motion management with defined thresholds that would pause the beam
• Templated language is strongly encouraged to improve consistency and reduce peer-to-peer calls.

2. Breast Cancer Guidelines

• Updated guidelines support billing 77412 for:
  • Active motion management during treatment delivery for left breast cancer for whole breast or postmastectomy radiation therapy
  • Active motion management during treatment delivery for right breast cancer with internal mammary nodal irradiation
  • Bilateral breast cancer when treatment is delivered concurrently to both breasts
  • Multiple photon isocenters are required to deliver treatment to a long chest wall with an unusually large superior-inferior field length, exceeding standard single isocenter limits
  • Concurrent use of mixed photon/electron fields for the breast boost
• Comparison plans are not required.
• 77412 not currently approved for APBI. EviCore open to review on case-by-case basis if there is demonstrated clear heart dose being avoided with active motion management.

3. Multiple Isocenters

• ASTRO emphasized that CPT code description does not distinguish between malignant and non-malignant disease for treatment of multiple isos. EviCore expressed concern over abuse of 77412 cases without patient shifts or new setups, including adjacent treatment sites.
• There is a distinction in the AMA CPT language for codes 77402 and 77412, where 2D is not listed for multiple isocenters but is included in the CPT descriptor. EviCore denying 2D multiple iso cases for bone mets and osteoarthritis. ASTRO will be reaching out to AMA to clear this up to revisit for policy changes.
• EviCore looking for patient repositioning and reimaging time
  • ASTRO countered with spine example, for example T10 and L2 lesions.

4. Image Guidance and Orthovoltage Coding

• The professional component of image guidance (77387) is approved for 2D, 3D, and IMRT treatments. No separate authorization required.
• Exception: superficial/orthovoltage treatments must use orthovoltage-specific codes (77436-77439) and cannot bill image guidance codes.
• This clarification is intended to reduce coding confusion and denials.

5. Prostate Treatment and Emerging Technologies

• Current policy does not approve 77412 for active motion management for prostate.
• eviCore is open to case-by-case review when clear clinical criteria, beam-off thresholds, and protocols are documented (e.g., MR-Linac, FLAME trial–based approaches).
• ASTRO will share supporting protocols and documentation to inform future guideline updates.