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12437 Results

Therapeutic radiology simulation-aided field setting; simple

Service Code
77280 (CPT) Therapeutic radiology simulation-aided field setting; simple
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Therapeutic radiology simulation-aided field setting; intermediate

Service Code
77285 (CPT) Therapeutic radiology simulation-aided field setting; intermediate
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Therapeutic radiology simulation-aided field setting; complex

Service Code
77290 (CPT) Therapeutic radiology simulation-aided field setting; complex
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Respiratory motion management simulation (List separately in addition to code for primary procedure)

Service Code
77293 (CPT) Respiratory motion management simulation (List separately in addition to code for primary procedure)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

3-dimensional radiotherapy plan, including dose-volume histograms

Service Code
77295 (CPT) 3-dimensional radiotherapy plan, including dose-volume histograms
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician

Service Code
77300 (CPT) Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications

Service Code
77301 (CPT) Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)

Service Code
77306 (CPT) Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)

Service Code
77307 (CPT) Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)

Service Code
77316 (CPT) Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)

Service Code
77317 (CPT) Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)

Service Code
77318 (CPT) Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Special teletherapy port plan, particles, hemibody, total body

Service Code
77321 (CPT) Special teletherapy port plan, particles, hemibody, total body
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician

Service Code
77331 (CPT) Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Treatment devices, design and construction; simple (simple block, simple bolus)

Service Code
77332 (CPT) Treatment devices, design and construction; simple (simple block, simple bolus)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)

Service Code
77333 (CPT) Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)

Service Code
77334 (CPT) Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy

Service Code
77336 (CPT) Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan

Service Code
77338 (CPT) Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology

Special medical radiation physics consultation

Service Code
77370 (CPT) Special medical radiation physics consultation
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

Reauthorization Guidelines

See Evolent - Radiation Oncology site for specific requirements

How to Submit

Please submit your request to Evolent - Radiation Oncology