Commercial Medical Policy Notification Effective September 10, 2025 Posted July 1, 2025 | Providers

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Commercial Medical Policy Notification Effective September 10, 2025 Posted July 1, 2025

Medical Policy	Revision
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System	Specialty Matched Consultant Advisory Panel review 5/21/2025. References updated. Per Medical Director/CAP review: Under “when not covered” section, added non-covered criteria: “Intensity Modulated Radiation Therapy (IMRT) is considered not medically necessary for prophylactic cranial irradiation in individuals with small cell lung cancer (SCLC).” Notification given 7/1/2025 for effective date 9/10/2025.

Medical Policy

Revision

Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System

Specialty Matched Consultant Advisory Panel review 5/21/2025. References updated. Per Medical Director/CAP review: Under “when not covered” section, added non-covered criteria: “Intensity Modulated Radiation Therapy (IMRT) is considered not medically necessary for prophylactic cranial irradiation in individuals with small cell lung cancer (SCLC).” Notification given 7/1/2025 for effective date 9/10/2025.

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