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Commercial Medical Policy Notification Effective September 10, 2025 Posted July 1, 2025
Medical PolicyRevision
Intensity Modulated Radiation Therapy for Tumors of the Central Nervous SystemSpecialty 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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