Clinical UM Guideline


Subject: Special Radiation Physics Consult and Treatment Procedure
Guideline #:  CG-THER-RAD-02 Publish Date:    12/27/2017
Status: Reviewed Last Review Date:    11/02/2017



This document addresses the use of special treatment procedures and work performed by a qualified medical physicist to address a specific question or problem related to a complex radiation therapy plan.


Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

Special physics consult is considered medically necessary for any of the following situations:

Special treatment procedure is considered medically necessary for any of the following situations:

Not Medically Necessary:

Special physics consult is considered not medically necessary for all other situations.

Special treatment procedure is considered not medically necessary for all other situations.


The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.




Special medical radiation physics consultation


Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)



ICD-10 Diagnosis



All diagnoses

Discussion/General Information


Radiation therapy uses high-energy radiation to shrink tumors and kill cancer cells. The radiation can be delivered outside the body (external-beam radiation), or inside the body near the cancer cells (internal radiation therapy or brachytherapy). A treatment plan is developed which includes the type of radiation therapy that should be used, the frequency and doses. For complex treatment plans and extenuating circumstances, sometimes a written analysis may be necessary to address a specific problem with the treatment plan or may require the assistance of a medical physicist. In this instance, a special physics consult may be necessary. A special physics consult is when the physician planning the radiation therapy (radiation oncologist) requests a medical physicist for a special consultative report or for specific physics services to an individual. A special physics consult would not be requested if a medical physicist is simply verifying the dose calculations performed by others. Generally, a special physics consult is not required more than once per radiation therapy course or once per brachytherapy implant.


When there is extra planning and monitoring effort by the physician involved in the use of special radiation therapy procedures, this is referred to as special treatment procedure. This involves significant additional work and effort by the physician and facility when treating the individual.




Brachytherapy (also known as internal radiation): A type of radiation treatment used to stop the growth of cancer cells by implanting radioactive material directly into the tumor or into the surrounding tissues.


Radiation therapy: Treatment with high energy radiation from X-rays or other sources of radiation.



Peer Reviewed Publications:

  1. Josipović M, Nyström H, Kjaer-Kristoffersen F. IMRT in a pregnant patient: how to reduce the fetal dose? Med Dosim. 2009; 34(4):301-310.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society for Radiation Oncology (ASTRO). Radiation oncology coding resource. 2017. For additional information visit the ASTRO website: Accessed on October 3, 2017.
  2. Dezarn WA, Cessna JT, DeWerd LA, et al. Recommendations of the American Association of Physicists in Medicine on dosimetry, imaging, and quality assurance procedures for 90Y microsphere brachytherapy in the treatment of hepatic malignancies. Med Phys. 2011; 38(8):4824-4845.
  3. Marbach JR, Sontag MR, Van Dyk J, Wolbarst AB. Management of radiation oncology patients with implanted cardiac pacemakers: report of AAPM Task Group No. 34. American Association of Physicists in Medicine. Med Phys. 1994; 21(1):85-90.
  4. Noridian Healthcare Solutions, LLC. Local Coverage Determination for Brachytherapy: Non-Intracoronary (L24281). Revised 01/01/2015. Available at: Accessed on October 3, 2017.








Medical Policy & Technology Assessment Committee (MPTAC) review.



Hematology/Oncology Subcommittee review. Updated References section. The document header wording updated from “Current Effective Date” to “Publish Date.”



MPTAC review.



Hematology/Oncology Subcommittee review.



MPTAC review. Initial document development.



Hematology/Oncology Subcommittee review. Initial document development.