BlueCHiP for Medicare and Commercial Products: Not Applicable PRIOR AUTHORIZATION
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POLICY STATEMENT BlueCHiP for Medicare and Commercial Products: Breast Intensity-modulated radiotherapy (IMRT) may be considered medically necessary as a technique to deliver whole-breast irradiation in patients receiving treatment for left-sided breast cancer after breast conserving surgery, and for individuals with large breasts when treatment planning with 3-dimensional (3D) conformal results in hot spots (focal regions with dose variation greater than 10% of target) and the hot spots are able to be avoided with IMRT.
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