Georgia Medicare Radiation Therapy Coverage

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Georgia Medicare Radiation Therapy Coverage

By Brevy Care Team · Last verified May 13, 2026

Section 1861(s)(1) of the Social Security Act covers physician radiation oncology services, and Section 1861(s)(2)(B) covers hospital outpatient radiation therapy. The implementing regulation at 42 CFR 410.35 specifies the conditions under which radiation therapy is a covered Medicare service: performed by or under the direct supervision of a physician, reasonable and necessary for diagnosis or treatment, furnished in compliance with radiation safety standards, and documented in the medical record. Medicare pays for radiation therapy under two distinct methodologies depending on the setting. Hospital outpatient department radiation therapy is paid under the Hospital Outpatient Prospective Payment System (OPPS) using Ambulatory Payment Classifications (APCs), with a coinsurance cap equal to the Part A inpatient deductible per service. Freestanding radiation therapy center treatment is paid under the Medicare Physician Fee Schedule (PFS) using a technical component (TC) billed by the facility and a professional component (PC) billed by the radiation oncologist; no coinsurance cap applies in this setting. The BBA 2015 Section 603 site-neutral payment provisions affect off-campus hospital provider-based departments, paying them at PFS rather than OPPS rates. The CMS Innovation Center Radiation Oncology Model proposed in 2019 has not been implemented as of 2026. Modern radiation techniques (IMRT, IGRT, SBRT, SRS, proton beam, brachytherapy) are all covered for appropriate indications, with proton beam coverage governed by Medicare Administrative Contractor Local Coverage Determinations. This guide explains how every layer of the framework operates, the cost-sharing structure for each technique, the Georgia radiation oncology landscape including the Emory Proton Therapy Center, and how beneficiaries access radiation therapy across the state. :::

::: callout Key Takeaways

1. Section 1861(s)(1) of the Social Security Act covers physician radiation oncology services. Section 1861(s)(2)(B) covers hospital outpatient radiation therapy. The implementing regulation at 42 CFR 410.35 specifies conditions of coverage.
2. Radiation therapy is paid under two methodologies: Hospital Outpatient Prospective Payment System (OPPS) for hospital-based settings, and the Medicare Physician Fee Schedule (PFS) with separate Technical Component and Professional Component for freestanding centers.
3. The OPPS coinsurance cap (Part A inpatient deductible, $1,736 in 2026) applies per service in the HOPD setting. No coinsurance cap applies in the freestanding PFS setting.
4. The BBA 2015 Section 603 site-neutral payment provisions reduce payment for services furnished at off-campus hospital provider-based departments (off-campus PBDs) by aligning their payment with PFS rates rather than OPPS rates.
5. Modern radiation techniques covered include intensity-modulated radiation therapy (IMRT), image-guided radiation therapy (IGRT), stereotactic body radiation therapy (SBRT), stereotactic radiosurgery (SRS), proton beam therapy, and brachytherapy (low-dose-rate and high-dose-rate).
6. Proton beam therapy coverage depends on the indication. Pediatric cancers, ocular melanoma, and skull base chordoma/chondrosarcoma are broadly covered. Adult prostate cancer proton therapy is controversial under Medicare; Palmetto GBA Jurisdiction J has a Local Coverage Determination specifying covered and non-covered indications.
7. The CMS Innovation Center Radiation Oncology Model (RO Model) was proposed in 2019 to create prospective bundled payments for 90-day radiation episodes covering 16 cancer types. The model has been postponed multiple times and has not been implemented as of 2026.
8. Georgia has a robust radiation oncology landscape: Emory Winship Cancer Institute (the state's only NCI-designated cancer center), Piedmont Cancer Institute, Wellstar Cancer Center, NGHS Cancer Center, AU/Wellstar MCG Cancer Center, Memorial Health Cancer Institute, Atrium Navicent Cancer Center, Phoebe Cancer Center, Grady Cancer Center, and the Emory Proton Therapy Center (one of approximately 40 U.S. proton centers). :::

The Radiation Therapy Coverage Framework

Medicare's radiation therapy framework combines two statutory authorities and two payment methodologies. The complexity reflects the dual delivery settings: hospital outpatient departments (using OPPS) and freestanding radiation centers (using the Physician Fee Schedule with technical and professional component billing). Understanding both layers is essential for beneficiaries who want to compare options, anticipate cost-sharing, and verify their bills.

Section 1861(s)(1): Physician Radiation Oncology Services

Section 1861(s)(1) of the Social Security Act establishes physician services as a covered Medicare benefit. Radiation oncology is a recognized medical specialty, and radiation oncologists (physicians board-certified by the American Board of Radiology in radiation oncology) bill professional radiation therapy services under Section 1861(s)(1). The professional component of radiation therapy includes:

• Initial consultation and treatment planning oversight
• Daily review and supervision of treatment delivery
• Weekly management visits during the course of treatment (CPT 77427)
• Treatment course completion and follow-up planning

Section 1861(s)(2)(B): Hospital Outpatient Radiation Therapy

Section 1861(s)(2)(B) covers hospital outpatient services. When radiation therapy is furnished in a hospital outpatient department, the technical component (linear accelerator time, treatment room, equipment, supplies, radiation therapist staff) is paid under the Hospital Outpatient Prospective Payment System (OPPS). The hospital bills under its provider number, and the radiation oncologist separately bills the professional component under the Medicare Physician Fee Schedule.

42 CFR 410.35: Radiation Therapy Services Conditions of Coverage

The implementing regulation at 42 CFR 410.35 specifies that radiation therapy services are covered when:

• Performed by or under the direct supervision of a physician
• Reasonable and necessary for diagnosis or treatment of an illness or injury
• Furnished in compliance with standards governing the safety of radioactive material
• Documented in the patient's medical record with appropriate treatment planning notes, dosimetry calculations, and treatment summaries

The regulation distinguishes between external beam radiation therapy (linear accelerator, cobalt-60, proton beam, etc.) and brachytherapy (sealed sources placed within or adjacent to the tumor), each with distinct billing and coverage rules.

Payment Methodology: Hospital Outpatient versus Freestanding

Radiation therapy in the United States is delivered in two main settings, and Medicare pays for each differently:

Hospital Outpatient Department (HOPD): Paid under OPPS using Ambulatory Payment Classifications (APCs). Beneficiary owes 20 percent Part B coinsurance, capped at the Part A inpatient deductible ($1,736 in 2026) per service. The hospital bills the technical component under its hospital provider number, and the physician separately bills the professional component.

Freestanding Radiation Therapy Center: Paid under the Medicare Physician Fee Schedule (PFS) using technical component (TC) and professional component (PC) Relative Value Units (RVUs). The freestanding center bills the TC under the center's provider number, and the radiation oncologist bills the PC under the physician's NPI. Beneficiary owes 20 percent Part B coinsurance per PFS-allowed amount; no per-service coinsurance cap applies, unlike OPPS.

BBA 2015 Section 603 Site-Neutral Payment

Section 603 of the Bipartisan Budget Act of 2015 (Public Law 114-74) reduced payment for services furnished at certain off-campus hospital provider-based departments (off-campus PBDs) by aligning their payment with PFS rates rather than OPPS rates. Off-campus PBDs that began operating after November 2, 2015, generally receive PFS-based payment. The site-neutral provisions affect radiation therapy in some hospital-affiliated centers located off the main hospital campus, with the practical consequence that beneficiaries at off-campus PBDs may have higher coinsurance exposure (no OPPS cap) than at on-campus HOPDs.

OPPS APC Framework for Radiation Therapy

CMS groups radiation therapy services into Ambulatory Payment Classifications (APCs), each with its own Medicare payment rate. Major APC categories include simple, intermediate, and complex treatment delivery; radiation therapy planning (with higher-level APCs for IMRT planning); stereotactic radiosurgery and SBRT delivery; proton beam treatment delivery; and brachytherapy source application. CMS updates APC rates annually in the OPPS final rule, published each November.

Each APC has its own coinsurance cap at the Part A inpatient deductible ($1,736 in 2026). For high-cost services like SRS, the 20 percent coinsurance is capped at $1,736. For lower-cost services like simple daily treatment delivery, the 20 percent coinsurance falls well below the cap.

Physician Fee Schedule Technical and Professional Components

In a freestanding radiation therapy center, the radiation therapy payment splits into:

• Technical Component (TC): Covers the equipment (linear accelerator, simulator, computer planning system), supplies, staff (radiation therapists, dosimetrists, medical physicists), and facility overhead. Billed by the freestanding center under modifier TC.
• Professional Component (PC): Covers the radiation oncologist's professional work (consultation, planning oversight, daily review, weekly management). Billed by the physician under modifier 26.
• Global Billing: Combined TC and PC, billed when the same entity owns both the equipment and the physician practice (no modifier needed).

The TC/PC split allows separate billing for the facility's contribution and the physician's contribution, similar to other radiologic services.

Modern Radiation Therapy Techniques

External Beam Radiation Therapy (EBRT)

2D Conformal Radiation Therapy (2D-CRT): The oldest external beam technique. Beam shaped using physical blocks. Used primarily for palliation and selected emergency settings. CPT codes 77401, 77402, 77407, 77412.

3D Conformal Radiation Therapy (3D-CRT): Multiple beam angles shaped using CT-based planning. Standard external beam technique for many cancers when IMRT is not indicated. CPT codes 77407 to 77416.

Intensity-Modulated Radiation Therapy (IMRT): Computer-controlled modulation of beam intensity using multileaf collimators (MLCs). IMRT allows precise dose sculpting around the tumor while sparing normal tissue. IMRT is the standard of care for head and neck cancers, prostate cancer, many breast cancers, lung cancers, and selected other diagnoses. CPT 77385 (simple IMRT) or 77386 (complex IMRT) for treatment delivery. CPT 77301 for IMRT planning. CPT 77338 for multi-leaf collimator design.

Image-Guided Radiation Therapy (IGRT): Imaging (typically cone-beam CT or kV imaging) performed before or during treatment to verify patient positioning and target location. IGRT is now standard practice with IMRT. CPT 77387 (image guidance, daily).

Volumetric Modulated Arc Therapy (VMAT): A variant of IMRT in which the linear accelerator gantry rotates around the patient while modulating beam intensity. VMAT delivers IMRT-quality plans in substantially shorter treatment times. Billed under IMRT codes.

Stereotactic Radiation Techniques

Stereotactic Radiosurgery (SRS): Single-fraction or up to 5-fraction high-dose treatment, traditionally for intracranial targets. CPT 77371 (multi-source SRS, e.g., Gamma Knife) or 77372 (single-source SRS, e.g., linac-based platforms). Coverage indications include brain metastases, primary brain tumors, arteriovenous malformations, trigeminal neuralgia, and acoustic neuroma.

Stereotactic Body Radiation Therapy (SBRT): Few-fraction (typically 3 to 5) high-dose treatment for extracranial targets. CPT 77373. Covered indications include early-stage non-small cell lung cancer (NSCLC) in medically inoperable patients, oligometastatic disease, liver metastases, spine metastases, and prostate cancer (5-fraction regimen now endorsed by the National Comprehensive Cancer Network).

Proton Beam Therapy

Proton beam therapy uses charged particles (protons) instead of photons. The Bragg peak property of protons allows precise deposition of energy at the tumor depth with reduced exit dose, sparing normal tissue beyond the target. Indications with broad coverage include:

• Pediatric cancers (most pediatric solid tumors)
• Ocular melanoma
• Skull base tumors (chordoma, chondrosarcoma)
• Selected head and neck cancers
• Selected re-irradiation cases

Indications with controversial coverage:

• Adult prostate cancer (large randomized trials have not consistently shown improved outcomes versus IMRT; Medicare coverage variable based on MAC LCD)
• Adult lung cancer
• Adult breast cancer
• Adult brain tumors

CPT codes 77520 (simple), 77522 (simple with compensator), 77523 (intermediate), 77525 (complex). Local Coverage Determinations from Medicare Administrative Contractors specify covered indications. Palmetto GBA Jurisdiction J has an LCD addressing proton beam therapy. The Emory Proton Therapy Center at Winship Cancer Institute is one of approximately 40 proton centers in the United States and serves Georgia and the broader Southeast.

Brachytherapy

Brachytherapy involves placement of sealed radioactive sources within or adjacent to the tumor.

Low-Dose-Rate (LDR) Brachytherapy: Permanent or temporary seed implants. Most commonly used for prostate cancer (I-125 or Pd-103 seeds) and ocular melanoma (radioactive plaque). CPT codes 77770 (LDR brachytherapy treatment delivery), 77761 to 77763 (intracavitary or interstitial application).

High-Dose-Rate (HDR) Brachytherapy: Remote afterloading using Ir-192 source temporarily placed and then removed. Used for cervical cancer, prostate cancer, breast cancer, and other selected diagnoses. CPT codes 77770 to 77772 (HDR brachytherapy treatment delivery, simple/intermediate/complex).

Treatment Planning and Simulation

Before treatment begins, radiation oncology requires planning:

• Simulation: CT-based imaging to localize the target volume. CPT 77280 to 77295.
• Treatment Planning: Calculation of dose distribution. CPT 77261 to 77263 (clinical planning), 77295 (3D planning), 77301 (IMRT planning), 77338 (multi-leaf collimator design).
• Dosimetry: Detailed calculation of dose to target and normal tissue.
• Physics Quality Assurance: Validation for IMRT, SBRT, SRS, and proton plans.

Planning is billed once per treatment course, distinct from daily treatment delivery codes.

Radiation Oncology Model Status

The CMS Innovation Center proposed the Radiation Oncology Model (RO Model) in 2019, finalized it in 2020, and intended a 2021 launch. The RO Model would have created a prospective bundled payment for 90-day episodes of radiation therapy covering 16 cancer types, replacing fee-for-service billing for participating physician groups and hospitals. The model was postponed multiple times by Congress and CMS. As of 2026, the RO Model has not been implemented and is considered effectively shelved. Some elements may be revisited in future payment reform proposals.

Quality Reporting

Radiation oncology is subject to the Merit-based Incentive Payment System (MIPS) quality reporting framework for physicians paid under the PFS. Hospitals report quality through the Hospital Outpatient Quality Reporting Program (OQR). Radiation-specific measures include plan of care documentation, pain assessment for radiation patients, and use of evidence-based techniques.

Beneficiary Cost-Sharing

Original Medicare

• HOPD setting: 20 percent Part B coinsurance after annual Part B deductible ($283 in 2026), capped at the Part A inpatient deductible ($1,736 in 2026) per service
• Freestanding center: 20 percent Part B coinsurance after annual Part B deductible; no per-service cap

A typical radiation course involves 5 to 40 daily treatment fractions over weeks to months. Daily coinsurance accumulates substantially. The inpatient deductible cap protects against runaway costs in the HOPD setting; the absence of a cap in the freestanding setting can mean substantial cumulative coinsurance without Medigap protection.

Medicare Supplement

Plan G covers the 20 percent Part B coinsurance and Part B excess charges; beneficiary owes the annual Part B deductible. Plan N covers the 20 percent coinsurance except for the $20 office-visit copay (generally not applicable to radiation treatment visits) and the $50 ER copay. Both plans effectively eliminate out-of-pocket cost-sharing for radiation therapy beyond the Part B deductible.

Medicare Advantage

Medicare Advantage plans typically charge specialist copay or percentage coinsurance per visit. Some MA plans require prior authorization for IMRT, SBRT, SRS, and proton beam therapy. The annual out-of-pocket maximum (Medicare Advantage MOOP, capped at $9,250 in-network in 2026 for most plans) protects against catastrophic costs across a radiation course.

Georgia Radiation Oncology Landscape

Emory Winship Cancer Institute

Emory Winship Cancer Institute is the only National Cancer Institute (NCI)-designated cancer center in Georgia. Winship operates radiation oncology at multiple sites:

• Winship Cancer Institute at Emory University Hospital
• Emory Saint Joseph's Cancer Center
• Emory Johns Creek Cancer Center
• Emory Decatur Cancer Center

The Emory Proton Therapy Center opened in Atlanta in 2018 as one of approximately 40 proton beam centers in the United States and the only proton center in Georgia. The Emory Proton Therapy Center treats pediatric and adult patients with diagnoses where proton therapy offers clinical advantage.

Other Major Hospital-Based Radiation Oncology Programs

Piedmont Cancer Institute operates radiation oncology at Piedmont Atlanta, Piedmont Fayette, Piedmont Henry, Piedmont Newnan, Piedmont Columbus, Piedmont Macon, and Piedmont Athens Regional.

Wellstar Cancer Center operates at Wellstar Kennestone, Wellstar North Fulton, Wellstar Cobb, Wellstar Spalding, and Wellstar West Georgia.

Northeast Georgia Health System Cancer Center operates at NGMC Gainesville and NGMC Braselton.

Memorial Health Curtis and Elizabeth Anderson Cancer Institute (HCA Healthcare) operates in Savannah as the largest cancer program in southeast Georgia.

AU Cancer Center / Wellstar MCG Cancer Center operates in Augusta as the academic cancer program for the Medical College of Georgia.

Atrium Health Navicent Cancer Center operates in Macon.

Phoebe Cancer Center operates in Albany, the primary cancer program for southwest Georgia.

Grady Cancer Center operates at Grady Memorial Hospital in Atlanta, serving the safety-net population.

Tanner Cancer Center operates at Tanner Medical Center Carrollton.

Freestanding Radiation Oncology Centers

GenesisCare (which acquired 21st Century Oncology in 2021) operates several Georgia freestanding centers across metro Atlanta and surrounding areas.

US Oncology Network practice partners operate freestanding centers in Atlanta and other Georgia cities.

Cancer Specialists of South Carolina and Georgia operates centers in the Augusta region.

Smaller regional groups operate centers in Macon, Albany, Valdosta, Brunswick, and other regional centers.

Rural Access Challenges

Rural Georgia has limited radiation oncology access. Patients in rural counties may travel 50 to 150 miles to the nearest radiation center, often in a regional hub like Albany, Tifton, Valdosta, Macon, Athens, Brunswick, or Augusta. The travel burden is substantial for fractionated radiation therapy requiring daily treatment for 5 to 40 days. Hypofractionated regimens (fewer, higher-dose fractions) have grown in adoption partly because they reduce travel burden for rural patients. Lodging assistance from the American Cancer Society Hope Lodge program and Patient Advocate Foundation can help bridge the financial gap.

Worked Examples

Example 1: Margaret, 78, Atlanta, Breast Cancer Hypofractionated IMRT at Emory Winship Cancer Institute

Margaret is diagnosed with early-stage left breast cancer. After lumpectomy, she receives adjuvant radiation therapy. Her radiation oncologist recommends 16-fraction hypofractionated IMRT (4 weeks of treatment, Monday through Friday). Treatment is delivered at Emory Winship Cancer Institute at Emory University Hospital (HOPD setting). Margaret has Original Medicare with Plan G.

Billing components per typical course:

• Initial consultation (CPT 99205): standard E/M payment
• Treatment planning (CPT 77301 IMRT planning + CPT 77338 MLC design): approximately $2,000
• Treatment delivery (CPT 77386 complex IMRT, 16 fractions): approximately $280 per fraction × 16 = $4,480
• Image guidance (CPT 77387, 16 fractions): approximately $20 per fraction × 16 = $320
• Weekly management (CPT 77427, 4 weeks): approximately $200 × 4 = $800
• Total approximate Medicare-allowed amount: $7,600

Beneficiary cost-sharing:

• 20% coinsurance: $1,520
• Each individual service has its own coinsurance cap at the Part A inpatient deductible ($1,736 in 2026); the IMRT planning service ($2,000 × 20% = $400) and the 16 daily delivery services ($280 × 20% = $56 each) are each well below the cap
• Plan G covers the $1,520 plus the $283 Part B deductible (after first met for the year)
• Margaret's out-of-pocket for radiation course: $0

Example 2: Robert, 82, Savannah, Prostate Cancer SBRT 5-Fraction at Memorial Cancer Institute

Robert is diagnosed with intermediate-risk prostate cancer. He elects stereotactic body radiation therapy (SBRT), a 5-fraction regimen delivered over 1 to 2 weeks. Treatment is delivered at Memorial Health Curtis and Elizabeth Anderson Cancer Institute in Savannah (HOPD setting). Robert has Original Medicare with Plan N.

Billing components:

• Initial consultation: standard E/M
• Treatment planning (CPT 77301 + CPT 77338): approximately $2,000
• SBRT treatment delivery (CPT 77373, 5 fractions): approximately $1,400 per fraction × 5 = $7,000
• Weekly management (CPT 77427, 1 to 2 weeks): approximately $200 × 2 = $400
• Total approximate Medicare-allowed amount: $9,400

Beneficiary cost-sharing:

• 20% coinsurance: $1,880
• Coinsurance cap: $1,736 per service. SBRT treatment delivery at $1,400 × 20% = $280 per fraction, far below the cap
• Plan N covers the coinsurance ($1,880). Radiation treatment delivery visits are not office or ER visits, so the $20 office copay and $50 ER copay do not apply
• Plan N does not cover Part B excess charges (15% above approved amount). Most freestanding and HOPD radiation programs accept Medicare assignment, so this rarely matters
• Robert's out-of-pocket for radiation course: minimal (Part B deductible if not previously met)

Example 3: Linda, 75, Macon, NSCLC SBRT at Atrium Navicent Cancer Center

Linda is diagnosed with stage IA non-small cell lung cancer. She is medically inoperable due to severe COPD. Her radiation oncologist recommends SBRT (3 fractions delivered over 1 to 2 weeks). Treatment is delivered at Atrium Health Navicent Cancer Center in Macon (HOPD). Linda has Original Medicare with Plan G.

Billing components:

• Initial consultation: standard E/M
• Treatment planning: approximately $2,000
• SBRT treatment delivery (CPT 77373, 3 fractions): approximately $1,400 × 3 = $4,200
• Weekly management: approximately $200 × 1 = $200
• Total approximate Medicare-allowed amount: $6,400

Beneficiary cost-sharing:

• 20% coinsurance: $1,280
• Plan G covers the $1,280 plus the Part B deductible
• Linda's out-of-pocket for radiation course: $0

Example 4: Charles, 80, Augusta, Glioblastoma Postoperative IMRT at AU Cancer Center / Wellstar MCG Cancer Center

Charles is diagnosed with glioblastoma multiforme after surgical resection. He receives adjuvant chemoradiation with temozolomide and 30-fraction IMRT (6 weeks of treatment, Monday through Friday). Treatment is delivered at the AU Cancer Center (now part of Wellstar MCG Cancer Center) in Augusta. Charles has Original Medicare with Plan G.

Billing components:

• Initial consultation: standard E/M
• Treatment planning (IMRT): approximately $2,000
• Treatment delivery (CPT 77386, 30 fractions): approximately $280 × 30 = $8,400
• Image guidance (CPT 77387, 30 fractions): approximately $20 × 30 = $600
• Weekly management (CPT 77427, 6 weeks): approximately $200 × 6 = $1,200
• Total approximate Medicare-allowed amount: $12,200

Beneficiary cost-sharing:

• 20% coinsurance: $2,440
• Plan G covers the $2,440 plus the Part B deductible
• Charles's out-of-pocket for radiation course: $0

The chemotherapy with temozolomide is billed separately under Part B (for oral chemotherapy meeting Part B drug payment criteria) or Part D (typically) depending on the specific drug formulation and dispensing setting.

Example 5: Patricia, 73, Columbus, Brain Metastases SRS at Piedmont Columbus Cancer Center

Patricia has metastatic breast cancer with three brain metastases. Her radiation oncologist recommends single-fraction stereotactic radiosurgery (SRS) to treat all three lesions. Treatment is delivered at Piedmont Columbus Cancer Center using a linac-based SRS platform (HOPD setting). Patricia has Original Medicare with Plan G.

Billing components:

• Initial consultation: standard E/M
• SRS treatment planning (specialized planning for SRS): approximately $2,500
• SRS treatment delivery (CPT 77372, single-source SRS, may include codes for multiple targets): approximately $8,800 for the SRS delivery APC
• Total approximate Medicare-allowed amount: $11,300

Beneficiary cost-sharing:

• 20% coinsurance: $2,260
• Coinsurance cap: $1,736 per service. The SRS treatment delivery ($8,800 × 20% = $1,760) is capped at $1,736
• Plan G covers the capped coinsurance plus the Part B deductible
• Patricia's out-of-pocket for SRS: $0

Example 6: Henry, 85, Athens, Prostate Cancer LDR Brachytherapy at NGMC Cancer Center

Henry is diagnosed with low-risk prostate cancer. He elects permanent seed brachytherapy (LDR brachytherapy with I-125 seeds). The procedure is performed at NGMC Cancer Center in Gainesville (HOPD setting). Henry has Original Medicare with Plan G.

Billing components:

• Initial consultation: standard E/M
• Brachytherapy treatment planning: approximately $800
• Brachytherapy seed application (CPT 55875 transperineal placement + CPT 77778 intracavitary brachytherapy supervision + supplies for I-125 seeds): approximately $5,000 to $8,000 depending on seed count and APC
• Total approximate Medicare-allowed amount: $7,500

Beneficiary cost-sharing:

• 20% coinsurance: $1,500
• Coinsurance cap: $1,736 per service. The brachytherapy procedure is below the cap
• Plan G covers the coinsurance plus the Part B deductible
• Henry's out-of-pocket for brachytherapy: $0

The radioactive source supplies (I-125 seeds) are paid separately under OPPS device payment policy. Total payment to the HOPD includes both the procedure payment and the device payment.

Common Mistakes and Pitfalls

1. Confusing Radiation Therapy with Chemotherapy

Radiation therapy uses ionizing radiation (X-rays, electrons, protons, gamma rays) to damage cancer cell DNA. Chemotherapy uses drugs. The two are often combined (chemoradiation) but are billed separately under distinct payment frameworks.

2. Believing IMRT Is Always Required

IMRT, IGRT, SBRT, and SRS are appropriate for specific indications based on the cancer type, tumor location, and proximity to critical structures. Older techniques (3D-CRT) remain the standard of care for many cancers and have lower cost-sharing exposure.

3. Assuming All Proton Beam Therapy Is Covered

Coverage of proton beam therapy depends on the indication. Pediatric cancers, ocular melanoma, and skull base chordoma/chondrosarcoma are broadly covered. Adult prostate cancer proton therapy is controversial and may be denied or paid only at IMRT-equivalent rates depending on the MAC LCD. Palmetto GBA Jurisdiction J's LCD specifies covered and non-covered proton indications.

4. Confusing Technical Component with Professional Component

In freestanding centers, the TC and PC are billed separately. The PC covers the radiation oncologist's professional services; the TC covers the facility, equipment, and staff. In HOPDs, the hospital bills the technical component under OPPS, and the physician bills the PC under PFS.

5. Overlooking the OPPS Coinsurance Cap

Each individual radiation service (each APC) has a coinsurance cap at the Part A inpatient deductible ($1,736 in 2026). Across a full course of treatment with many fractions, the total coinsurance can be substantial; the cap applies per service, not per course.

6. Treating Freestanding Center Coinsurance Like HOPD

Freestanding centers paid under PFS do NOT have the inpatient-deductible coinsurance cap. Coinsurance is 20 percent of each allowed amount, no cap. For high-cost services like proton beam, this matters.

7. Forgetting the BBA 2015 Section 603 Site-Neutral Adjustment

Some off-campus hospital provider-based departments are paid at PFS rates rather than OPPS rates. This affects whether the OPPS coinsurance cap applies. Verify the setting designation when comparing options.

8. Missing Prior Authorization for Medicare Advantage

Many Medicare Advantage plans require prior authorization for IMRT, SBRT, SRS, and proton beam therapy. Original Medicare generally does not require prior authorization for radiation therapy. Failing to obtain prior authorization under MA can result in claim denial.

9. Misunderstanding Hypofractionation

Hypofractionated regimens deliver higher doses per fraction in fewer fractions (e.g., 16-fraction breast radiation versus traditional 25 to 30 fraction). Coverage is the same; the total Medicare-allowed amount is generally lower because fewer treatment delivery codes are billed.

10. Believing the Radiation Oncology Model Is in Effect

The RO Model proposed in 2019 has not been implemented as of 2026. Radiation therapy continues to be paid under standard OPPS, PFS, and ASC payment systems.

11. Confusing LDR and HDR Brachytherapy

LDR brachytherapy uses permanent seeds (most commonly for prostate cancer). HDR brachytherapy uses temporary remote afterloading (most commonly for cervical and selected prostate cancers). The billing codes, payment, and coinsurance differ.

12. Overlooking the Treatment Planning Charge

Treatment planning is billed once per course and can be substantial (approximately $2,000 for IMRT planning). Beneficiaries should ask for an estimate of the total treatment cost, not just the daily delivery cost.

13. Missing the Weekly Management Charge

CPT 77427 (weekly radiation oncology management) is billed once per week during the course of treatment. This is a separate professional service from treatment planning and treatment delivery.

14. Assuming Plan N Has $20 Copays on Every Radiation Visit

The Plan N $20 office-visit copay applies to office E/M visits, not to radiation treatment delivery visits. Beneficiaries should not be charged $20 per radiation fraction.

Brevy and How We Can Help

Brevy (brevy.com) is an eldercare advocacy organization that helps Georgia Medicare beneficiaries and their families understand Medicare coverage rules, including radiation therapy. We can help you read your radiation therapy explanation of benefits, distinguish facility fees from professional fees, understand the OPPS APC and PFS TC/PC payment structures, verify the application of the coinsurance cap, and decide whether to appeal a denied radiation claim or pursue prior authorization for IMRT, SBRT, SRS, or proton beam therapy under a Medicare Advantage plan. We do not provide medical care; we provide information and advocacy.

::: accordion Q1: What is radiation therapy?

Radiation therapy is a cancer treatment that uses high-energy ionizing radiation (X-rays, electrons, protons, gamma rays) to damage cancer cell DNA. It is delivered either as external beam radiation (linear accelerator, proton beam) or brachytherapy (sealed radioactive sources placed in or near the tumor).

Q2: Does Medicare cover radiation therapy?

Yes. Medicare covers radiation therapy under Section 1861(s)(1) (physician services) and Section 1861(s)(2)(B) (hospital outpatient services), with implementing regulations at 42 CFR 410.35. Coverage is available when the therapy is reasonable and necessary, performed by or under physician supervision, and documented appropriately.

Q3: How is radiation therapy paid by Medicare?

In hospital outpatient departments (HOPDs), radiation therapy is paid under the Hospital Outpatient Prospective Payment System (OPPS) using Ambulatory Payment Classifications. In freestanding radiation centers, it is paid under the Medicare Physician Fee Schedule with separate Technical Component (billed by the facility) and Professional Component (billed by the physician).

Q4: What is the OPPS coinsurance cap?

Each individual radiation service (each APC) has a coinsurance cap at the Part A inpatient deductible ($1,736 in 2026). This means the beneficiary cannot owe more than $1,736 in coinsurance for any single service. The cap applies per service, not per course.

Q5: Does the coinsurance cap apply at freestanding centers?

No. Freestanding radiation centers are paid under the Medicare Physician Fee Schedule, which does not include the OPPS coinsurance cap. Coinsurance is 20 percent of each allowed amount, no cap. For high-cost services, this matters.

Q6: What is intensity-modulated radiation therapy (IMRT)?

IMRT is a computer-controlled external beam radiation technique that modulates beam intensity using multileaf collimators to sculpt precise dose distributions around the tumor while sparing normal tissue. IMRT is the standard of care for head and neck, prostate, many breast, lung, and selected other cancers. CPT codes 77385 (simple) and 77386 (complex) for treatment delivery.

Q7: What is stereotactic body radiation therapy (SBRT)?

SBRT delivers high-dose radiation in a small number of fractions (typically 3 to 5) to extracranial targets with stereotactic precision. Covered indications include early-stage NSCLC in medically inoperable patients, oligometastatic disease, liver metastases, spine metastases, and prostate cancer. CPT 77373.

Q8: What is stereotactic radiosurgery (SRS)?

SRS delivers single-fraction or up to 5-fraction high-dose radiation to intracranial targets with stereotactic precision. Covered indications include brain metastases, primary brain tumors, AVMs, trigeminal neuralgia, and acoustic neuroma. CPT 77371 (Gamma Knife) or 77372 (linac-based SRS).

Q9: Does Medicare cover proton beam therapy?

Coverage of proton beam therapy depends on the indication and the Medicare Administrative Contractor's Local Coverage Determination. Pediatric cancers, ocular melanoma, and skull base chordoma/chondrosarcoma are broadly covered. Adult prostate proton therapy is controversial. Palmetto GBA Jurisdiction J's LCD specifies covered and non-covered indications for Georgia beneficiaries.

Q10: Where is the closest proton beam center to Georgia?

The Emory Proton Therapy Center, opened in Atlanta in 2018, is the only proton beam facility in Georgia and one of approximately 40 in the United States. It serves pediatric and adult patients with proton-indicated diagnoses from across the Southeast.

Q11: What is brachytherapy?

Brachytherapy involves placement of sealed radioactive sources within or adjacent to the tumor. Low-dose-rate (LDR) brachytherapy uses permanent or temporary seed implants (most commonly for prostate cancer). High-dose-rate (HDR) brachytherapy uses temporary remote afterloading with Ir-192 source (most commonly for cervical, prostate, and breast cancers).

Q12: How much will I pay out-of-pocket for radiation therapy?

You owe 20 percent Part B coinsurance after the annual Part B deductible ($283 in 2026). In HOPD settings, each service is capped at the Part A inpatient deductible ($1,736 in 2026). Medicare Supplement Plans G and N cover the coinsurance, leaving only the Part B deductible. Medicare Advantage plans charge specialist copay or percentage coinsurance per visit with an annual out-of-pocket maximum.

Q13: What is hypofractionated radiation therapy?

Hypofractionated regimens deliver higher doses per fraction in fewer fractions (e.g., 16-fraction breast radiation versus traditional 25 to 30 fraction). Hypofractionation reduces treatment duration, travel burden, and total cost. Coverage is the same as conventionally fractionated radiation.

Q14: Do I need prior authorization for radiation therapy?

Original Medicare generally does not require prior authorization for radiation therapy. Many Medicare Advantage plans do require prior authorization for IMRT, SBRT, SRS, and proton beam therapy. Failing to obtain prior authorization under MA can result in claim denial.

Q15: What is the Radiation Oncology Model?

The CMS Innovation Center proposed the Radiation Oncology Model (RO Model) in 2019, intended to create prospective bundled payments for 90-day radiation episodes covering 16 cancer types. The model has been postponed multiple times and has not been implemented as of 2026.

Q16: What is the BBA 2015 Section 603 site-neutral payment provision?

Section 603 of the Bipartisan Budget Act of 2015 reduced payment for services furnished at off-campus hospital provider-based departments (off-campus PBDs) by aligning their payment with PFS rates rather than OPPS rates. Off-campus PBDs that began operating after November 2, 2015, generally receive PFS-based payment. The practical consequence for radiation therapy is that beneficiaries at off-campus PBDs may have higher coinsurance exposure (no OPPS cap) than at on-campus HOPDs.

Q17: What is the difference between treatment planning and treatment delivery?

Treatment planning involves simulation (CT imaging to localize the target), dosimetry (calculation of dose distribution), and physics quality assurance. Treatment planning is billed once per course (e.g., CPT 77301 for IMRT planning, approximately $2,000). Treatment delivery is the daily radiation administration (e.g., CPT 77386 for complex IMRT delivery, approximately $280 per fraction). Both are billed during the course of treatment.

Q18: What is image-guided radiation therapy (IGRT)?

IGRT uses imaging (cone-beam CT or kV imaging) before or during each treatment to verify patient positioning and target location. IGRT is now standard practice with IMRT. CPT 77387, billed daily.

Q19: Does Medicare cover the treatment planning charge?

Yes. Treatment planning (CPT 77261 to 77299) is a covered Medicare service, billed once per course of treatment. Coinsurance applies to the planning charge as to other services.

Q20: What is the weekly management charge (CPT 77427)?

CPT 77427 is the weekly radiation oncology management service, billed by the radiation oncologist once per week during the course of treatment. It covers the physician's review of the patient's progress, side-effect management, and treatment adjustments. Standard 20 percent coinsurance applies.

Q21: Where is radiation therapy delivered in Georgia?

Major radiation oncology programs include Emory Winship Cancer Institute (the only NCI-designated cancer center in Georgia), Piedmont Cancer Institute, Wellstar Cancer Center, NGHS Cancer Center, AU/Wellstar MCG Cancer Center, Memorial Health Cancer Institute, Atrium Navicent Cancer Center, Phoebe Cancer Center, Grady Cancer Center, and Tanner Cancer Center. The Emory Proton Therapy Center is the only proton beam facility in Georgia. Numerous freestanding centers operate across the state.

Q22: How does Medicare Advantage cover radiation therapy?

Medicare Advantage plans must cover the same radiation therapy services as Original Medicare under the Medicare Advantage parity rule. However, MA plans have their own provider networks, copays/coinsurance, and prior authorization requirements. Review your plan's Evidence of Coverage and Summary of Benefits to understand specific cost-sharing.

Q23: Can I appeal a denied radiation therapy claim?

Yes. Under Original Medicare, you have five levels of appeal: redetermination by Palmetto GBA Jurisdiction J, reconsideration by a Qualified Independent Contractor, ALJ hearing, Medicare Appeals Council, and federal district court. Medicare Advantage and Part D have similar five-level appeals frameworks. GeorgiaCares SHIP, the Medicare Rights Center, Center for Medicare Advocacy, Atlanta Legal Aid, and Georgia Legal Services Program offer free assistance.

Q24: How do hospital-based and freestanding radiation centers compare?

For the same procedure, hospital outpatient departments (paid under OPPS) and freestanding centers (paid under PFS) may have different total Medicare-allowed amounts and different cost-sharing structures. HOPDs have the coinsurance cap per service; freestanding centers do not. Beneficiaries should ask for cost estimates from each setting when comparing options.

Q25: How can Brevy help me with radiation therapy questions?

Brevy (brevy.com) is an eldercare advocacy organization that helps Georgia Medicare beneficiaries understand Medicare coverage rules. We can help you read your radiation therapy explanation of benefits, distinguish facility fees from professional fees, understand the OPPS and PFS payment structures, verify the application of the coinsurance cap, and decide whether to appeal a denied claim or pursue prior authorization. We can also connect you with GeorgiaCares SHIP and other free counseling resources.

Find personalized help understanding your radiation therapy coverage at brevy.com. :::

Standard Disclaimers

This article is for general informational purposes only and does not constitute legal, medical, financial, or insurance advice. Medicare rules, payment rates, APCs, RVUs, and Local Coverage Determinations change periodically. Verify all information with the relevant Medicare Administrative Contractor, the Centers for Medicare and Medicaid Services, your provider, and your Medicare Supplement or Medicare Advantage plan before making decisions. Brevy (brevy.com) provides advocacy and information services; we do not provide medical care or legal representation, and the content of this article does not establish any provider-patient or attorney-client relationship.

::: cta Contact Resources for Georgia Medicare Radiation Therapy

1. Medicare : 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, medicare.gov
2. Palmetto GBA Jurisdiction J (Georgia Medicare Administrative Contractor) : 1-877-567-9230
3. Kepro QIO (Beneficiary and Family-Centered Care Quality Improvement Organization) : 1-844-455-8708
4. GeorgiaCares SHIP (Georgia's State Health Insurance Assistance Program) : 1-866-552-4464
5. Georgia DCH Medicaid Member Services : 1-866-211-0950
6. American Society for Radiation Oncology (ASTRO) : astro.org
7. American Society of Clinical Oncology (ASCO) : asco.org
8. American Cancer Society : 1-800-227-2345, cancer.org
9. National Cancer Institute Cancer Information Service : 1-800-422-6237, cancer.gov
10. Cancer Support Community : 1-888-793-9355, cancersupportcommunity.org
11. Patient Advocate Foundation : 1-800-532-5274, patientadvocate.org
12. Social Security Administration : 1-800-772-1213, TTY 1-800-325-0778, ssa.gov
13. HHS Office for Civil Rights : 1-800-368-1019, TTY 1-800-537-7697
14. HHS Office of Inspector General Hotline : 1-800-447-8477 (1-800-HHS-TIPS)
15. Medicare Rights Center : 1-800-333-4114, medicarerights.org
16. Center for Medicare Advocacy : 1-860-456-7790, medicareadvocacy.org
17. Atlanta Legal Aid Society : 404-377-0701, atlantalegalaid.org
18. Georgia Legal Services Program : 1-800-498-9469, glsp.org
19. Eldercare Locator : 1-800-677-1116
20. 211 Georgia (United Way of Greater Atlanta) : dial 2-1-1 :::