ASTRO 2026 Active Motion Management recommendations

[Gfunk6]

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ASTRO just published its 2026 Active Motion Management Model Policy, and it draws a much clearer line than many people have been using in practice. AMM requires that intrafraction motion information actively and continuously influences radiation delivery in real time, such as beam on/off, tracking, gating, or adaptive modification. If motion data does not directly affect beam delivery during treatment, ASTRO explicitly states that it does not meet the definition of AMM.

ASTRO cites respiratory gating, triggered imaging, fiducial tracking, MR-guided RT, and DIBH tied to real-time beam control as appropriate examples. Typical indications include lung, upper abdominal, breast DIBH, prostate with real-time fiducial tracking, and selected patients with anticipated intrafraction motion. Bottom line: AMM is not CBCT, setup imaging, or passive motion monitoring. If the beam is not responding to motion in real time, ASTRO says it is not AMM.

This directly conflicts with Evil Corp guidelines which says 77412 only applies due to respiratory motional management.

 

[Ray D. Ayshun]

ASTRO just published its 2026 Active Motion Management Model Policy, and it draws a much clearer line than many people have been using in practice. AMM requires that intrafraction motion information actively and continuously influences radiation delivery in real time, such as beam on/off, tracking, gating, or adaptive modification. If motion data does not directly affect beam delivery during treatment, ASTRO explicitly states that it does not meet the definition of AMM.

ASTRO cites respiratory gating, triggered imaging, fiducial tracking, MR-guided RT, and DIBH tied to real-time beam control as appropriate examples. Typical indications include lung, upper abdominal, breast DIBH, prostate with real-time fiducial tracking, and selected patients with anticipated intrafraction motion. Bottom line: AMM is not CBCT, setup imaging, or passive motion monitoring. If the beam is not responding to motion in real time, ASTRO says it is not AMM.

This directly conflicts with Evil Corp guidelines which says 77412 only applies due to respiratory motional management.

Technically speaking, if you're tracking fiducials you aren't managing motion necessarily. You're responding to it. ASTRO has defined active motion response. Sure, it's harder, but watching the target go up and down isn't managing motion..If they wanted those other things included they should have been more precise with their verbiage.

 

[Palex80]

Technically speaking, if you're tracking fiducials you aren't managing motion necessarily. You're responding to it.

You gotta track those magnetic fiducials on the MR linac. Then you are managing motion, by moving the target.

 

[Ray D. Ayshun]

You gotta track those magnetic fiducials on the MR linac. Then you are managing motion, by moving the target.

Rectal gas is actively moving the target.

 

[WildRivers]

A bit semantic

“Managing the effects of motion” is probably what we all are trying to do.

Helpful guidance, in my opinion.

Should have came out December 2025. Being proactive about these things should be part of what the society does, but here we are.

 

[BobbyHeenan]

I fiducial track on prostate SBRT cases but should I be doing it for say FLAME micro boost moderate hypofrac or standard frac cases?

Wouldn’t make any difference on the wRVU side/professional side but I’m sure the hospital would like it.

 

[medgator]

I fiducial track on prostate SBRT cases but should I be doing it for say FLAME micro boost moderate hypofrac or standard frac cases?

Wouldn’t make any difference on the wRVU side/professional side but I’m sure the hospital would like it.

Eventually hospital technical revenue improvements (or cuts) will find their way to you via wRVU contracting I would bet

 

[Ray D. Ayshun]

A bit semantic

“Managing the effects of motion” is probably what we all are trying to do.

Helpful guidance, in my opinion.

Should have came out December 2025. Being proactive about these things should be part of what the society does, but here we are.

Well that's what ITV's and PTV's do. I am being somewhat semantic as that's what attorneys are wont to do, but this is further evidence of imprecision and uninvolvement on the part of our professional organizations. Granted, evicore can't understand what multi-iso means.

 

[StealthTech]

Would exac trac for brain imrt be considered amm by this definition?

 

[FletchersGarb]

Would exac trac for brain imrt be considered amm by this definition?

Does it do automatic beam control?

 

[StealthTech]

It does intrafraction imaging and will hold the treatment if movement detected

 

[Gfunk6]

It does intrafraction imaging and will hold the treatment if movement detected

Then, yes it meets criteria as "gating." Not dissimilar to DIBH.

 

[StealthTech]

Thanks. Question is whether insurance will actually approve it over cbct alone.

 

[TheWallnerus]

Thanks. Question is whether insurance will actually approve it over cbct alone.

CBCT in and of itself is of course approved whenever EBRT is approved as the codes include image guidance (and no separate CBCT code exists anymore). For CBCT “reads” insurance companies usually already had their own existing (IGRT) policies which they ported over into this new dystopian era.

 

[TheWallnerus]

Does it do automatic beam control?

There seems to be allowance for manual (non-automatic) beam control in the ASTRO AMM guidelines? If so that surprised me.

 

[evilbooyaa]

There seems to be allowance for manual (non-automatic) beam control in the ASTRO AMM guidelines? If so that surprised me.

Yes - gating counting as manual beam control is an important distinction to make and one EvilCore has been fighting on

Would exac trac for brain imrt be considered amm by this definition?

Really, really interesting thought. If you're tracking intrafraction then yes.

I fiducial track on prostate SBRT cases but should I be doing it for say FLAME micro boost moderate hypofrac or standard frac cases?

Wouldn’t make any difference on the wRVU side/professional side but I’m sure the hospital would like it.

If you are placing Fiducials in all these pts anyways, there is no harm to asking for it. You may have to do a p2p to get 77412 approved for prostate (and that brings up a question if the juice is worth the squeeze if your professional RVUs would be otherwise unchanged) but I could see a logistical argument for patients getting FLAME-style boost with fiducial tracking.

A forward thinking admin would want you to do 77412 and reimburse you for the extra p2ps necessary that will end up making them 10-100x that reimbursement....

 

[drowsy12]

Let me know if you ever come across a forward thinking admin!

 

[ramsesthenice]

Clarity would be great. I was referred a cervical patient for HDR boost. Her tumor involved a good amount of uterus and I thought it was going to be easy to do with a hybrid applicator. But she has a tiny introitus with a lot of scaring and the only feasible HDR option is a perineal template. However, I think getting needles to track into the uterine body from the perinium will be a challenge. I ultimately decided the best option would be to do an adaptive MRL SBRT boost to make a brachy like plan. I didn't bother asking for SBRT because they won't approve it for a cervical boost. But I did ask for 5 fractions of IMRT with motion management.

Motion management denied. I do the P2P. I tell him what I want to do. He agreed its the best option. He also agreed that continuous imaging with tumor tracking and active beam management was appropriate. But he said using it for management of random pelvic motion doesn't meet the definition of active motion management. It is supposed to address predictable excursions you also attempt to actively minimize to bill for active motion management. If you are not using breath hold, compression, etc, no approval.

By this definition, there will be no 77412 for pelvic tumors which would include prostate. The ASTRO definition would be quite welcome in my mind.

 

[TheWallnerus]

Clarity would be great. I was referred a cervical patient for HDR boost. Her tumor involved a good amount of uterus and I thought it was going to be easy to do with a hybrid applicator. But she has a tiny introitus with a lot of scaring and the only feasible HDR option is a perineal template. However, I think getting needles to track into the uterine body from the perinium will be a challenge. I ultimately decided the best option would be to do an adaptive MRL SBRT boost to make a brachy like plan. I didn't bother asking for SBRT because they won't approve it for a cervical boost. But I did ask for 5 fractions of IMRT with motion management.

Motion management denied. I do the P2P. I tell him what I want to do. He agreed its the best option. He also agreed that continuous imaging with tumor tracking and active beam management was appropriate. But he said using it for management of random pelvic motion doesn't meet the definition of active motion management. It is supposed to address predictable excursions you also attempt to actively minimize to bill for active motion management. If you are not using breath hold, compression, etc, no approval.

By this definition, there will be no 77412 for pelvic tumors which would include prostate. The ASTRO definition would be quite welcome in my mind.

ASTRO recs/guidelines are, almost, of no power to affect what insurance companies will or won’t cover. ESPECIALLY if it’s a guideline resulting in an insurance company having to pay more.

I hope your billers/coders still let you do the motion management but also let you bill 77407.

 

[Grubbe-a-dub-dub]

Is this something new to prior auth approve a 77412 for left sided DIBH, but deny it for the boost? Had 2 cases like this.

Is the expectation to not use DIBH for the boost now? Seems a bit asinine....

 

[TheWallnerus]

Is this something new to prior auth approve a 77412 for left sided DIBH, but deny it for the boost? Had 2 cases like this.

Is the expectation to not use DIBH for the boost now? Seems a bit asinine....

You should be prior authing for all the 77412s you need, boost included; boosting should be as "hidden" as possible from the ins co's eyes in these instances. I know filling out the prior auth sheet may make one "confess" as to whether a boost is planned or not. But really what is boost? Who is boost? Why is boost?

 

[Grubbe-a-dub-dub]

Yea we do this, but they deny the 77412 for the boost portion. Reading through the guidelines, they will approve it for "Concurrent use of mixed photon/electron fields for the breast boost" which also seems kinda dumb, why not just for sole photon or electron plans?

 

[Ray D. Ayshun]

Yea we do this, but they deny the 77412 for the boost portion. Reading through the guidelines, they will approve it for "Concurrent use of mixed photon/electron fields for the breast boost" which also seems kinda dumb, why not just for sole photon or electron plans?

I think they want you to prove the resection cavity/boost volume is near the heart. I had to justify 77412 for left sided apbi. They wanted proximity to heart, particularly given IMRT planning. They wanted a p2p for 5 77412s, but would auto approve 16 77412s if 3D tangent whole breast.

 

[Grubbe-a-dub-dub]

On the P2P she said a screenshot would suffice, but what proximity to the heart is acceptable for 77412? Seems very subjective. DIBH will almost always reduce heart and LAD dose on left sided cases, so it's splitting hairs over nonsense.

 

[Ray D. Ayshun]

On the P2P she said a screenshot would suffice, but what proximity to the heart is acceptable for 77412? Seems very subjective. DIBH will almost always reduce heart and LAD dose on left sided cases, so it's splitting hairs over nonsense.

My impression is, they just want you to jump through the hoop. The coding change is brilliant in the context of how most physicians are paid. This doesn't really affect us in any obvious way, so they know we're apt to accept a little less tech revenue in order to just get on with our lives.

 

[TheWallnerus]

Hey remember how all those smart, non dumb people who helped the AMA and RUC walk through the CPT redefinitions said their ideas and verbal legerdemain would help eliminate prior auth hassles because the codes were designed “technique agnostic”?

Obviously, no, we don’t remember. The next time there are code redefinitions I’m sure roughly about the same people will be at the table again. And no one will remember again.