2026 Radiation Oncology Payment Cuts: The Payer Gap

The 2026 radiation oncology payment cuts that freestanding centers are seeing do not match the number CMS published. The CY 2026 physician fee schedule final rule put the specialty’s change at about negative 1 percent. By April 1, 2026, more than two-thirds of radiation oncologists answering an ASTRO survey reported declines of 10 percent or more, and the president of a large multi-site practice told AJMC that independent clinics had seen first-quarter revenue fall by as much as 30 to 40 percent in some locations. Both numbers are real. They measure different things.

The CMS estimate describes Medicare’s payment for the specialty’s whole mix of services. The survey describes what practices collected from every payer after commercial plans and Medicaid programs handled a new code set in their own ways. Here is the gap, one mechanism at a time, and what a billing team can do about each.

If your January remits came in short and you could not find a single cause, it is because there were four causes.

The two sets of numbers

Measure	Figure	Source
CMS impact estimate for radiation oncology, CY 2026 PFS	about -1 percent	CMS impact table, as cited by ASTRO and AuntMinnie
ASTRO member survey, released April 1, 2026	more than two-thirds reported declines of 10 percent or more; half said advanced treatments are frequently delayed or denied by insurers, citing prior authorization and trouble processing the new codes	ASTRO news release, Newswise republication
ASTRO comments on the CY 2027 rules, September 14, 2026	“declines of 10% or more, with many reporting cuts of 20% to 30%”	ASTRO news release, Newswise republication
Independent clinics, first quarter 2026	revenue down “up to 30% or 40%” depending on location	Todd Doyle, MD, New York Oncology Hematology and OneOncology, AJMC, April 15, 2026
LUGPA estimate for prostate IMRT billed as 77407	10 to 20 percent below 2025 IMRT payment unless Level 3 complexity is justified	LUGPA policy alert, December 2025

Why the Medicare number was small

Medicare’s aggregate change was modest because planning and management codes rose a few percent while CMS priced the three new delivery codes from hospital outpatient cost data, assuming 35 percent of delivery at Level 3 (77412), 55 percent at Level 2 (77407) and 10 percent at Level 1 (77402). A single-isocenter IMRT prostate course bills 77407, which pays less per fraction than the 2025 IMRT G-code did, and the separate technical image guidance line was removed; the payer contract readiness post calculates the difference for a 20-fraction course and the 2026 fee schedule post covers the rule itself.

Mechanism 1: payers that paid the new codes at old rates, or not at all

“The private payers did not go in and update their fee schedules,” Dr. Doyle told AJMC. His group contacted its top payers in every market in November and December 2025 to warn them the codes were changing. Some payers said patients mid-treatment would not need new authorizations and then denied those claims. He noted that many contracts do not require revenue-neutral repricing, that CMS has little power over commercial payers outside Medicare Advantage, and that a payer saves money every month it leaves the codes unrevalued.

On the remit this looks like one of three things. A contract that lists 77386 and 77014 by code has no row for 77407 or 77387, so the payer denies the line as not on the fee schedule, prices it at a default percentage of Medicare, or crosswalks it to an old rate. A contract written as a percentage of the current Medicare fee schedule repriced automatically to the lower 2026 delivery amount, and the technical IGRT payment ended. And a contract with a flat per-fraction IMRT rate now receives a code whose descriptor says “3D or IMRT,” which some payers priced as 3D.

Mechanism 2: 77412 denials and downgrades

Level 3 requires any one of four conditions: multiple isocenters with photons, a single isocenter with active motion management, total skin electrons, or mixed electron and photon fields. UnitedHealthcare’s commercial policy 2026T0613L (effective March 1, 2026) says 77412 “should be used only when” one of those applies and that “documentation must clearly describe the circumstances that justify Level 3 rather than Level 2.” eviCore’s Cigna coding manual allows one unit of 77402, 77407 or 77412 per date of service, and LUGPA called eviCore’s accompanying 2026 clinical guideline “the most restrictive utilization management policy we have seen to date,” citing forced downgrades from IMRT to 3D.

The Cureus review by Jahraus and colleagues (January 2026) states the rule plainly: “IGRT alone does not justify the use of 77412,” while 4D cone-beam CT before treatment does count as motion management. ASTRO’s January updates described payers reading “multiple isocenters” as multiple anatomic sites and applying fraction limits to 77412 across the board.

Mechanism 3: 77387-26 denied as bundled

The technical component of image guidance is bundled into 77402, 77407 and 77412 in every setting, and the professional component is reported as 77387 with modifier 26. Both UnitedHealthcare’s policy (“the professional component of IGRT should be reported as 77387-26”) and eviCore’s coding manual (“one unit of CPT 77387 with modifier-26 is allowed per date of service”) say so in writing. Denials still arrived in early 2026 as “bundled” or “not separately payable,” and ASTRO reported working with UnitedHealthcare on an edit that blocked 77387 professional payment. Quote the payer’s own policy language in the appeal.

Mechanism 4: Medicaid programs

On March 25, 2026, ASTRO sent a letter to all 50 state Medicaid directors reporting that many programs had not updated billing systems or fee schedules for the 2026 codes, that some lacked the revised codes entirely, and that others valued them at rates ASTRO called unsustainable. By late April ASTRO reported that 17 states had updated their guidance and 10 more had acknowledged the letter. ASTRO also wrote to the CMS Administrator on April 9 and on April 15 requested an urgent meeting with CMS leadership, noting that 77407 RVUs had fallen slightly while 77412 rose and asking CMS to raise 77407.

The 2027 proposed revaluation

CMS’s own claims data showed the actual mix. Level 3 made up about 18 percent of 2026 treatment volume, not 35 percent. The CY 2027 physician fee schedule proposed rule (released July 14, 2026) would raise 77402 by about 19 percent, 77407 by about 10 percent and 77412 by about 8 percent at the fee schedule, and by about 26, 17 and 14 percent under the hospital outpatient rule, while planning and management codes lose practice expense value and the non-QP conversion factor falls to $32.84 from $33.40. ASTRO’s September comments asked CMS to correct a hospital APC assignment it says still undervalues a commonly delivered service, which its earlier updates identified as Level 2. The final rules are expected in early November 2026.

What to do now

Quantify the loss by course, not by code. Price a 20-fraction IMRT course under your 2025 contract and under what the payer actually paid in 2026, including the missing technical IGRT line. Bring one page per payer to the first discussion; the template is in the contract readiness post.
Write the escalation letter with these points: the January 1, 2026 code restructuring changed descriptors, not the service delivered; request revenue-neutral repricing of 77402, 77407, 77412 and 77387-26 effective January 1, 2026; request reprocessing of 77387-26 denials and 77412 downgrades; quote the payer’s own coding policy; ask for a written fee schedule row for each new code; set a response date.
Document Level 3 before the first fraction. The note should name the criterion and the method: the motion management technique (gating, tracking, 4D CBCT), the number of isocenters, mixed fields, or total skin electrons.
Appeal every bundled denial of 77387-26 with three attachments: the 2026 CPT descriptor, the fee schedule PC/TC status showing the technical component is bundled, and the payer’s own policy sentence requiring 77387-26.
Report each payer that has not repriced to ASTRO’s Payer Support and Resolution Center and ACRO’s data collection effort (both member channels).
Check the Medicaid fee schedule in every state you bill. If 77402, 77407, 77412 or 77387 is missing, request a manual price in writing and keep claims within timely filing while the state loads the codes.
Prevent denials caused by your own coding errors. Iridium Suite’s claim scrubber checks every service line as it is entered and for 2026 warns when a deleted delivery, IMRT, guidance or port film code is billed and requires the 26 modifier on 77387; see the claim scrubber.
Read the 2027 final rules in November. The proposed increases reach a commercial contract only if it tracks current-year Medicare and the payer loads the 2027 file; a fixed-rate contract does not change.

Why 2026 radiation oncology payment cuts fell more than CMS projected: the payers that did not reprice, the 77412 denials, and what to do about both