MVP/Care Core National 2015 Radiation Therapy Prior Authorization List (Effective January 1, 2015)

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1 MVP/Care Core National 2015 Radiation Therapy Prior Authorization List (Effective January 1, 2015) CODE CODE TYPE Description 0330 REVCODE RADIOLOGY/THERAPEUTIC - GENERAL CLASSIFICATION 0333 REVCODE RADIOLOGY/THERAPEUTIC - RADIATION THERAPY 0339 REVCODE RADIOLOGY/THERAPEUTIC - OTHER 0344 REVCODE THERAPEUTIC RADIOPHARMACEUTICALS 0973 REVCODE PROFESSIONAL FEES - RADIOLOGY/THERAPEUTIC 0182T CPT High dose rate electronic brachytherapy, per fraction 0190T CPT Placement of intraocular radiation source applicator CPT CPT CPT Placement of radiation therapy afterloading expandable catheter into the breast for interstitial radioelement application following partial mastectomy on date separate from partial mastectomy Placement of radiation therapy afterloading expandable catheter into the breast for interstitial radioelement application following partial mastectomy,concurrent with partial mastectomy Placement of radiation therapy afterloading brachytherapy catheter into the breast for interstitial radioelement application following partial mastectomy CPT Bronchoscopy (rigid or flexible), with placement of catheter for intracavitary radioelement application CPT Placement of interstitial device for radiation therapy guidance, percutaneous, intra-thoracic, single or multiple CPT Placement of needles, catheters, and other devices into the head and/or neck region CPT Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum and/or jejunum as appropriate; w/ transendoscopic intraluminal tube or catheter placement CPT CPT Placement of interstitial device(s) for radiation therapy guidance, Open, Intra-abdominal, Intra-pelvic and/or retroperitoneum, including image guidance, single or multiple Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), open, intra-abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if performed, single or multiple (List separately in addition to code for primary procedure) 1

2 55875 CPT Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or out cytosocopy CPT Fiducial marker placement in the prostate CPT Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application CPT Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy CPT Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy CPT Insertion of Heyman capsulesfor clinical brachytherapy CPT US transrectal prostate volume study for brachytherapy CPT Ultrasound guidance for interstitial radioelement application CPT Computed Tomography Guidance for Stereotactic Localization CPT CT guidance for placement of radiation therapy fields CPT Therapeutic Radiology treatment planning; simple CPT Therapeutic Radiology treatment planning; intermediate CPT Therapeutic Radiology treatment planning; complex CPT Therapeutic Radiology Simulation; simple CPT Therapeutic Radiology Simulation; intermediate CPT Therapeutic Radiology Simulation; complex Effective CPT Respiratory motion management simulation 03/16/ CPT 3-dimensional radiotherapy plan, including dose-volume histograms CPT Unlisted procedure; Therapeutic Radiology treatment planning CPT Basic Radiation Dosimetry CPT IMRT Planning Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of CPT interest), includes basic dosimetry calculation(s) CPT CPT Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) Brachytherapy isodose plan; simple (calculation(s) made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) CPT Brachytherapy isodose plan; intermediate (calculation(s) made from 5 to 10 sources, or 2

3 remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) CPT Brachytherapy isodose plan; complex (calculation(s) made from over 10 sources, or remote afterloading brachytherapy, 12 channels), includes basic dosimetry calculation(s) CPT Special Teletherapy port plan, particles, hemibody, total body CPT Special radiation dosimetry CPT Treatment Devices; simple CPT Treatment Devices; intermediate CPT Treatment Devices; complex CPT Continuing medical physics consultation CPT Multi-leaf collimator (MLC) device(s) for IMRT, design and construction per IMRT plan CPT Special medical physics consultation CPT Stereotactic radiosurgery treatment delivery, complete course of treatment of cerebral lesion(s) 1 session, multi-source Cobalt 60 based CPT Stereotactic radiosurgery treatment delivery, complete course of treatment of cerebral lesion(s) 1 session, linac based CPT Stereotactic Body Radiation Therapy delivery per fraction 1 or more lesions; including image guidance not to exceed 5 fractions CPT Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple CPT CPT Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed CPT Unlisted procedure, medical radiation physics CPT Radiation treatment delivery, superficial and/or ortho voltage, per day CPT Radiation treatment delivery; single treatment area, one or two ports; and two or fewer simple blocks; >1 MeV; simple CPT CPT Radiation treatment delivery; two separate treatment areas; three or more ports on a single treatment area; or three or more simple blocks; >1 MeV; intermediate Radiation treatment delivery; three or more separate treatment areas; custom blocking; tangential ports; wedges; rotational beam; field-in-field or other tissue compensation that does not meet IMRT guidelines; or electron beam; >1 MeV; complex CPT Therapeutic Radiology Port Films CPT Neutron beam tx, simple 3

4 77423 CPT Neutron beam tx, complex CPT CPT Intraoperative radiation treatment delivery, x-ray, single treatment session Intraoperative radiation treatment delivery, electrons, single treatment session CPT Radiation treatment management, five treatments CPT CPT CPT CPT Radiation treatment management, with complete course of therapy consisting of 1-2 fractions Stereotactic radiation treatment management cerebral lesion(s) complete course of treatment consisting of 1 session Stereotactic body radiation treatment management per treatment course; 1 or more lesions, including image guidance entire course not to exceed 5 fractions Intraoperative radiation treatment management CPT Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation) CPT Unlisted procedure, therapeutic radiology treatment management CPT Proton treatment delivery, simple w/o compensation CPT Proton treatment delivery, simple w/ compensation CPT Proton treatment delivery, intermediate CPT Proton treatment delivery, complex CPT Hyperthermia treatment; externally generated, deep CPT Hyperthermia treatment; externally generated, superficial CPT Hyperthermia generated by interstitial probe(s); 5 or fewer applicators CPT Hyperthermia generated by interstitial probe(s); 5 or more applicators CPT Hyperthermia generated by intracavitary probe(s) CPT Infusion or instillation of radioelement solution (includes 3-month follow-up care) CPT Intracavitary radiation source application; simple CPT Intracavitary radiation source application; intermediate CPT Intracavitary radiation source application; complex CPT Interstitial radiation source; simple CPT Interstitial radiation source; intermediate CPT Interstitial radiation source; complex CPT Remote afterloading high dose rate radionuclide brachytherapy; 1 channel CPT Remote afterloading high dose rate radionuclide brachytherapy; 2-12 channels CPT Remote afterloading high dose rate radionuclide brachytherapy; over 12 channels 4

5 77789 CPT Apply surface radiation CPT Radio Isotope Supervision, Handling, Loading CPT Radium/radioisotope therapy A4648 HCPCS Tissue marker, implantable, any type each A4650 HCPCS Implant radiation dosimeter, each C1715 HCPCS Brachytherapy needle C1716 HCPCS Brachytherapy source, non-stranded, gold-198, per... C1717 HCPCS Brachytherapy source, non-stranded, gold-198 per C1719 HCPCS Brachytherapy source, non-stranded, non-high dose... C1728 HCPCS Catheter, brachytherapy seed administration C2616 HCPCS Brachytherapy source, non-stranded, yttrium -90, per source C2634 HCPCS Brachytherapy source, non-stranded, high activity,... C2635 HCPCS Brachytherapy source, non-stranded, high activity,... C2636 HCPCS Brachytherapy linear source, non-stranded, paladiu... C2637 HCPCS Brachytherapy source, non-stranded, ytterbium-169,... C2638 HCPCS Brachytherapy source, stranded, iodine-125, per so... C2639 HCPCS Brachytherapy source, non-stranded, iodine-125, pe... C2640 HCPCS Brachytherapy source, stranded, palladium-103, per... C2641 HCPCS Brachytherapy source, non-stranded, palladium-103,... C2642 HCPCS Brachytherapy source, stranded, cesium-131, per so... C2643 HCPCS Brachytherapy source, non-stranded, cesium-131, pe... C2698 HCPCS Brachytherapy source, stranded, not otherwise spec... C2699 HCPCS Brachytherapy source, non-stranded, not otherwise C9725 HCPCS Placement of endorectal intracavitary applicator for high intensity brachytherapy C9726 HCPCS Placement and removal (if performed) of applicator into breast for radiation therapy C9728 HCPCS Placement of interstitial device(s) for radiation therapy/surgery guidance (eg, fiducial markers, dosimeter), other than prostate (any approach), single or multiple G0173 HCPCS Stereotactic, One Treatment 5

6 G0251 HCPCS Stereotactic, 2-5 Treatments G0339 HCPCS Robotic stereotactic surgery 1 session G0340 HCPCS Robotic stereotactic radio surgery 2 through 5 sessions G6001 Ultrasonic guidance for placement of radiation therapy fields. MPFS code in place of for 2015 Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy. MPFS code in place of for 2015 G6002 G6003 G6004 G6005 G6007 simple blocks or no blocks; up to 5 MeV. MPFS code in place of for 2015 simple blocks or no blocks; 6-10 MeV. MPFS code in place of for 2015 simple blocks or no blocks; MeV. MPFS code in place of for 2015 simple blocks or no blocks; 20 MeV or greater. MPFS code in place of for 2015 treatment area, use of multiple blocks; up to 5 MeV. MPFS code in place of for 2015 G6008 G6009 G6010 G6011 G6012 G6013 treatment area, use of multiple blocks; 6-10 MeV. MPFS code in place of for 2015 treatment area, use of multiple blocks; MeV. MPFS code in place of for 2015 treatment area, use of multiple blocks; 20 MeV or greater. MPFS code in place of for 2015 tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV. MPFS code in place of for 2015 tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV. MPFS code in place of for 2015 tangential ports, wedges, rotational beam, compensators, electron beam; MeV. MPFS code in place of for

7 G6014 G6015 G6016 G6017 tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater. MPFS code in place of for 2015 Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session. MPFS code in place of for 2015 Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session. MPFS code in place of 0073T for 2015 Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg,3d positional tracking, gating, 3D surface tracking), each fraction of treatment. MPFS code in place of 0197T for 2015 Q3001 HCPCS Brachytherapy Radioelements S2095 Effective 03/16/14 HCPCS S8030 HCPCS Tantalum ring application Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres 7