Medical Policy Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

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1 Medical Policy Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 175 BCBSA Reference Number: Related Policies Intensity Modulated Radiation Therapy of the Prostate, #090 Stereotactic Radiosurgery & Fractionated Stereotactic Radiosurgery, #277 Cryosurgical Ablation of the Prostate, #149 High-Dose Rate Temporary Prostate Brachytherapy, #353 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO Blue SM and Medicare PPO Blue SM Members Brachytherapy using permanent transperineal implantation of radioactive seeds in treatment of localized prostate cancer when used as monotherapy or in conjunction with external beam radiation therapy (EBRT) may be considered MEDICALLY NECESSARY. Prior Authorization Information Commercial Members: Managed Care (HMO and POS). Commercial Members: PPO, and Indemnity Medicare Members: HMO Blue SM Medicare Members: PPO Blue SM 1

2 CPT Codes / HCPCS Codes / ICD-9 Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes CPT codes: Code Description Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy Ultrasound, prostate volume study for brachytherapy treatment planning (separate procedure) Brachytherapy isodose plan, simple (calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources) Brachytherapy isodose plan, intermediate (multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources) Brachytherapy isodose plan, complex (multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources) Interstitial radiation source application; simple Interstitial radiation source application; intermediate Interstitial radiation source application; complex HCPCS Codes HCPCS codes: C2636 C2637 C2638 C2639 C2640 C2641 C2642 C2643 Q3001 ICD-9 Diagnosis Codes Code Description Brachytherapy source, nonstranded, palladium-103, per 1 mm Brachytherapy source, nonstranded, ytterbium-169, per source Brachytherapy source, stranded, iodine-125, per source Brachytherapy source, nonstranded, iodine-125, per source Brachytherapy source, stranded, palladium-103, per source Brachytherapy source, nonstranded, palladium-103, per source Brachytherapy source, stranded, cesium-131, per source Brachytherapy source, nonstranded, cesium-131, per source Radioelements for brachytherapy, any type, each ICD-9-CM diagnosis codes: Code Description 185 Malignant neoplasm of prostate Carcinoma in situ of prostate 2

3 ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description C61 Malignant neoplasm of prostate D07.5 Carcinoma in situ of prostate Description Brachytherapy is a procedure in which a radioactive source is used to treat a localized cancer. With brachytherapy of the prostate, radioisotope "seeds" are used to deliver tumoricidal radioactivity directly to the tumor while sparing surrounding normal tissue. Seeds can be permanently or temporarily implanted. Biologic advantages of brachytherapy compared to external beam radiation therapy (EBRT) are related to the lower dose and dose rate delivered to the target tumor. Enhanced normal tissue repair occurs at the lower dose rates while tumor cell repair does not occur as quickly; thus, from a radiobiological perspective, low-dose rates cause ongoing tumor destruction in the setting of normal tissue repair. Permanent brachytherapy may be used alone as monotherapy or may be combined with EBRT (together known as combined modality therapy) as a way to boost the dose of radiation therapy delivered to the cancerous tumor. Brachytherapy is most often performed as a single procedure in the outpatient setting, Summary Permanent brachytherapy provides freedom from biochemical recurrence at acceptable risk and may be considered as an option in the treatment of localized prostate cancer. Brachytherapy combined with EBRT is considered an option in patients with intermediate and high-risk prostate cancer. This approach provides radiation dose to the prostate and extraprostatic coverage as well. Therefore, the available evidence for permanent brachytherapy in the treatment of localized prostate cancer when used as monotherapy or in conjunction with EBRT is sufficient to demonstrate improvements in net health outcomes and may be considered medically necessary. Policy History Date Action 5/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/ /2013 New references from BCBSA National medical policy. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates. 9/2011 Reviewed - Medical Policy Group Urology, Obstetrics and Gynecology. 7/2011 Reviewed - Medical Policy Group Hematology and Oncology. 9/2010 Reviewed - Medical Policy Group -Hematology and Oncology. 4/1/10 Medical Policy 175 created, effective 4/1/10 Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines 3

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5 21. Sylvester JE, Grimm PD, Blasko JC et al. 15-Year biochemical relapse free survival in clinical Stage T1-T3 prostate cancer following combined external beam radiotherapy and brachytherapy; Seattle experience. Int J Radiat Oncol Biol Phys 2007; 67(1): Dattoli M, Wallner K, True L et al. Long-term outcomes after treatment with brachytherapy and supplemental conformal radiation for prostate cancer patients having intermediate and high-risk features. Cancer 2007; 110(3): Koontz BF, Chino J, Lee WR et al. Morbidity and prostate-specific antigen control of external beam radiation therapy plus low-dose-rate brachytherapy boost for low, intermediate, and high-risk prostate cancer. Brachytherapy 2009; 8(2): Langley S, Ahmed HU, Al-Qaisieh B et al. Report of a consensus meeting on focal low dose rate brachytherapy for prostate cancer. BJU Int 2012; 109 Suppl 1: National Comprehensive Cancer Network. Prostate cancer. Clinical Practice Guidelines in Oncology, v Available online at: Last accessed May Grills IS, Martinez AA, Hollander M et al. High dose rate brachytherapy as prostate cancer monotherapy reduces toxicity compared to low dose rate palladium seeds. J Urol 2004; 171(3): Ollendorf DA, Hayes J, McMahon P, et al. Management options for low-risk prostate cancer: a report on comparative effectiveness and value. Boston, MA: Institute for Clinical and Economic Review, December Available online at: Last accessed May Rosenthal SA, Bittner NH, Beyer DC et al. American Society for Radiation Oncology (ASTRO) and American College of Radiology (ACR) practice guideline for the transperineal permanent brachytherapy of prostate cancer. Int J Radiat Oncol Biol Phys 2011; 79(2): ACR-ASTRO. Practice Guideline for Intensity Modulated Radiation Therapy (IMRT) Available online at: Last accessed May Frank SJ, Arterbery VE, Hsu IC et al. American College of Radiology Appropriateness Criteria permanent source brachytherapy for prostate cancer. Brachytherapy 2011; 10(5):