Accelerated Partial Breast Irradiation (APBI) for Breast Cancer [Preauthorization Required]

Transcription

1 Accelerated Partial Breast Irradiation (APBI) for Breast Cancer [Preauthorization Required] Medical Policy: MP-SU Original Effective Date: February 24, 2011 Reviewed: Revised: This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), MCS Health Management Options, Inc. (HMO) and MCS Advantage, Inc. (Classicare) and, provider s contract; unless specific contract limitations, exclusions or exceptions apply. Please refer to the member s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions. Breast conserving Therapy (BCT) or breast-conserving surgery (BCS) has been shown to be an effective option for the treatment of early-stage breast cancer compared to mastectomy. Using external beam radiation therapy to the whole breast, excellent local recurrence rates have been achieved in prospective, randomized studies with follow-up of 20 years. More recently, internal (Brachyterapy) partial breast radiation therapy is also offered after BCS. Accelerated partial breast irradiation (APBI) is a technique in which the portion of the breast at the highest risk of recurrence (the tissue surrounding the lumpectomy cavity) receives a shortened course of high dose radiation therapy. There are several techniques that can deliver breast brachytherapy including multiple catheters placed through the breast, a balloon catheter inserted into the lumpectomy cavity, bead or seed implants, single dose intraoperative treatment and others. Regardless of which technique of APBI is employed, the scientific justification for APBI is that the vast majority of recurrences after standard breast conserving treatment occur in the vicinity of the tumor bed. Following WBRT or APBI, the patient may also be treated with adjuvant therapy for several months after surgery to reduce the risk of recurrence. Adjuvant treatments may include various types and combinations of additional boost radiation therapy, hormonal manipulation and chemotherapy. 1

2 The APBI technique that has been in use the longest is insterstial brachytherapy, which requires a clinician to insert 10 to 20 catheters though multiple incisions on either side of the affected breast. The catheters allow delivery of a radiation source to the tissues that surround the malignancy. This technique requires a clinician to insert a single catheter applicator during the lumpectomy procedure (open cavity placement) or up to 10 weeks after surgery (closed cavity placement) through a single incision lateral to the Lumpectomy site or in the crease under the breast. Typically, the catheter remains in place for the duration of treatment, which allows delivery of a radiation source directly into the lumpectomy cavity twice daily for five days. Most intracavitary brachytherapy techniques require a remote computer controlled, high-dose rate (HDR) afterload to insert and retract the radiation source into and from the single-use catheter that delivers the radiation. Also required are accessories to implant and explants the device. Intracavitary brachytherapy techniques vary by catheter type (i.e., single balloon-tipped, single with multiple lumens, multiple catheters housed within a single applicator), implantation timing, and radiation source (i.e., isotopes, radioactive seeds, Miniature electronic x-ray tubes). COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits and coverage. INDICATIONS, (MCS) considers medically necessary Accelerated Partial Breast Irradiation (APBI) after breast-conserving surgery for members with early stage breast cancer when all of the following criteria are met: Member has invasive ductal carcinoma or ductal carcinoma in situ (DCIS) diagnosis Total tumor size (Invasive and DCIS) is 3 centimeter in size Microscopic Surgical Margins of excision are Negative at least 2 mm in all directions Negative axillary lymph node dissection or sentinel lymph node evaluation 2

3 CODING INFORMATION CPT Codes CPT Codes Placement of radiotherapy afterloading balloon catheter into breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy Placement of radiotherapy afterloading balloon catheter into breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure) Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following ( at the time of or subsequent to) partial mastectomy, includes imaging guidance 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, volume implant calculations, over 10 sources/ribbons used, spatial reconstruction, remote afterloading brachytherapy, over 12 sources) Intracavitary radiation source application; simple Intracavitary radiation source application; intermediate Intracavitary radiation source application; complex Interstitial radiation source application; simple Interstitial radiation source application; intermerdiate Interstitial radiation source application; complex Remote afterloading high dose rate radionuclide brachytherapy 1 channel 3

4 77786 Remote afterloading high dose rate radionuclide brachytherapy; 2-12 channels Remote afterloading high dose rate radionuclide brachytherapy; over 12 channels Supervision, handling, loading of radiation source *Current Procedural Terminology (CPT ) 2011 American Medical Association: Chicago, IL. *Note: Separate reimbursement will not be provided for the temporary implantation of a cavity evaluation device (CED)/cavity maintenance catheter performed at the same time as breast-conserving surgery in anticipation of brachytherapy because it is considered to be incidental to the breast-conserving surgery. ICD-9 CM Diagnosis Codes ICD-9 CM CODES Malignant Neoplasm of central portion of female breast Malignant neoplasm of upper-inner quadrant of female breast Malignant neoplasm of lower-inner quadrant of female breast Malignant neoplasm of upper-outer quadrant of female breast Malignant neoplasm of lower-outer quadrant of female Malignant neoplasm of axillary tail of female breast Malignant neoplasm of other specified sites of female breast Malignant neoplasm of breast (female), unspecified site Carcinoma in situ of Breast 2011 ICD-9-CM For Physicians, VOLUMES I & II, Professional Edition (American Medical Association. HCPCS CODES HCPCS CODES C1715 C1717 C1719 C2616 Brachytherapy needle Brachytherapy source, non-stranded, high dose rate Iridium-192, per source Brachytherapy source, non-stranded, non-high dose rate Iridium-192, per source Brachytherapy source, non-stranded, Yttrium-90, per source 4

5 C2698 Brachytherapy source, stranded, not otherwise specified, per source C9726 Q3001 Placement and removal (if performed) of applicator into Breast for radiation therapy Radio elements for Brachytherapy, any type, each *2011 HCPCS LEVEL II Professional Edition (American Medical Association). REFERENCES 1. American Brachytherapy Society. Breast Brachytherapy TASK GROUP. Martin Keisch, MD., Douglas Arthur, MD., Rakesh Patel, MD., Mark Rivard, PhD., Franck Vicini, MD., February, BlueCross BlueShield Association. Technology Evaluation Assessment. Accelerated Radiotherapy after Breast conserving surgery for early Breast Cancer ECRI institute. Accelerated partial-breast Irradiation using intracavitary brachyterapy to treat early stage breast cancer. Published: 04/15/ ECRI institute. New radiation options may reduce regimen from several weeks to days for early stage breast cancer patients. Published: 10/01/ Hologic (The Woman s Health Company). Mammosite Targetet Radiation Therapy- Mammosite. Society Recommendations for Patient Selection. Accessed January Mattheew. C. Biagioli, MD, MS, and Eleanor E.R. Harris, MD. From Cancer Control: Journal of thee Moffitt Cancer Center. Accelerated Partial Breast Irradiation: Potential Roles Following Breast-Conserving Surgery. Posted 11/11/2010. Cancer Control. 2010; 17(3): Centers for Medicare & Medicaid Services (CMS). First Coast Service Options, Inc., LCD for Accelerated Partial Breast Irradiation (APBI) L For services performed on or after 03/02/ Radioisotopes in Medicine. Updated 26 January

6 POLICY HISTORY DATE ACTION COMMENT February 24, 2011 Origination of Policy his document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member s plan in effect as of the date services are rendered., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion, (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide. 6