Non-coronary Brachytherapy I. Policy University Health Alliance (UHA) will reimburse for non-coronary brachytherapy when it is determined to be medically necessary and when it meets the medical criteria guidelines (subject to limitations and exclusions) indicated below. II. Criteria/Guidelines A. The following brachytherapy applications are covered (subject to Limitations/Exclusions and Administrative Guidelines): 1. Head and Neck brachytherapy a. When used as monotherapy for the treatment of small primary tumors; or b. For recurrent disease used in conjunction with external beam radiotherapy (EBRT) 2. Ocular brachytherapy for choroidal melanoma is covered in patients meeting the following criteria: a. Unilateral choroidal melanoma has been confirmed b. Apical height of the tumor is 2.5 to 10.0 mm c. Maximum basal tumor diameter of 18.0 mm or less 3. Soft tissue sarcoma brachytherapy is covered when used as part of combination therapy in patients with positive margins or margins less than 5mm. See the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines on Soft Tissue Sarcoma for detailed patient selection criteria. 4. Prostate brachytherapy using either LDR or HDR is covered for the treatment of localized prostate cancer used as monotherapy or in conjunction with EBRT. 5. Endobronchial brachytherapy is covered in the following clinical situations: a. In patients with patients with primary endobronchial tumors who are not otherwise candidates for surgical resection or EBRT due to co-morbidities or location of the tumor. b. As palliative therapy for airway obstruction or severe hemoptysis in patients with primary, metastatic or recurrent endobronchial tumors. 6. Cervical, Uterine, Endometrial and Vulvar/Vaginal brachytherapy is covered when used as an alternative to surgery in conjunction with EBRT in order to reduce recurrence of cancer and complications associated with treatment (see NCCN s Clinical Practice Guidelines for Cervical cancer and uterine neoplasms for detailed patient selection criteria). 7. Breast brachytherapy is covered in the following clinical situations: a. Using balloon brachytherapy in the initial treatment of stage I or II breast cancer when used as a local boost irradiation in patients who are also treated with breastconserving surgery and whole-breast external beam radiotherapy. b. Accelerated partial breast irradiation (APBI), using balloon brachytherapy as the sole form of radiotherapy after surgical excision is covered if all of the following criteria are Page 1
met: (This criteria is based on the American Society of Breast Surgeons consensus statement for APBI): i. The patient is 45 years or older ii. The patient has invasive ductal carcinoma or ductal carcinoma in situ (DCIS) iii. Total tumor size (invasive and DCIS) is less than or equal to 3cm iv. Negative microscopic surgical margins of excision v. Sentinel lymph node negative 8. TheraSpheres are covered for radiation therapy or as a neoadjuvant to surgery or transplantation for unresectable HCC in patients who have appropriately positioned hepatic arterial catheters. 9. SIR-Spheres are covered for the treatment of unresectable metastatic liver tumors from primary colorectal cancer with adjuvant IHAC of FUDR. B. Brachytherapy is a constantly evolving field and the above recommendations are subject to modifications as new data become available. C. NOTE: This UHA payment policy is a guide to coverage, the need for prior authorization and other administrative directives. It is not meant to provide instruction in the practice of medicine and it should not deter a provider from expressing his/her judgment. Even though this payment policy may indicate that a particular service or supply is considered covered, specific provider contract terms and/or members individual benefit plans may apply, and this policy is not a guarantee of payment. UHA reserves the right to apply this payment policy to all UHA companies and subsidiaries. UHA understands that opinions about and approaches to clinical problems may vary. Questions concerning medical necessity (see Hawaii Revised Statutes 432E-1.4) are welcome. A provider may request that UHA reconsider the application of the medical necessity criteria in light of any supporting documentation. III. Limitations/Exclusions A. Electronic brachytherapy is not covered because it has not been shown to improve health outcomes compared to standard brachytherapy. B. TheraSpheres is not covered for patients with any of the following: 1. Technetium-99 macro aggregated albumin hepatic arterial perfusion scintigraphy showing any disposition to the gastrointestinal tract that cannot be corrected by angiographic techniques. 2. Shunting of blood to the lungs that could result in delivery of greater than 16.5 millicuries of radiation to the lungs. 3. If hepatic artery catheterization is contraindicated; such as patients with vascular abnormalities, bleeding diathesis, or portal vein thrombosis, and who have severe liver dysfunction or pulmonary insufficiency. C. SIR-Spheres is not covered for patients who have had any of the following: 1. Disseminated extra-hepatic malignant disease. 2. Previous EBRT to the liver. 3. Ascites or are in clinical liver failure. Page 2
IV. Administrative Guidelines 4. Markedly abnormal synthetic and excretory liver function tests. 5. Greater than 20% lung shunting of the hepatic artery blood flow determined by Technetium MAA scan. 6. Pre-assessment angiogram that demonstrates abnormal vascular anatomy that would result in significant reflux of hepatic arterial blood to the stomach, pancreas or bowel. 7. Treated with capecitabine within the past two months, or who will be treated with capecitabine at any time following treatment with SIR-Spheres a. Portal vein thrombosis A. Prior authorization is not required. B. UHA reserves the right to perform retrospective review using the above criteria to validate if services rendered met payment determination criteria and to ensure proper reimbursement is made. C. The following CPT codes are specific to brachytherapy. Inclusion of a code in the table below does not guarantee that it will be reimbursed. 77326 Brachytherapy isodose plan calculation code range; simple, intermediate or complex (calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources) 77327 intermediate (multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources) complex (multiplane isodose plan, volume implant calculations, over 10 77328 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources) 77750 Infusion or instillation of radioelement solution (includes three months follow-up care) 77761 Intracavitary radiation source application; simple, intermediate or complex 77762 intermediate 77763 complex 77776 Interstitial radiation source application; simple, intermediate or complex 77777 intermediate 77778 complex 77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel 77786 2-12 channels 77787 over 12 channels 77789 Surface application of radiation source 77790 Supervision, handling, loading of radiation source Q3001 Radioelements for brachytherapy, any type, each Page 3
Applicable CPT codes for breast brachytherapy: 19296 19297 19298 Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement applications following partial mastectomy, includes imaging guidance on date separate from partial mastectomy concurrent with partial mastectomy (List separately in addition to code for primary procedure) multiple tube or button type catheters, performed at the same session or subsequent session Applicable CPT codes for prostate brachytherapy: 55860 Exposure of prostate, any approach, for insertion of radioactive substance (Medicare) 55875 55876 76001 76873 Transperitoneal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy Placement of interstitial device(s) for radiation therapy guidance (e.g., fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician (e.g., nephrostolithotomy, ERCP, bronchoscopes, transbronchial biopsy) Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) 76965 Ultrasonic guidance for interstitial radioelement application Applicable CPT codes for endobronchial brachytherapy: 31643 Bronchoscopy (rigid or flexible); with placement of catheter(s) for intracavitary radioelement application Applicable CPT codes for gynecologic brachytherapy: 57155 Insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy 58346 Insertion of heyman capsules for clinical brachytherapy 58999 Unlisted procedure, female genital system (non-obstetrical) Applicable for Yttrium 90 (Y90) microsphere hepatic brachytherapy: S2095 Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using yttrium-90 microspheres Codes that do not meet payment determination criteria: 0182T High dose electronic brachytherapy, per fraction Page 4
V. Policy History Policy Number: M.RAD.08.120101 Current Effective Date: 01/01/2012 Original Document Effective Date: 01/01/2012 Previous Revision Dates: N/A HCR_MPP-0092-012813 Page 5