Accelerated Partial Breast Irradiation (APBI) for Breast Cancer [Pre-authorization Required] Medical Policy: MP-SU-01-11 Original Effective Date: February 24, 2011 Reviewed: February 24, 2012 Revised: This policy applies to products subscribed by the following corporations, MCS Life Insurance Company (Commercial), 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. Accelerated partial breast irradiation (APBI) refers to the use of limited focused adjuvant radiation therapy (RT) as an alternative to conventional whole breast irradiation (WBI) for selected patients with early breast cancer following breast-conserving surgery. Since APBI delivers radiation to a limited volume of tissue (partial breast irradiation), a higher dose of radiation can be delivered in a shorter period of time (hypofractionated accelerated RT) than with WBI. Rationale for APBI: Most local recurrences after breast conserving therapy with surgery and postoperative radiation are within one to two centimeters of the original surgical site. This observation led to the concept of accelerated partial breast irradiation (APBI), which targets radiotherapy to the region of the tumor bed and a 1 to 2 cm surrounding margin, rather than the whole breast. Thus, APBI has been evaluated in patients with early breast cancer and a low risk for recurrence in an effort to achieve comparable local control with a shortened treatment duration and decreased toxicity. As a result of reducing the volume of breast tissue that receives the 1
tumoricidal dose of RT, it is possible to safely use a larger than standard dose of radiation with each treatment, thereby reducing the duration of treatment (Uptodate, 2012). There are three options for the delivery of APBI, which includes brachytherapy, intraoperative radiotherapy, or external beam radiation. Conformal external beam radiation is the most commonly sued delivery system (Uptodate, p. 3, 2012). I. External beam techniques for APBI- External beam radiotherapy with conformal technique can be used to deliver APBI. The radiation is delivered postoperatively and thus, after the pathology is reviewed and clean surgical margins are ensured. In addition, the treatment is noninvasive and standard dosimetry and treatment equipment is employed. Conformal external beam radiotherapy- Three-dimensional conformal external beam radiotherapy provides a noninvasive method for APBI. This technique combines multiple radiation treatment fields to deliver a specific dose of radiotherapy to the tumor bed region while sparing the majority of normal surrounding tissue and solid organs. Intensity modulated radiotherapy- Intensity modulated radiotherapy uses a linear accelerator to deliver precisely focused small beams of radiation that follow the exact contours of a tumor or target volume. Higher radiation doses can be used because the damage to surrounding tissue is limited, possibly resulting in treatment that is more effective. Computer imaging is used to evaluate the tumor throughout the course of treatment, permitting the most precise dose and treatment changes based on the changing tumor characteristics. II. Brachytherapy techniques for APBI- Brachytherapy is the temporary or permanent placement of radioactive material into body tissues for local radiation treatment. Brachytherapy can be delivered with interstitial, intracavitary, or intraoperative delivery systems. Interstitial brachytherapy- For interstitial brachytherapy, several small hollow catheters are placed into the breast surrounding the partial mastectomy site. Potential disadvantages of this approach include the risk of infection and poor cosmesis with scarring due to the multiple catheters. Catheter Placement- The number of catheters used is dependent upon the size and shape of the target. The placement of the catheters is determined using radiation treatment planning software along with stereotactic mammography, ultrasound, or computed tomography guidance. 2
Radioactive seed insertion- High or low dose radioactive seeds are inserted into the catheters as described above. The catheters are removed after five days, when treatment is completed. III. Intracavitary brachytherapy- For intracavitary brachytherapy, a radiation delivery device is placed into the partial mastectomy site. Single lumen and multi-lumen balloon catheter and non-balloon devices have all been used successfully. The presumed advantage of the mult-ilumen devices as compared with single lumen catheters is more precise dosimetric planning and safer treatment delivery, avoiding skin and other organ damage. Intraoperative radiation therapy- Intraoperative radiation therapy condenses the entire therapeutic dose into a single fraction, permitting surgery and radiation to be completed in one day. Potential advantages include accurate delivery of radiotherapy directly to the surgical margins and a decreased dose of radiation to skin and subcutaneous tissue since these can be retracted during treatment. Drawbacks to the use of intraoperative radiation include the extended time in the operating room and the lack of final pathology information at the time of radiation. 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 3
CODING INFORMATION CPT Codes (List may not be all inclusive) CPT Codes 19296 Placement of radiotherapy afterloading balloon catheter into breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy +19297 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) 19298 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 77326 Brachytherapy isodose plan; simple (calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources) 77327 Brachytherapy isodose plan ; Intermediate (Multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources) 77328 Brachytherapy isodose plan, complex (multiplane isodose, volume implant calculations, over 10 sources/ribbons used, spatial reconstruction, remote afterloading brachytherapy, over 12 sources) 77761 Intracavitary radiation source application; simple 77762 Intracavitary radiation source application; intermediate 77763 Intracavitary radiation source application; complex 77776 Interstitial radiation source application; simple 77777 Interstitial radiation source application; intermerdiate 77778 Interstitial radiation source application; complex 77785 Remote afterloading high dose rate radionuclide brachytherapy 1 channel 77786 Remote afterloading high dose rate radionuclide brachytherapy; 2-12 channels 4
77787 Remote afterloading high dose rate radionuclide brachytherapy; over 12 channels 77790 Supervision, handling, loading of radiation source *Current Procedural Terminology (CPT ) 2012 American Medical Association: Chicago, IL. ICD-9 CM Diagnosis Codes (List may not be all inclusive) ICD-9 CM CODES 174.1 Malignant Neoplasm of central portion of female breast 174.2 Malignant neoplasm of upper-inner quadrant of female breast 174.3 Malignant neoplasm of lower-inner quadrant of female breast 174.4 Malignant neoplasm of upper-outer quadrant of female breast 174.5 Malignant neoplasm of lower-outer quadrant of female 174.6 Malignant neoplasm of axillary tail of female breast 174.8 Malignant neoplasm of other specified sites of female breast 174.9 Malignant neoplasm of breast (female), unspecified site 233.0 Carcinoma in situ of Breast *2012 ICD-9-CM For Physicians, VOLUMES I & II, Professional Edition (American Medical Association) HCPCS CODES (List may not be all inclusive) HCPCS CODES C1715 C1717 C1719 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 5
C2616 Brachytherapy source, non-stranded, Yttrium-90, per source C2698 C9726 Q3001 Brachytherapy source, stranded, not otherwise specified, per source Placement and removal (if performed) of applicator into Breast for radiation therapy Radio elements for Brachytherapy, any type, each *2012 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, 2007. Accessed January 12, 2012 http://www.americanbrachytherapy.org/guidelines/abs_breast_brachytherapy_taskgro up.pdf 2. BlueCross BlueShield Association. Technology Evaluation Assessment. Accelerated Radiotherapy after Breast conserving surgery for early Breast Cancer. Accessed January 12, 2012 http://www.bcbs.com/blueresources/tec/vols/24/24_09.pdf 3. ECRI institute. Accelerated partial-breast Irradiation using intracavitary brachyterapy to treat early stage breast cancer. Published: 04/15/2009. www.ecri.org Accessed January 12, 2012. https://members2.ecri.org/components/target/pages/10434.aspx 4. ECRI institute. New radiation options may reduce regimen from several weeks to days for early stage breast cancer patients. Published: 10/01/2007. www.ecri.org Accessed January 12, 2012. https://members2.ecri.org/components/trends/pages/10243.aspx 5. Hologic (The Woman s Health Company). Mammosite Targetet Radiation Therapy- Mammosite. Society Recommendations for Patient Selection. Accessed January 2011. http://www.mammosite.com/radiation-therapy/treatment-options.cfm 6. 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): 191-204. Accessed January 12, 2012. http://www.moffitt.org/ccjroot/v17n3/pdf/191.pdf 6
7. Centers for Medicare & Medicaid Services (CMS). First Coast Service Options, Inc., LCD for Accelerated Partial Breast Irradiation (APBI) L29070. For services performed on or after 03/02/2009. Accessed January 12, 2012. http://www.cms.gov/medicarecoverage-database/details/lcddetails.aspx?lcdid=29070&contrid=198&ver=3&contrver=1&coverageselection=local &ArticleType=All&PolicyType=Final&s=Puerto+Rico&KeyWord=Accelerated+Partial+Bre ast+irradiation+(apbi)&keywordlookup=title&keywordsearchtype=and&bc=gaaaab AAAAAA& 8. http://www.world-nuclear.org/info/inf55.html. Radioisotopes in Medicine. Updated 26 January 2011. Accessed January 12, 2012. http://www.nirs.org/mononline/nm710.pdf 9. Uptodate. (2012). Accelerated partial breast irradiation. Retrieved from www.uptodate.com/contents/accelerated-partial-breast-irradiation?view POLICY HISTORY DATE ACTION COMMENT February 24, 2011 Origination of Policy February 24, 2012 Yearly Review Under the description section, a more detailed explanation of the techniques used in APBI was documented. References Updated This 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. 7