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Medical Policy: 08.01.04
Original Effective Date: December 1998
Reviewed: May 2011
Revised: October 2009
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Brachytherapy is a form of radiation therapy for cancer, in which a radioactive material is implanted into the cancerous tissue. The most familiar technique of this is the use of radioactive seeds that are permanently implanted in the prostate tissue. These seeds contain radioisotopes of relatively low energy, short half- lives, low dose rates, and limited range. The seeds are between 4 and 5 millimeters in size. Placement of the seeds is guided by transrectal ultrasound. Its purpose is to deliver a direct tumoricidal dosage of radiation to the tumor itself, while sparing tissue surrounding the tumor.
Prostate brachytherapy as monotherapy is a standard treatment for patients with stage T1c or T2a tumors, Gleason grade 2-6 and a serum PSA level of 10 ng/ml or less. For patients with intermediate-risk cancers, permanent brachytherapy may be combined with external beam radiation therapy with or without neoadjuvant androgen deprivation therapy. Patients with high-risk cancers are generally considered poor candidates for permanent brachytherapy, however according to the National Comprehensive Cancer Network (NCCN) prostate cancer treatment guidelines, with the addition of neoadjuvant external beam radiation therapy and androgen deprivation, brachytherapy may be effective in select patients.
High-dose rate brachytherapy is a form of radiotherapy for localized prostate cancer in which the radiation is delivered directly to the prostate tumor through temporary implants. Hollow needles are inserted into the prostate gland guided by transrectal ultrasound to follow a preplanned treatment template. The radioactive substance, usually iridium-192 (Ir-192) is inserted into each needle via remote afterloading. High-dose rate brachytherapy is designed to allow for more effective radiation targeting to the prostate tumor while limiting radiation exposure to critical surrounding structures such as the rectum and urethra. Total irradiation time is generally no more than 10 to 12 minutes.
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Prior Approval:
Not applicable
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Policy:
Permanent brachytherapy may be considered medically necessary for the following applications;
- As monotherapy for the treatment of localized prostate cancer
- As boost therapy in conjunction with external beam radiation therapy, conformal three-dimensional radiotherapy or hormonal therapy for patients with more advanced tumors
High-dose rate brachytherapy may be considered medically necessary as monotherapy or in conjunction with external beam radiation therapy in the treatment of localized prostate cancer.
High dose rate temporary brachytherapy as salvage treatment for prostate cancer is considered investigational.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- CPT 76965 Ultrasonic guidance for interstitial radioelement application
- CPT 77776 Interstitial radiation source application; simple
- CPT 77777 Interstitial radiation source application; intermediate
- CPT 77778 Interstitial radiation source application; complex
- CPT 77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel
- CPT 77786 Remote afterloading high dose rate radionuclide brachytherapy; 2-12 channels
- CPT 77787 Remote afterloading high dose rate radionuclide brachytherapy; over 12 channels
- CPT 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
- CPT 76873 Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure)
- CPT 77326 Brachytherapy isodose plan; simple (calculation made from single plane, 1 to 4 sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources)
- CPT 77327 Brachytherapy isodose plan; intermediate (multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources)
- CPT 77328 Brachytherapy isodose plan; complex (multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources)
- CPT 77790 Supervision, handling, loading of radiation source
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Selected References:
- Crook J, Lukka H, Klotz L, Bestic N, Johnston M; Genitourinary Cancer Disease Site Group of the Cancer Care Ontario practice Guidelines Initiative: Systematic overview of the evidence for brachytherapy in clinically localized prostate cancer. Canadian Medical Association Journal 2001 Apr 3; 164(7): 976-81.
- Nag, S. The American Brachytherapy Society, Oak Brook, Il, USA. Brachytherapy for prostate cancer: summary of American Brachytherapy Society recommendation. Seminars in Urologic Oncology 2000 May; 18 (2):133-6.
- Beyer, D. The evolving role of prostate brachytherapy. Cancer Control 2001, 8 (2): 163-170.
- Wallner K, Merrick G, True L, Cavanagh W, Simpson C, Butler W. I-125 versus Pd-103 for low-risk prostate cancer: morbidity outcomes from a prospective randomized multicenter trial. Cancer J. 2002 Jan-Feb;8(1):67-73.
- Norderhaug I,et al. Brachytherapy for prostate cancer: a systematic review of clinical and cost effectiveness. Eur Urol. 2003 Jul;44(1):40-6.
- Sherertz T, Wallner K, Merrick G, Cavanagh W, Butler W, Reed D, True L The prognostic significance of Gleason pattern 5 in prostate cancer patients treated with Pd 103 plus beam radiation therapy. Cancer J. 2004 Sep-Oct;10(5):301-6
- Franca CA, Vieira SL, Bernabe AJ, Penna AB. The seven-year preliminary results of brachytherapy with Iodine-125 seeds for localized prostate cancer treated at a Brazilian single-center. Int Braz J Urol. 2007 Nov-Dec;33(6):752-62; discussion 762-3.
- Hurwitz MD. Technology Insight: combined external-beam radiation therapy and brachytherapy in the management of prostate cancer. Nat Clin Pract Oncol 2008; 5(11):668-76.
- Corner C, Rojas AM, Bryant L et al. A phase II study of high-dose rate afterloading brachytherapy as monotherapy for the treatment of localized prostate cancer. Int J Radiat Oncol Biol Phys 2008; 72(2): 441-6.
- Demanes DJ, Brandt D, Schour L et al. Excellent results from high-dose rate brachytherapy and external beam for prostate cancer are not improved by androgen deprivation. Am J Clin Oncol. 2009 Aug; 32(4): 342-7.
- Joseph KJ, Alvi R, Skarsgard D et al. Analysis of health related quality of life (HRQoL) of patients with clinically localized prostate cancer, one year after treatment with external beam radiotherapy (EBRT) alone versus EBRT and high dose rate brachytherapy (HDRBT). Radiat Oncol. 2008; 3-20.
- Hoskin PJ, Motohashi K, Bownes P et al. High dose rate brachytherapy in combination with external beam radiotherapy in the radical treatment of prostate cancer: initial results of a randomized phase three trial. Radiother Oncol. 2007;84 (2):114-120.
- National Comprehensive Cancer Network (NCCN®). Practice Guidelines in Oncology. Prostate Cancer; v.2.2009. Available at: http://www.nccn.org/professionals/physicians_gls/pdf/prostate.pdf.
- Demanes DJ, Martenez AA, Ghilezan M et al. High dose-rate monotherapy: Safe and effective brachytherapy for patients with localized prostate cancer. Int J Radiat Oncol Biol Phys 2011 Feb 9. [Epub ahead of print].
- Martinez AA, Demanes A, Vargas C et al. High dose rate prostate brachytherapy: an excellent accelerated- hypofractionated treatment for favorable prostate cancer. Am J Clin Oncol 2010; 33(5):481-8.
- Martinez AA, Gonzalez J, Ye H et al. Dose escalation improves cancer-related events at 10-years for intermediate- and high-risk prostate cancer patients treated with hypofractionated high dose rate boost and external beam radiotherapy. Int J Radiat Oncol Biol Phys.2011; 79(2):363-70.
- Deutsch I, Zelefsky MJ, Zhang Z et al. Comparison of relapse-free survival in patients treated with ultra-high dose IMRT versus combination HDR brachytherapy and IMRT. Brachytherapy 2010; 9(4): 313-8.
- Wilder RB, Barme GA, Gilbert RF et al. Preliminary results in prostate cancer patients treated with high dose rate brachytherapy and intensity modulated radiation therapy (IMRT) vs. IMRT alone. Brachytherapy 2010; 9(4): 341-8.
- The American Brachytherapy Society (ABS) Prostate High-Dose rate Task Group. Available online at: http://www.americanbrachytherapy.org/guidelines/HDRTaskGroup.pdf. Last access April 2, 2011.
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Policy History:
Date Reason Action
May 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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