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Medical Policy: 06.01.28
Original Effective Date: August 2011
Reviewed:
Revised:
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:
Real-time intra-fraction target tracking during radiation therapy enables adjustment of the target radiation while it is being delivered to compensate for organ movement. The technology is intended to provide clinicians with continuous position information, or localization, of a tumor target during external beam radiation therapy with sub-millimeter precision. Real time tracking, which may or may not use radiographic images, is one of several techniques referred to as “image-guided radiation therapy” (IGRT). For the purposes of this policy real-time tracking is defined as frequent or continuous target tracking in the treatment room during radiation therapy, with periodic or continuous adjustment to targeting made on the basis of target motion detected by the tracking system.
During radiation therapy it is important to target the tumor so that treatment is delivered to the tumor, but surrounding tissue is spared. In some anatomic locations (i.e. lung, liver, and prostate tumors) intrafraction motion can be significant due to respiratory or cardiac motion or, in the case of the prostate, constant changes in bladder and bowel filling. This organ motion may present significant limitations for margin reduction around the clinical target volume and negatively impact safe dose escalation which is used in an attempt to improve long-term tumor control and improve patient survival. Data also suggest that a strong relationship may exist between obesity and organ shift, indicating that without some form of target tracking, the target volume may not receive the intended dose for patients who are moderately to severely obese.
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Prior Approval:
Not applicable
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Policy:
Real-time intra-fraction target tracking, or intra-fraction localization, may be considered medically necessary.
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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-CM diagnostic codes.
- 0197T Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment.
- A4648 Tissue marker, implantable, any type, each
- C1879 Tissue marker (implantable)
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Selected References:
- Wong JR, Gao Z, Merrick S et al. Potential for higher treatment failure in obese patients: correlation of elevated body mass index and increased daily prostate deviations from the radiation beam isocenters in an analysis of 1,465 computed tomographic images. Int J Radiat Oncol Biol Phys 2009; 75(1):49-55.
- Tanyi JA, He T, Summers PA et al. Assessment of planning target volume margins for intensity-modulated radiotherapy of the prostate gland: role of daily inter-and intrafraction motion. Int J Radiat Oncol Biol Phys. 2010 Dec 1;78(5):1579-85. Epub 2010 May 14.
- Shah AP, Kupelian PA, Willoughby TR et al. An evaluation of intrafraction motion of the prostate in the prone and supine positions using using electromagnetic tracking. Radiother Oncol. 2011 Apr;99(1):37-43. Epub 2011 Mar 30
- Quigley MM, Mate TP, Sylvester JE. Prostate tumor alignment and continuous, real-time adaptive radiation therapy using electromagnetic fiducials: clinical and cost-utility analyses. Urol Oncol. 2009 Sep-Oct;27(5):473-82. Epub 2008 Jul 14.
- Kupelian P, Willoughby T, Mahadevan A et al. Multi-institutional clinical experience with the Calypso System in localization and continuous, real-time monitoring of the prostate gland during external radiotherapy. Int J Radiat Oncol Biol Phys. 2007 Mar 15;67(4):1088-98. Epub 2006 Dec 21.
- Nguyen PL, Gu X, Lipsitz SR et al. Cost implications of the rapid adoption of newer technologies for treating prostate cancer. J Clin Oncol 2011 Apr 20; 29(12):1517-24. Epub 2011 Mar 14.
- Sandler HM, Liu PY, Dunn RL et al. Reduction in patient-reported acute morbidity in prostate cancer patients treated with 81-Gy intensity-modulated radiotherapy using reduced planning target volume margins and electromagnetic tracking: assessing the impact of margin reduction study. Urology 2010; 75(5):1004-08.
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Policy History:
Date Reason Action
August 2011 Evidence review New policy
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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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