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Medical Policy: 08.01.04
Original Effective Date: December 1998
Reviewed: March 2008
Revised: November 2006
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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. Brachytherapy alone is recommended as a treatment for patients with high probability of organ-confined disease, those with stage T1c or T2a tumors, a Gleason sum of less than 7 and a serum PSA level of 10 ng/ml or less. Those candidates with a significant risk of extraprostatic extension should be treated with supplemental external beam radiation therapy (EBRT).
A variation of brachytherapy for treatment of prostate cancer is called high dose rate temporary brachytherapy. This more recent treatment has been investigated as an alternative to the permanently implanted radioactive seeds used in conventional brachytherapy. With high dose temporary brachytherapy, different radioactive isotope seeds are used that provide more radiation than the permanent seeds. They are inserted for predetermined periods of time, usually 8 to 12 minutes. The treatments are usually delivered one or two times a day over the course of several days.
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 temporary brachytherapy for prostate cancer is considered investigational.
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Procedure Codes and Billing
Guidelines:
- To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- CPT code 76965 Ultrasonic guidance for interstitial radioelement application
- CPT code 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
- CPT code 55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple
- CPT code 77776 Interstitial radiation source application; simple
- CPT code 77777 Interstitial radiation source application; intermediate
- CPT code 77778 Interstitial radiation source application; complex
- CPT code 77781 Remote afterloading high intensity brachytherapy; 1-4 source positions or catheters
- CPT code 77782 Remote afterloading high intensity brachytherapy; 5-8 source positions or catheters
- CPT code 77783 Remote afterloading high intensity brachytherapy; 9-12 source positions or catheters
- CPT code 77784 Remote afterloading high intensity brachytherapy; over 12 source positions or catheters
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- A review of the medical literature and recommendations from Wellmark's Medical Policy Advisory Council (MPAC), a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies. The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
- 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
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave.
Des Moines, IA 50309
*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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