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Medical Policy: 08.01.11
Original Effective Date: February 2005
Reviewed: May 2007
Revised:
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 for breast cancer involves the direct placement of radioactive material inside the breast. Brachytherapy techniques differ in timing of implantation, dose rate, loading techniques, and the radioisotopes used in the implanted sources.
Intracavitary balloon brachytherapy involves the temporary placement of a single balloon-tipped catheter into the cavity left by the excised breast tumor. When filled with saline the balloon conforms to the cavity walls. Through a lumen within the saline-filled balloon, a radiation seed (iridium-192) is deployed to the target site using a high-dose-rate afterloader system. The seed delivers high dose radiation to the surrounding breast tissue for up to 20 minutes. The standard intracavitary brachytherapy protocol for breast cancer includes 2 treatments per day for 5 days. At the conclusion of the 5 day treatment period the balloon-tipped catheter is deflated and removed.
Interstitial brachytherapy uses multiple radiation sources placed in 2 or more planes through the breast, with computerized treatment planning to optimize dose homogeneity in the target. The number, spacing, and radiation strength of sources vary with the breast volume to be treated. Both low-and high-dose rate interstitial techniques are used. In the low-dose rate technique, radioactive seeds are temporarily implanted and deliver radiation continuously over 4 days and then are removed. Low-dose rate brachytherapy is usually administered to hospitalized patients. In the high-dose rate technique, a computer-controlled device loads highly radioactive isotope sources into catheters that have been placed in the tumor bed. The patient is then exposed to the radiation for a brief period and then the radioactive sources are withdrawn. High-dose rate brachytherapy is usually administered in the outpatient setting as 8 fractions twice daily over 4 days.
Policy:
Interstitial or balloon brachytherapy may be considered medically necessary when used as a component in breast conservation treatment of early stage I or II breast cancer.
Breast brachytherapy is considered investigational when used for other conditions of the breast or stages of breast cancer not identified above.
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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-CM diagnostic codes.
The following codes or code ranges may be used to report brachytherapy:
- 77326 through 77328 Brachytherapy isodose calculation (code range)
- 77750 Infusion or instillation of radioelement solution
- 77761 through 77763 Intracavitary radioelement application (code range)
- 77776 through 77778 Interstitial radioelement application (code range)
- 77781 through 77784 Remote afterloading high intensity brachytherapy (code range)
- 77790 Supervision, handling, loading of radioelement
- 0182T High dose rate electronic brachytherapy, per fraction
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Selected References:
- Edmundson GK et al. Accelerated treatment of breast cancer: dosimetric comparisons between interstitial HDR brachytherapy, MammoSite balloon brachytherapy, and external beam quadrant radiation. Int J Radiat Oncol Biol Phys 2003 Oct 1;57(2Suppl):S307-8.
- Fisher B, Anderson S, Bryant J et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. NEJM 2002 Oct 17;347(16):1233-41.
- King TA, et al. Long-term results of wide-field brachytherapy as the sole method of radiation therapy after segmental mastectomy for T1,2 breast cancer. AM J Surg 2000 Oct;180(4):299-304.
- Pawlik TM, et al. Potential applicability of balloon catheter-based accelerated partial breast irradiation after conservative surgery for breast carcinoma. Cancer 2004 Feb 1;100(3):490-8.
- Huang E, Buchholz TA, Meric F et al. Classifying local disease recurrences after breast conservation therapy based on location and histology. Cancer 2002; 95(10): 2059-67.
- Dragun AE, Aguero EG, Harmon JF et al. Chest wall dose in MammositeTM breast brachytherapy: radiobiologic estimations of late complication risk based on dose-volume considerations. Brachytherapy. 2005; 4(4):259-63.
- Vicini FA< Beitsch PD, Quiet CA et al. First analysis of patient demographics, technical reproducibility, cosmesis, and early toxicity: results of the American Society of Breast Surgeons MammoSite breast brachytherapy trial. Cancer. 2005 Sep 15; 104(6):1138-48.
- McCormick B. Partial-breast radiation for early staged breast cancers: hypothesis, existing data, and a planned phase III trial. J Natl Compr Canc Netw. 2005 May;3(3):301-7.
- Chen PY, Vicini FA, Benitez P et al. Long-term cosmetic results and toxicity after accelerated partial-breast irradiation: a method of radiation delivery by interstitial brachytherapy for the treatment of early-stage breast carcinoma. Cancer 2006; 106(5):991-9.
- Jeruss JS, Vicini FA, Beitsch PD et al. Initial outcomes for patients treated on the American Society of Breast Surgeons MammoSite clinical trial for ductal carcinoma-in-situ of the breast. Ann Surg Oncol 2006; 13(7):967-76.
- Kuske RR, Winter K, Arthur DW et al. Phase II trial of brachytherapy alone after lumpectomy for select breast cancer: toxicity analysis of RTOG 95-17. Int J Radiat Oncol Biol Phys 2006; 65(1):45-51.
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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, Iowa 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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