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Medical Policy Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds

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Medical Policy Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds Medical Policy Brachytherapy for Clinically Localized Prostate Cancer Using Permanently Implanted Seeds Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 175 BCBSA Reference Number: 8.01.14 Related Policies Intensity Modulated Radiation Therapy of the Prostate, #090 Stereotactic Radiosurgery & Fractionated Stereotactic Radiosurgery, #277 Cryosurgical Ablation of the Prostate, #149 High-Dose Rate Temporary Prostate Brachytherapy, #353 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO BlueSM and Medicare PPO BlueSM Members Brachytherapy using permanent transperineal implantation of radioactive seeds in treatment of localized prostate cancer when used as monotherapy or in conjunction with external beam radiation therapy (EBRT) may be considered MEDICALLY NECESSARY. Prior Authorization Information Commercial Members: Managed Care (HMO and POS) Prior authorization is NOT required.. Commercial Members: PPO, and Indemnity Prior authorization is NOT required. Medicare Members: HMO BlueSM Prior authorization is NOT required. Medicare Members: PPO BlueSM Prior authorization is NOT required. 1 CPT Codes / HCPCS Codes / ICD-9 Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member. A draft of future ICD-10 Coding related to this document, as it might look today, is included below for your reference. Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable. CPT Codes CPT codes: Code Description 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy 76873 Ultrasound, prostate volume study for brachytherapy treatment planning (separate procedure) 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 plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources) 77776 Interstitial radiation source application; simple 77777 Interstitial radiation source application; intermediate 77778 Interstitial radiation source application; complex HCPCS Codes HCPCS codes: Code Description C2636 Brachytherapy source, nonstranded, palladium-103, per 1 mm C2637 Brachytherapy source, nonstranded, ytterbium-169, per source C2638 Brachytherapy source, stranded, iodine-125, per source C2639 Brachytherapy source, nonstranded, iodine-125, per source C2640 Brachytherapy source, stranded, palladium-103, per source C2641 Brachytherapy source, nonstranded, palladium-103, per source C2642 Brachytherapy source, stranded, cesium-131, per source C2643 Brachytherapy source, nonstranded, cesium-131, per source Q3001 Radioelements for brachytherapy, any type, each ICD-9 Diagnosis Codes ICD-9-CM diagnosis codes: Code Description 185 Malignant neoplasm of prostate 233.4 Carcinoma in situ of prostate ICD-10 Diagnosis Codes ICD-10-CM Diagnosis codes: Code Description C61 Malignant neoplasm of prostate D07.5 Carcinoma in situ of prostate 2 Description Brachytherapy is a procedure in which a radioactive source is used to treat a localized cancer. With brachytherapy of the prostate, radioisotope "seeds" are used to deliver tumoricidal radioactivity directly to the tumor while sparing surrounding normal tissue. Seeds can be permanently or temporarily implanted. Biologic advantages of brachytherapy compared to external beam radiation therapy (EBRT) are related to the lower dose and dose rate delivered to the target tumor. Enhanced normal tissue repair occurs at the lower dose rates while tumor cell repair does not occur as quickly; thus, from a radiobiological perspective, low-dose rates cause ongoing tumor destruction in the setting of normal tissue repair. Permanent brachytherapy may be used alone as monotherapy or may be combined with EBRT (together known as combined modality therapy) as a way to boost the dose of radiation therapy delivered to the cancerous tumor. Brachytherapy is most often performed as a single procedure in the outpatient setting, Summary Permanent brachytherapy provides freedom from biochemical recurrence at acceptable risk and may be considered as an option in the treatment of localized prostate cancer. Brachytherapy combined with EBRT is considered an option in patients with intermediate and high-risk prostate cancer. This approach provides radiation dose to the prostate and extraprostatic coverage as well. Therefore, the available evidence for permanent brachytherapy in the treatment of localized prostate cancer when used as monotherapy or in conjunction with EBRT is sufficient to demonstrate improvements in net health outcomes and may be considered medically necessary. Policy History Date Action 9/2014 New references added from BCBSA National medical policy. 5/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 8/2013 New references from BCBSA National medical policy. 11/2011- Medical policy ICD 10 remediation: Formatting, editing and coding updates. 4/2012 No changes to policy statements. 9/2011 Reviewed - Medical Policy Group – Urology, Obstetrics and Gynecology. No changes to policy statements. 7/2011 Reviewed - Medical Policy Group – Hematology and Oncology. No changes to policy statements. 9/2010 Reviewed - Medical Policy Group -Hematology and Oncology. No changes to policy statements. 4/1/10 Medical Policy 175 created, effective 4/1/10 Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References 1. Rodrigues G, Yao X, Loblaw DA et al. Low-dose rate brachytherapy for patients with low- or intermediate-risk prostate cancer: A systematic review. Can Urol Assoc J 2013; 7(11-12):463-70. 2. Grimm P, Billiet I, Bostwick D et al. Comparative analysis of prostate-specific antigen free survival outcomes for patients with low, intermediate and high risk prostate cancer treatment by radical therapy. Results from the Prostate Cancer Results Study Group. BJU Int 2012; 109 Suppl 1:22-9. 3. Peinemann F, Grouven U, Hemkens LG et al. Low-dose rate brachytherapy for men with localized prostate cancer. Cochrane Database Syst Rev 2011; (7):CD008871. 3 4. Giberti C, Chiono L, Gallo F et al. Radical retropubic prostatectomy versus brachytherapy for low- risk prostatic cancer: a prospective study. World J Urol 2009; 27(5):607-12. 5. Peinemann F, Grouven U, Bartel C et al. Permanent interstitial low-dose-rate brachytherapy for patients with localised prostate cancer: a systematic review of randomised and nonrandomised controlled clinical trials. Eur Urol 2011; 60(5):881-93. 6. Bannuru RR, Dvorak T, Obadan N et al. Comparative evaluation of radiation treatments for clinically localized prostate cancer: an updated systematic review. Ann Intern Med 2011; 155(3):171-8. 7. Institute for Clinical and Economic Review (ICER). Brachytherapy/proton beam therapy for clinically localized, low-risk prostate cancer. Available online at: http://www.icer-review.org/bt-pbt/. Last accessed May 26, 2014. 8. Zietman AL. Localized prostate cancer: brachytherapy. Curr Treat Options Oncol 2002; 3(5):429-36. 9. Crook JM, Gomez-Iturriaga A, Wallace K et al. Comparison of health-related quality of life 5 years after SPIRIT: Surgical Prostatectomy Versus Interstitial Radiation Intervention Trial. J Clin Oncol 2011; 29(4):362-8. 10. Ragde H, Elgamal AA, Snow PB et al. Ten-year disease free survival after transperineal sonography-guided iodine-125 brachytherapy with or without 45-gray external beam irradiation in the treatment of patients with clinically localized, low to high Gleason grade prostate carcinoma. Cancer 1998; 83(5):989-1001. 11. Pickles T, Keyes M, Morris WJ. Brachytherapy or conformal external radiotherapy for prostate cancer: a single-institution matched-pair analysis. Int J Radiat Oncol Biol Phys 2010; 76(1):43-9. 12. Martinez AA, Demanes J, 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. 13. Coen JJ, Zietman AL, Rossi CJ et al. Comparison of high-dose proton radiotherapy and brachytherapy in localized prostate cancer: a case-matched analysis. Int J Radiat Oncol Biol Phys 2012; 82(1):e25-31. 14. Nepple KG, Stephenson AJ, Kallogjeri D et al. Mortality After Prostate Cancer Treatment with Radical Prostatectomy, External-Beam Radiation Therapy, or Brachytherapy in Men Without Comorbidity. Eur Urol 2013. 15. Williams SB, Lei Y, Nguyen PL et al. Comparative effectiveness of cryotherapy vs brachytherapy for localised prostate
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