Testicular Cancer

Radiation Therapy: Brachytherapy; Testicular Cancer

POLICY INITIATED: 06/30/2019 MOST RECENT REVIEW: 06/30/2019 POLICY # HH-5326

Overview Statement The purpose of these clinical guidelines is to assist healthcare professionals in selecting the medical service that may be appropriate and supported by evidence to improve patient outcomes. These clinical guidelines neither preempt clinical judgment of trained professionals nor advise anyone on how to practice medicine. The healthcare professionals are responsible for all clinical decisions based on their assessment. These clinical guidelines do not provide authorization, certification, explanation of benefits, or guarantee of payment, nor do they substitute for, or constitute, medical advice. Federal and State law, as well as member benefit contract language, including definitions and specific contract provisions/exclusions, take precedence over clinical guidelines and must be considered first when determining eligibility for coverage. All final determinations on coverage and payment are the responsibility of the health plan. Nothing contained within this document can be interpreted to mean otherwise. Medical information is constantly evolving, and HealthHelp reserves the right to review and update these clinical guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from HealthHelp. All trademarks, product names, logos, and brand names are the property of their respective owners and are used for purposes of information/illustration only.

Associated Procedure Codes: Procedure Code Description Code Intraoperative radiation treatment delivery, x-ray, single treatment session 77424 Intraoperative radiation treatment delivery, electrons, single treatment session 77425 Infusion or instillation of radioelement solution (includes 3 months follow-up care) 77750 Intracavitary radiation source application; simple 77761 Intracavitary radiation source application; intermediate 77762

Intracavitary radiation source application; complex 77763

Remote afterloading high dose rate radionuclide skin surface brachytherapy, 77767 includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel

Clinical Guidelines for Medical Necessity Review of Radiation Therapy Services. http://www.healthhelp.com | © 2019 HealthHelp. All rights reserved. 16945 Northchase Dr #1300, Houston, TX 77060 (281) 447‐7000

Remote afterloading high dose rate radionuclide skin surface brachytherapy, 77768 includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions Remote afterloading high dose rate radionuclide interstitial or intracavitary 77770 brachytherapy, includes basic dosimetry, when performed; 1 channel Remote afterloading high dose rate radionuclide interstitial or intracavitary 77771 brachytherapy, includes basic dosimetry, when performed; 2-12 channels Remote afterloading high dose rate radionuclide interstitial or intracavitary 77772 brachytherapy, includes basic dosimetry, when performed; over 12 channels Interstitial radiation source application, complex, includes supervision, handling, 77778 loading of radiation source, when performed Surface application of low dose rate radionuclide source 77789

High dose rate electronic brachytherapy, skin surface application, per fraction, 0394T includes basic dosimetry, when performed High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per 0395T fraction, includes basic dosimetry, when performed Low dose rate (LDR) prostate brachytherapy services, composite rate G0458

Definition:

1. Brachytherapy is a form of radiation therapy, which utilizes a radioactive source placed in or in close proximity to the tumor. It can be done by placing the radioactive source on the surface of the body or within a body cavity depending on the area to be treated.

Guideline: Radiation therapy utilizing Brachytherapy for testicular cancer will require review by the Medical Director and/or individual health plan to determine medical appropriateness.

References 1. Bekelman, Justin E., Gosia Sylwestrzak, John Barron, Jinan Liu, Andrew J. Epstein, Gary Freedman, Jennifer Malin, and Ezekiel J. Emanuel. “Uptake and Costs of Hypofractionated vs Conventional Whole Breast Irradiation After Breast Conserving Surgery in the United States, 2008–2013.” JAMA 312, no. 23 (December 10, 2014). doi:10.1001/jama.2014.16616. 2. Goyal S, Khan AJ, Vicini F et al. Factors associated withoptimal cosmetic results at 36 months in patients treated with accelerated partial breast irradiation (APBI) on the American Society of Breast Surgeons (ASBrS) MammoSite Breast Brachytherapy Registry Trial. Annals of Surgical Oncology 2009:16(9):2450-2458. 3. Niehoff P, Polgar C, Ostertag H et al. Clinical experience with the MammoSite radiation therapy system for brachytherapy of breast cancer: results from an international phase II trial. Radiotherapy and Oncology 2006;79(3):316-320. 4. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. V 1.2016. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed: May 1, 2016. 5. Smith, Benjamin D., Soren M. Bentzen, Candace R. Correa, Carol A. Hahn, Patricia H. Hardenbergh, Geoffrey S. Ibbott, Beryl Mccormick, Julie R. Mcqueen, Lori J. Pierce, Simon N. Powell, Abram Recht, Alphonse G. Taghian, Frank A. Vicini, Julia R. White, and Bruce G. Haffty. “Fractionation for Whole Breast Irradiation: An American Society for Radiation Oncology (ASTRO) Evidence-Based Guideline.” International Journal of Radiation Oncology.Biol.Phys. 81, no. 1(2011):59-68. doi:10.1016/j. ijrobp.2010.04.042. 6. Vicini F, Beitsch PD, Quiet CA et al. Three-year analysis of treatment efficacy, cosmesis, and toxicity by the American Society of Breast Surgeons MammoSite breast brachytherapy registry trial in patients treated with accelerated partial breast irradiation (APBI). Cancer 2008;112(4)758-766.