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DESCRIPTIONProstate brachytherapy can be delivered in a variety of ways. Perhaps the most familiar technique is the use of radioactive seeds permanently implanted into prostate tissue. These seeds contain isotopes that slowly emit radiation of relatively low energy.
In contrast, temporary prostate brachytherapy involves use of higher energy radioisotopes such as iridium-192. These isotopes deliver radiation at higher dose rates, which may be more effective in destroying rapidly dividing cancer cells. In this technique, needle catheters are placed into the prostate gland using transrectal ultrasound guidance. Once the needles are placed, a dosimetric plan is developed and the radioactive source is inserted into each needle using an afterloading device. The radioactive source is left in the needle for a predetermined time, called the “dwell” time. The radiation usually is delivered once or twice daily over a course of several days. The dwell time can be altered at various positions along the needle’s length to control dose distribution to the target volume and critical surrounding structures, such as the rectum or urethra. This strategy contrasts with permanent seed implantation in which dosimetry is calculated prior to needle placement and which cannot be altered after seed implantation.
The treatment typically consists of 4,000 to 5,000 cGy delivered with external beam radiation therapy (EBRT) to the prostate and periprostatic tissues, while the high-dose rate brachytherapy (HDR BT) is used as the method of dose escalation to the prostate gland. The total boost doses are variable. In addition, studies are also being conducted using high-dose rate brachytherapy as the sole treatment modality (monotherapy) in those with prostate cancer.
It is an accepted premise that increasing doses of radiation therapy are associated with improved biochemical control (i.e., stable levels of prostate-specific antigen [PSA]), and thus there has been keen interest in exploring different techniques of dose escalation while simultaneously limiting both early and late toxicities in surrounding tissues. In patients with locally advanced disease, it is hypothesized that local failure may be related to the large volume of tumor and radioresistant cell clones, both of which might respond to higher radiation doses. High-dose rate prostate brachytherapy has been primarily investigated as an adjunct to EBRT as a technique of dose escalation. Other techniques for dose escalation include EBRT using intensity-modulated radiation therapy (IMRT) for treatment planning and delivery, proton beam radiotherapy (which may also use IMRT), or EBRT combined with brachytherapy using interstitial seeds.
POLICYHigh-dose rate prostate brachytherapy may be considered medically necessary as monotherapy or in conjunction with external beam radiation therapy in the treatment of localized prostate cancer.
High-dose rate prostate brachytherapy is considered investigational in the treatment of prostate cancer when used as salvage therapy.
POLICY GUIDELINESHigh-dose rate brachytherapy as monotherapy is being used in low- and intermediate-risk patients with localized prostate cancer. High-dose rate brachytherapy combined with EBRT (3-dimensional conformal radiotherapy [3D-CRT], intensity-modulated or proton) may be used for more advanced or aggressive prostate cancers. Adequate dose escalation should be achieved with combination high-dose rate temporary brachytherapy and 3D-CRT. IMRT should be limited only to cases in which 3D-CRT planning is not able to meet dose volume constraints for normal tissue tolerance. Permanent low-dose rate (LDR) brachytherapy using only implanted seeds is generally used in patients whose prostate cancer is considered low risk. Active surveillance is generally recommended for very low-risk prostate cancer. Permanent brachytherapy combined with EBRT is used (sometimes along with androgen deprivation) to treat higher risk disease.
Prostate cancer risk is often defined using the following criteria:
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY11/2000: Approved by Medical Policy Advisory Committee (MPAC), CPT code 76872-76873 added
5/23/2001: Code Reference section revised, CPT code 55860, 77326-77328, 77781-77784 added, ICD-9 procedure code 60.0, 92.27 added, ICD-9 diagnosis code 185,198.82, 233.4 added, HCPCS “All Codes - For brachytherapy needles and radioelements” added
6/13/2001: Code Reference section updated, CPT code 76965, 77776-77778 added
2/8/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
9/20/2002: CPT codes 76872-76873 deleted
8/16/2005: Code Reference section updated, CPT code 55859, 77761, 77762, 77763, 77790 added, CPT code 77326-77328 code range listed separately and description revised, CPT code 77776-77778, 77781-77784 code range listed separately, ICD-9 procedure code 60.99 added, ICD-9 procedure code 92.27 description revised, ICD-9 diagnosis code 185, 198.82, 233.4 deleted, HCPCS “All Codes - For brachytherapy needles and radioelements” deleted, HCPCS Q3001 added
8/28/2006: Policy reviewed, no changes
12/28/2006: Code reference section updated per the 2007 CPT/HCPCS revisions
12/31/2008: Code reference section updated per the 2009 CPT/HCPCS revisions
06/30/2009: Policy Description section updated to explain procedure; Policy Statement section updated to state monotherapy or in conjunction with external beam radiation therapy may be considered medically necessary while salvage therapy remains investigational; Non-Covered Codes Table removed, Covered Codes Table added, CPT code 76873 added to covered table, CPT codes 77761, 77762, and 77763 deleted from covered table, ICD-9 Diagnosis code 185 added to covered table, HCPCS code C1717 added to covered table, added statement to covered table regarding HCPCS C-codes
4/12/2010: Description and policy statement reviewed, no changes. Code reference section updated. Description revised for CPT code 55876. CPT codes 77781, 77782, 77783, 77784 deleted from covered table due to codes were deleted as of 12-31-2008.
07/29/2011: Policy reviewed; no changes.
07/19/2012: Policy reviewed. Policy statement unchanged. Policy guidelines updated to add that adequate dose escalation should be achieved with combination permanent brachytherapy and 3D CRT. Therefore, IMRT should be limited only to cases in which 3D CRT planning is not able to meet dose volume constraints for normal tissue tolerance.
10/17/2013: Policy reviewed; no changes.
12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 77316, 77317, and 77318.
08/31/2015: Code Reference section updated for ICD-10. Removed ICD-9 procedure codes 60.0 and 60.99, added ICD-9 procedure code 92.23, and removed HCPCS C1717.
SOURCE(S)Blue Cross Blue Shield Association policy # 8.01.33
Blue Cross Blue Shield Association policy # 8.01.14
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.