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DESCRIPTIONBrachytherapy, or the interstitial implantation of radioactive seeds is an option for treatment of prostate cancer that has been proposed as an alternative or complement to external beam radiotherapy (EBRT).
The radioactive seeds are implanted permanently, using the transperineal route, as a potentially curative treatment for localized prostate cancer. This procedure is intended to deliver tumoricidal radioactivity directly to the tumor and improve local control, while sparing surrounding tissue. It requires the use of a surgical suite, but can also be done as an outpatient procedure. Treatment can be completed in a single session.
Brachytherapy, generally, is not indicated for patients with large prostate size or those with a urethral stricture since the procedure results in short-term swelling of the prostate which can lead to urinary obstruction. As with all forms of radiation therapy, there are concerns regarding the long-term risk of treatment-related secondary malignancies.
Permanent brachytherapy generally utilizes either iodine-125 or palladium-103. Use of iodine-125 requires more seeds, and there is thus less dosimetric dependence on any single seed.
Permanent brachytherapy may be used alone as monotherapy or may be combined with EBRT (together known as combined modality therapy – CMT) as a way to boost the dose of radiation therapy delivered to the tumor.
POLICYBrachytherapy using permanent transperineal implantation of radioactive seeds may be considered medically necessary in treatment of localized prostate cancer when used as monotherapy or in conjunction with external beam radiation therapy (EBRT) (See Policy Guidelines).
Focal or subtotal prostate brachytherapy is considered investigational in the treatment of prostate cancer.
POLICY GUIDELINESInvestigative 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.
Permanent brachytherapy using only implanted seeds is generally used in patients whose prostate cancer is considered low risk. Permanent brachytherapy combined with EBRT is used (sometimes along with androgen deprivation) to treat higher risk disease. Adequate dose escalation should be achieved with combination permanent brachytherapy and 3D-CRT. Intensity Modulated Radiation Therapy (IMRT) should be limited only to cases in which 3D-CRT planning is not able to meet dose volume constraints for normal tissue tolerance.
Prostate cancer risk is often defined using the following criteria:
The procedure is usually performed in 2 stages; a prostate volume study (CPT code 76873) followed on a later date by the implant itself, which is performed in the operating room under general or epidural anesthesia. Iodine or palladium are the typical isotopes used; and the selection of isotope is usually based on physician preference. A CT scan is usually performed at some stage after the procedure to determine the quality of the seed placement.
POLICY HISTORY11/1997: Approved by the Medical Policy Advisory Committee (MPAC)
8/1999: Addition of medically necessary indication approved by MPAC
5/21/2001: Code Reference section updated, CPT code 55859, 76965 added, ICD-9 procedure code 60.0, 92.28, 92.29 added
7/13/2001: Policy exception for FEP added
2/14/2002: Investigational definition added
4/18/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated, HCPCS G0256, G0261 added
8/3/2005: Code Reference section updated, CPT code 76873, 77326, 77327, 77328, 77761, 77762, 77763, 77776, 77777, 77778 description revised, CPT code 77799 added, ICD-9 procedure code 60.99 added, ICD-9 procedure code 60.0 deleted, ICD-9 diagnosis code 233.4 description revised, HCPCS Q3001 added, HCPCS G0256, G0261 deleted
12/27/2006: Code Reference section updated per the 2007 CPT revisions
6/26/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
6/18/2009: Policy description updated, policy statement updated. CPT4 codes 77402, 77403 and 77406 added to the covered table. HCPC codes C1715, C 2638,C2639, C2640 and C2641 added to covered table.
7/10/2009: CPT code 77404 added to covered table. CPT code 55859 deleted from the covered table due to the code is a deleted code as of 12-31-2006.
7/16/2009: Policy revisions approved by Medical Policy Advisory Committee (MPAC)
3/22/2010: Code reference section updated. Description revised for CPT code 55876.
08/03/2011: Policy reviewed. Policy statement unchanged. Deleted outdated references from the Sources section.
07/19/2012: Added the following policy statement: Focal or subtotal prostate brachytherapy is considered investigational in the treatment of prostate cancer. Policy guidelines updated regarding the use of IMRT.
12/21/2012: Added the following new 2013 CPT code to the Code Reference section: G0458.
10/23/2013: Policy reviewed; no changes.
SOURCE(S)Blue Cross & Blue Shield Association policy No. 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.